Orlistat for Weight Loss: Remembering All the Tools of the Trade

Introduction :
New medications like the gastric inhibitory polypeptide (GIP) and glucagon-like peptide-1 receptor agonist (GLP-1 RA) have been making headlines as more effective weight loss medications. However, in the light of recent manufacturing delays, cost and side effects, older weight loss medications should still be considered.

Case Description:
A 58-year-old female with history of metabolic syndrome and depression presented to endocrinology clinic to discuss weight loss medications. On presentation, she was at her maximum weight of 205 pounds (BMI 37.5). She previously enrolled in the Veterans Affairs Hospital ‘MOVE’ program and started metformin 1000mg twice a day with minimal weight loss. Her insurance did not cover GLP-1 RAs and both bupropion-naltrexone and phentermine-topiramate were contraindicated since she was already taking bupropion and had a history of kidney stones. The patient was started on orlistat 120mg three times a day, which she tolerated, and in 2 months had a 4% weight loss to 197 pounds (BMI 36). Over the next 7 months she lost an additional 16 pounds (BMI 32.9) and no longer qualified for bariatric surgery. After 2.5 years, the patient has lost 57 pounds (BMI 27.1, 28% weight loss), her A1c has decreased from 6.8% to 6.1%, her total cholesterol has decreased from 202 to 127, and her LDL from 101 to 58 (atorvastatin 10mg was added at the same time as orlistat). She now self titrates orlistat based on her meals and averages taking the medication one to two times a day.

Discussion:
Orlistat functions by inhibiting gastrointestinal lipases, resulting in decreased absorption of fat by 30%. It has been shown to promote and maintain weight loss of an average of 3.8%, as well as reduce the risk of developing type 2 diabetes and lower cholesterol. While other weight loss medications, such as bupropion-naltrexone, phentermine-topiramate, and GLP-1 RAs have contraindications in patients with significant cardiac history, hyperthyroidism, seizures, and pancreatitis, orlistat has no contraindications. This medication is ideal in patients who eat a high fat diet or do not want to administer injections and is cost effective with minimal contraindications. The limiting factor is gastrointestinal side effects such as fatty stool and fecal incontinence, which occur in approximately 25% of patients. These side effects decrease in frequency with long-term use and are reduced when given with psyllium. In summary, this case highlights orlistat as an effective weight loss medication in the appropriate patient.