Excerpted from Pioneer Press, Thursday, 27 March 2003.

Health: Despite Stigma, Doctors Still Rely On Diet Drugs

Tara Parker-Pope, Wall Street Journal -- In this post Fen-Phen world, prescription diet pills are often thought of as a thing of the past.

But a number of weight-loss experts are still quietly prescribing a wide range of drugs that can help people lose weight.

The diet-drug arsenal includes the heavily marketed Meridia and Xenical as well as older-line appetite suppressants such as phentermine, that many doctors think work just as well. In addition, a handful of doctors are beginning to use other drugs that aren't approved for weight loss but may help some patients shed pounds. Among them: the antidepressant Wellbutrin, the seizure drug Topamax, and diabetes drugs Glyset, Precose and Glucophage.

"In my opinion, it's worth treating obesity, the medical problem, with medicine," says Louis Aronne, director of the comprehensive weight-control program at New York Presbyterian Hospital. He says roughly one-third of his patients use a prescription drug to help with weight loss.

At a time when more than half the country is considered overweight, prescription diet pills remain a surprisingly well-kept secret. Among many doctors, diet pills have fallen out of favor ever since the popular diet drug combination Fen-Phen and a similar drug, Redux, were linked with serious heart problems and pulled from the market. And patients, assuming effective prescription diet drugs aren't available anymore, have flocked to controversial over-the-counter remedies such as ephedra, the supplement that has been linked with the death of Baltimore pitcher Steve Bechler.

When Ed Harmon sought advice for losing weight, he was skeptical when his doctor, Baltimore weight-loss specialist Paul Rivas, suggested diet pills. "I looked at him and said, 'yeah, right,' " says Harmon, 48, a retired corrections officer from Pasadena, Md. " 'I'm 427 pounds, and you're telling me these little pills will make me lose weight?' "

But five months later and more than 100 pounds lighter, he is a believer. "I had a lot of cravings; I was a binge eater, and now it's completely stopped," says Harmon, whose diet-drug combination includes the appetite suppressants phentermine and phendimetrazine as well as the antidepressant Effexor.

Rivas says he often uses a combination of drugs, depending on the nature of patients' eating habits. "It's not a one size fits all."

Doctors who prescribe drugs to help dieters say the pills have their limits, and will only work if the patient is also willing to make diet and lifestyle changes. For some patients, appetite suppressants such as Meridia and phentermine may lose their effectiveness over time. And studies show that after patients stop taking diet pills, they often gain the weight back.

While some of the drugs may produce dramatic results in a few patients, overall, the diet drugs have produced only modest results, helping people shed about 10 percent of their body weight.

One of the biggest limitations of weight-loss drugs, however, is cost. Insurance companies won't cover drugs or weight-loss programs for the vast majority of patients, and the drugs aren't cheap. For instance, a month's supply of Meridia costs about $86. Phentermine costs about $30 a month. "Our patients already are paying a lot of money for treatment," says Samuel Klein, president of the North American Association for the Study of Obesity who instead advocates an aggressive lifestyle-management program at Washington University in St. Louis.

Some of the pills have significant side effects. Xenical, which limits the amount of fat the body absorbs, can cause stomach upset and uncontrollable diarrhea, particularly in users who continue eating high-fat foods. And last year, Topamax maker Johnson & Johnson halted weight-loss studies because of side effects, including tingling sensations in fingers and toes, memory problems and fatigue.

Wellbutrin hasn't been very effective for weight loss in studies, but it may be an option for those who need an antidepressant anyway.

Some diabetes drugs may also help trigger weight loss in certain patients, even those who don't have diabetes. In one study of the drug Glucophage, patients lost about 10 percent of their body weight after a year. Other doctors are prescribing Glyset and Precose, which slow down carbohydrate absorption. The drugs haven't performed well in diet studies, but some doctors think the study group was eating too many carbohydrates, blunting the drugs' effectiveness.

One concern is that many of the diet drugs, sold under the brand names Adipex, Bontril and Tenuate, among others, are touted by Web sites offering to prescribe the drugs via an online doctor. The worry is that many of the drugs can interact with other medicines, including antidepressants, and in some patients they can cause serious side effects.

Advocates of diet drug use say patients need to know drugs are available to help them lose weight, but they need to find a nonjudgmental doctor to prescribe them.

"We must get primary-care doctors to acknowledge the biological issues these patients face," says Madelyn H. Fernstrom, at the University of Pittsburgh's weight-management center.

Excerpted from Pioneer Press, Thursday, 27 March 2003.