Received: 30 September 2022 Revised: 25 September 2023 Accepted: 30 October 2023

DOI: 10.1111/obr.13683

REVIEW
Weight management / Intervention

Consensus on pharmacological treatment of obesity in Latin

America

Ana María Cappelletti 1,2 | Alex Valenzuela Montero 3 | Cintia Cercato 4 |

5 6
John Jairo Duque Ossman | Pablo Enrique Fletcher Vasquez |
7
Juan Eduardo García García | Leonardo Guadalupe Mancillas-Adame 8 |
Herald Andrés Manrique 9 | Flor de María Ranchos Monterroso 10 |
Pablo Segarra 11,12 | Trina Navas 13

1
Favaloro University, Buenos Aires, Argentina
2
Argentine Society of Nutrition, Buenos Aires,
Summary
Argentina A panel of 10 experts in obesity from various Latin American countries held a Zoom
3
Chilean Society of Obesity, Santiago de Chile,
meeting intending to reach a consensus on the use of anti-obesity medicines and
Chile
4 make updated recommendations suitable for the Latin American population based on
Endocrinology and Metabology Service,
Clinics Hospital, University of São Paulo the available evidence. A questionnaire with 16 questions was developed using the
Medical School, São Paulo, Brazil
5
Patient, Intervention, Comparison, Outcome (Result) methodology, which was iter-
Colombian Association of Endocrinology,
Diabetes and Metabolism, Armenia, Colombia ated according to the modified Delphi methodology, and a consensus was reached
6
Latinamerican Federation of Endocrinology, with 80% or higher agreement. Failure to reach a consensus led to a second round of
Panama City, Panama
analysis with a rephrased question and the same rules for agreement. The recommen-
7
Salvador Zubiran National Institute of Medical
Sciences and Nutrition, Tlalpan, Mexico dations were drafted based on the guidelines of the American College of Cardiology
8
University Hospital and Medical School, Foundation/American Heart Association Task Force on Practice. This panel of
Autonomous University of Nuevo Leo  n,
experts recommends drug therapy in patients with a body mass index of ≥30 or
Monterrey, Mexico
9 ≥27 kg/m2 plus at least one comorbidity, when lifestyle changes are not enough to
Peruvian Society of Endocrinology, Lima, Peru
10
Guatemalan Association of Endocrinology, achieve the weight loss objective; alternatively, lifestyle changes could be maintained
Metabolism and Nutrition, Guatemala City, while considering individual parameters. Algorithms for the use of long-term medica-
Guatemala
11
tions are suggested based on drugs that increase or decrease body weight, results,
Ecuadorian Society of Endocrinology, Quito,
Ecuador contraindications, and medications that are not recommended. The authors con-
12
Ecuadorian Society of Internal Medicine, cluded that anti-obesity treatments should be individualized and multidisciplinary.
Quito, Ecuador
General Hospital “Dr. José Gregorio
13
KEYWORDS
Hernandez”, Los Magallanes, Caracas,
Latin America, obesity, pharmacotherapy, weight management
Venezuela

Correspondence
Ana María Cappelletti, Favaloro University,
Buenos Aires, Argentina.
Email: [email protected]

Abbreviations: BMI, body mass index; CNCDs, chronic non-communicable diseases; EBM, evidence-based medicine; LE, level of evidence; PICO, Patient, Intervention, Comparison, Outcome
 n); WHO, World Health Organization.
(Result); R, grade of recommendation; SAN, Argentinian Society of Nutrition (Sociedad Argentina de Nutricio

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.

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Funding information
Adium Pharma

1 | I N T RO DU CT I O N This universal classification, which is useful for population studies,

has some limitations in assessing individuals in clinical practice
Chronic non-communicable diseases (CNCDs) are the primary cause because of the presence of other factors that increase the risk of
of death worldwide, accounting for 60% of the overall mortality. The comorbidities beyond BMI, in particular, the amount and distribution
frequency of CNCDs continues to increase, particularly in low- and of body fat. Sharma and Kushner suggested that the Edmonton Obe-
medium-income countries (most Latin American countries), and their sity Staging System, which considers clinical, psychological, and func-
economic burden for the current period (2011–2025) is estimated to tional comorbidities, allows for the assessment of the effect of these
generate losses of USD 7 billion. “These diseases drive inequity; con- comorbidities in individuals beyond body weight and optimizes treat-
tribute to poorer economic outcomes for individuals, communities, ment decision-making (Table 2).8
and societies; and create significant challenges to development. The Cappelletti and Katz, in their manual Obesity Crossroads and
economic impact of CNCDs must be better understood, and their nega- Approaches, define obesity as a “Chronic, multifactorial disease with
tive consequences for societies mitigated.”1 an impact on the neuro-immune-metabolic and psychosocial balance.
The global prevalence of obesity has almost tripled since 1975. Its inflammatory condition resulting from increased dysfunctional adi-
Most of the population lives in countries where overweight and obe- pose tissue, accounts for the association with its comorbidities.”9
2
sity are causing more deaths than underweight. In 1997, the World The results of the Awareness, Care, and Treatment In Obesity
Health Organization (WHO) acknowledged obesity as a global health maNagement International Observation trial10 should be highlighted
problem, which was previously associated only with high-income with regard to obesity treatment; its primary objective was to identify
countries; however, evidence shows that overweight and obesity in perceptions, attitudes, behaviors, and potential barriers to the effec-
adults are much more frequent than underweight in Latin America tive care of patients with obesity and healthcare practitioners using a
and Northern Africa. Therefore, this CNCD is currently among the pri-
mary public health challenges, with México as the second highest
combined prevalence of overweight and obesity in adults globally.3 TABLE 1 Classification based on body mass index (BMI).
Diabetes, cardiovascular diseases, musculoskeletal system disorders, Classification BMI (kg/m2)
and certain types of cancers are attributable to overweight and
Low weight <18.5
obesity.4
Normal weight 18.5–24.9
In 2000, Peña and Bacallao published data from several countries
Overweight 25–29.9
in Central and South America, warning that poverty was a new public
Obesity ≥30
health challenge.5 These data were considered by the Pan American
Grade I 30.0–34.9
Health Organization, because the global prevalence of overweight in
the adult population was 36.6% and that of obesity was 11.5%; how- Grade II 35.0–39.9

ever, the prevalence was 59% and 24.6% in the Americas, respec- Grade III ≥40
tively. This figure is more than double the world average, making our Source: Based on https://www.who.int/es/news-room/fact-sheets/detail/
region the highest in obesity in the world; furthermore, there is a sex obesity-and-overweight.
difference, because women are more likely to develop obesity than
men.6
TABLE 2 Edmonton Obesity Staging System (EOSS).
In 2008, a panel of experts from The Obesity Society of North
America examined the evidence and argued the importance of classi- S0 No signs, physical or psychological symptoms
fying obesity as a disease. The panel unanimously and definitively No functional limitations

stated that obesity is “a complex condition with several causal con- S1 Subclinical risk factors
My psychological impairment
tributors, including many factors that, to a large extent, are beyond
S2 Comorbidities requiring therapy
the control of the individual; this disease results in a lot of distress, is
Obesity-associated psychological disorders
a cause of poor health, functional impairment, impaired quality of life, Moderate functional limitations affecting quality of life
severe illnesses, and higher mortality. Successful treatment, though
S3 End-organ damage
difficult to achieve, results in a significant number of benefits.”7 Significant obesity-related psychological symptoms
The definition of overweight and obesity suggested by the WHO Significant functional limitations affecting quality of life
is “abnormal or excessive fat accumulation that presents a health S4 Severe clinical involvement
risk”3; it is estimated using the body mass index (BMI) (body weight in Severe psychological involvement
Severe functional limitations
kilograms divided by the square height in meters [kg/m2]). The sug-
gested values for obesity classification are presented in Table 1.2 Source: Based on Sharma and Kushner.8
 1467789x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13683, Wiley Online Library on [16/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CAPPELLETTI ET AL. 3 of 21

survey in 11 countries on five continents, including 14,502 adults with state that achieving the maximum weight loss in the shortest possible
obesity and 2785 healthcare practitioners. Half of the individuals time is not the key to successful treatment. “Reducing waist circum-
with obesity said they did not talk to their physician about how to lose ference should be considered even more important than weight loss
weight. When looking into the reasons, the primary reason was the per se, as it is linked to a decrease in visceral fat and associated cardi-
lack of initiative from the practitioners. Healthcare providers said that ometabolic risks. Finally, preventing weight regain is the cornerstone
they believe that patients have little interest or motivation to control of lifelong treatment, for any weight loss technique used: behavioural
their weight, which may be an obstacle for discussions on weight con- or pharmaceutical treatments or bariatric surgery.”20
trol. However, 68% of people with obesity said that they would like New obesity management guidelines from different countries
their physician to start a conversation on the topic, and only 3% felt highlight the importance of avoiding the stigmatization of people liv-
insulted by such a conversation.10 ing with obesity, including the management of psychological issues,
The Argentinean Society of Nutrition (Sociedad Argentina de such as self-esteem, body image, and quality of life. These aspects
 n [SAN]) published the “SAN Position: obesity is a chronic
Nutricio should be considered together with optimizing eating patterns and
disease,” with regard to the condition “… is a chronic disease with a physical activity to reduce the imbalance of calories consumed/
very high and growing prevalence with a complex pathogenic etiology expended typical of this disease.20–23 This therapeutic approach
and results in multiple comorbidities exhibiting a high early mortality; should be complemented with adjuvant pharmacotherapy when con-
therefore, obesity is an urgent public health imperative.” Among its sidered appropriate.
proposals, it highlights the need for universal coverage, including non- According to the available literature, properly prescribed anti-
pharmacological and pharmacological strategies.11 obesity medications improve patient compliance and prevent long-
In 2020, a joint international consensus statement was published term weight regain. However, some barriers prevent their adequate
in the Nature Medicine journal to put an end to weight stigmatization. use by practitioners, probably related to the history of such drug ther-
The document involved the participation of a multidisciplinary team apy and poor knowledge of obesity as a chronic, complex, and relaps-
of international experts, including representatives of scientific organi- ing disease.24
zations, who reviewed the available evidence on the causes and dam-
age of obesity and developed recommendations to eliminate any
obesity-associated biases. “The research indicates that the weight 2 | DE VE L OPIN G LAT I N A ME RI CAN
stigmatization may result in physical and psychological harm and that GUIDELINES ON PHARMACOLOGICAL
the individuals affected have a decreased probability of receiving ade- MANAGEMENT OF OBESITY
quate care; for these reasons, this stigmatization is detrimental to
health, undermines human and social rights and is inacceptable in The Latin American Federation of Endocrinology took the initiative to
modern societies.”12 bring together Latin American experts who shared concerns about the
The challenge raised in relation to containing the global obesity need to develop guidelines for the pharmacological management of
epidemic requires a multisectoral, multidisciplinary, and relevant obesity in the region. All participants in this consensus had over
approach based on the individual culture of each specific 10 years of academic training and experience in the treatment of
population.13 overweight and obese people living with obesity; they were members
To date, political and public health measures have so far been of institutions and scientific societies in their respective countries,
insufficient to address this situation. Accordingly, continuous educa- although they did not act on behalf of these organizations. The objec-
tion of the treating or primary care physician is essential,14 as they are tive of this study was to update and provide scientific evidence-based
the first contacts of the patient with the healthcare system; hence, recommendations for the pharmacological treatment of adult patients
they are the ones who may initiate the correct approach to the dis- living with obesity with access to all levels of care and suitable for
ease. According to the consensus of the authors of this document, the inclusion in the multidisciplinary management of the disease.
approach for people living with obesity should be based on five
pillars:
2.1 | Methodology
1. healthy diet sustainable over time;
2. avoiding sedentarism; To accomplish these goals, the 10 experts embraced the following
3. reliable and safe medication; methodology:
4. long-term management and follow-up; and
5. acceptance of the frustration of “not always doing what is perfect” 1. A questionnaire with 16 questions was developed using the
in the obesogenic environment we live in. Patient, Intervention, Comparison, Outcome (Result) (PICO) meth-
odology. Once the questionnaire was completed, a pilot test was
15–22
Key international guidelines indicate that lifestyle changes to conducted with 10 specialists with the same characteristics as the
achieve a 5%–10% body weight reduction are the foundation for selected group. The result was a complete understanding of
treatment, with a view to improve comorbidities. European guidelines the document, so the original design was maintained (Appendix A).
 1467789x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13683, Wiley Online Library on [16/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 of 21 CAPPELLETTI ET AL.

2. The modified Delphi methodology was used to reach a consensus ulatory frameworks in each country. In some countries, drugs and
on a particular topic through iteration of questions. Each question pharmacological compounds may be prescribed without any regula-
was subjected to iteration; then, a consensus answer was obtained tion and may even be purchased with non-medical prescriptions. In
with 80% agreement or higher. Failure to reach a consensus led to other countries, the rules are very strict, so approval, regulations, con-
a second round of analysis with the reformulated question. trols, and monitoring differ significantly from one country to another.
3. Literature review according to evidence-based medicine (EBM): The experts participating in this consensus conducted a compre-
the EBM scale was used to classify the information into levels of hensive search on the approval and current regulations for the pre-
evidences A, B, and C (Table 3). The classes of recommendations scription of anti-obesity medications in each country. However,
were based on the American College of Cardiology Foundation/ access to information was difficult, limited, and confusing, which hin-
American Heart Association (ACCF/AHA) standards, determining dered the possibility of obtaining a list of approved drugs.
25
Classes I, II (IIa and IIb), and III (Table 4). During discussions, concerns were expressed regarding the indis-
criminate prescription of medications by physicians who were not
Consensus coordination was employed to develop the PICO question- specialists in obesity, as well as the sale of over-the-counter sub-
naire and submit it for validation. An initial literature search was con- stances with no evidence of effectiveness or safety, contrary to medi-
ducted and continued during the consensus discussion; four expert cal ethics, which jeopardizes the health of patients living with the
meetings were held in October, November, and December 2021. The disease. Hence, general practitioners and specialists are advised to
questions were iterated until the experts reached an agreement of keep themselves updated on the comprehensive therapeutic manage-
80% or higher (Figure 1). ment of this pathology, so that the patients receive the necessary
benefits from the management of their condition.
This consensus focused on analyzing the available evidence on
2.2 | Anti-obesity drugs available in Latin America the efficacy and safety of approved medications or on the process of
approval in most Latin American countries. Table 5 lists the mecha-
Notwithstanding the fact that Latin America is a region with ethnic nisms of action, indications, doses, adverse reactions, contraindica-
and cultural similarities among the 20 member countries, the availabil- tions, and warnings.26–78
ity of anti-obesity medications varied broadly, with very dissimilar reg- Obesity is associated with multiple comorbidities, which improve
with a body weight reduction of 5%–10%. The clinical comorbidities
are listed in Table 6.16,79–82
TABLE 3 Levels of evidence.

A level evidence Data derived from multiple randomized clinical

trials or meta-analyses
3 | C O N S E N S U S ST A T E M E N T
B level evidence Data derived from a randomized clinical trial or
numerous non-randomized trials
The experts participating in this consensus emphasized the impor-
C level evidence Consensus of expert opinions and/or small,
tance of comprehensive therapy management for obesity, including
retrospective trials and registries
the following:
Source: Based on Jacobs et al.25

1. healthy and enjoyable diet sustainable over time;

2. increased daily physical activity;
TABLE 4 Classes of recommendations. 3. progression to practicing aerobic and anaerobic programmed
exercise;
Recommendation
4. motivational and behavioral management of the patient and family
Class I Evidence or general agreement on the benefits, environment;
usefulness, and effectiveness of a particular
5. increasing self-control and self-esteem; and
treatment or intervention
6. avoiding stigmatization of individuals with obesity.
Class II Conflicting evidence and/or divergent opinions about
the use/efficacy of a specific therapy or intervention
Class IIa The weight of the evidence is in favor of its use and The following recommendations are based on one of the key
efficacy approaches for treating patients with obesity: pharmacological ther-
Class IIb The use or efficacy is milder according to the evidence apy. The level of evidence (LE) and grade of recommendation (R) are
or opinions indicated at the end of each consensus recommendation.
Class III The general evidence agrees that a particular treatment Based on evidence and in accordance with the current treatment
or procedure is neither useful nor effective and, in philosophy, pharmacological treatment plays a vital and complemen-
some cases, may even be detrimental
tary role in lifestyle changes and behavioral cognitive therapy for peo-
Source: Based on Jacobs et al.25 ple with obesity.
 1467789x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13683, Wiley Online Library on [16/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CAPPELLETTI ET AL. 5 of 21

FIGURE 1 Sequence of experts' participation in the

consensus.

3.1 | Indications It is a direct indicator of intra-abdominal fat and a good predictor of

cardiometabolic diseases. It also provides independent and additional
Pharmacological treatment is indicated in patients with a BMI of ≥30 information to BMI to predict morbidity and mortality93; however,
or ≥27 kg/m with at least one comorbidity when lifestyle changes
2
there are different suggestions regarding the measurement site and
are insufficient to achieve weight loss objectives or maintain those cutoff points. Specific values for waist circumference have recently
goals (LE: A; R: I).15–22,83–91 The clinical and anthropometric parame- been suggested depending on the patient's BMI category, which
83–95
ters for prescribing pharmacological therapy are (LE: A; R: I) allows for better identification of a high risk of future coronary events
(Table 7).5,13,89–95
• age; Based on the above, this consensus group suggested the follow-
• BMI; ing pharmacological treatment algorithm for people living with obesity
• waist circumference; that is always associated with lifestyle modification strategies
• body composition and adipose tissue distribution; (Figure 2).
• cardiometabolic, functional, or mental comorbidities affecting qual-
ity of life; and
• previous attempts to lose weight. 3.2 | Treatment duration

Other individual parameters to consider include Pharmacological therapy may be prescribed indefinitely if the patient
responds without any significant side effects (LE: B; R:
• patient motivation level; 16,20,85,89,99–101
IIa). Treatment may be discontinued under the follow-
• patient willingness to undergo long-term treatment; ing circumstances:16,20,85,90
• availability of medicines in each country; and
• purchasing power of patients. • lack of therapeutic response (<5% weight loss after 12 weeks with
the optimal recommended dose);
Evidence is insufficient to make a recommendation for the maximum • intolerance of active components;
age for pharmacological therapy. However, this group of experts con- • changes in clinical scenario; and
siders that medication prescriptions should be specifically individual- • women wanting to become pregnant or pregnant during therapy
16,85,93,96,97
ized after 65 years old. BMI is strongly correlated with (R: I).
total body fat mass, but it is not an accurate indicator of cardiometa-
bolic risk at the individual level.98 Short-term pharmacotherapy may be considered in special situations,
Waist circumference (measured at the end of normal expiration at for instance, bariatric surgery, to improve the patient's general condi-
the midpoint between the upper part of the iliac crest and the lower tion prior to the intervention (LE: C; R: IIa).102
17,21,92–95
margin of the last palpable rib in the mid-axillary line) is con- Once the therapeutic objective is achieved, patients should be
sidered the best anthropometric parameter to define central obesity. followed up and monitored regularly. If the weight loss is regained
 TABLE 5 Anti-obesity medications available in Latin America.
6 of 21

Drug
Central action
Short term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
26–28
Phentermine Phentermine is a ≥16 years old (up to Prescription - Frequent: Headache, - Pregnancy and lactation. - Co-administration with
sympathomimetic 12 weeks). 8 mg three times per day increased blood - Uncontrolled high blood other weight-lowering
phenylethylamine. Its Initial body mass index before meals—oral pressure/heart rate, pressure. medications is not
anorexic effect is due to (BMI) ≥ 30 kg/m2 administration. insomnia, mouth - History of cardiovascular recommended.
an increased release (obesity) or 15–37.5 mg of extended dryness, constipation, disease. - Caution in activities
mostly of noradrenaline BMI ≥ 27 kg/m2 release (ER) once a day, anxiety. - For 14 days following the requiring alertness.
in the central nervous (overweight) in the before breakfast/1–2 h - Cardiovascular: administration of - May increase seizures in
system and of dopamine presence of at least one after breakfast. Palpitations, monoaminoxidase patients with epilepsy.
and serotonin to a lesser weight-associated 18.75 mg twice a day, tachycardia, ischemic inhibitors. - Discontinue the
extent. comorbidity. before breakfast and events. - Hyperthyroidism. medication in case of
before 18:00 h - Central nervous system: - Glaucoma. intolerance.
Overstimulation, - Anxiety disorders. - In diabetic patients may
restlessness, dizziness, - History of drug abuse. lower the requirements
euphoria, dysphoria, - Known hypersensitivity for insulin or
tremors, headache, or idiosyncrasy to antidiabetic agents.
psychosis. sympathomimetic
- Gastrointestinal: amines.
Unpleasant taste,
diarrhea, constipation.
- Allergies: Urticaria.
- Endocrine: Erectile
dysfunction, changes in
libido.
Amphepramone29–31 Amphepramone or >16 years (for up to - 25 mg capsules: One - Cardiovascular: - Pregnancy and lactation. - Caution in cardiovascular
diethylpropion is a 12 weeks). capsule three times a Palpitations, - Hypersensitivity to the disease (including
sympathomimetic Initial BMI ≥ 30 kg/m2 day before each meal. tachycardia, ECG drug. arrythmias).
phenylethylamine. It (obesity) or - ER 75 mg capsules: One changes, increased - Patients with - Do not administer
stimulates the neurons BMI ≥ 27 kg/m2 capsule before blood pressure, chest idiosyncrasy to together with or less
to release and maintain (overweight) in the breakfast. pain, arrythmias sympathomimetic than 14 days after using
high levels of presence of at least one (including ventricular amines. monoaminoxidase
catecholamines weight-associated arrythmia). - Arousal, emotionally inhibitors (risk of
including dopamine and comorbidity. - Neurological: Dyskinesia, unstable individuals hypertensive crisis).
noradrenalin. blurred vision, susceptible or with a - May increase seizures in
overstimulation, history of drug or some epileptic patients.
restlessness, euphoria, alcohol abuse. - Extended use may lead
tremor, malaise, anxiety, - Patients with glaucoma, to dependency with
insomnia, dizziness, hyperthyroidism, withdrawal syndrome
depression, somnolence, advanced upon discontinuation of
mydriasis, headache. atherosclerosis or therapy.
- Gastrointestinal: Mouth severe hypertension,
dryness, nausea, severe renal disease.
vomiting, diarrhea,
CAPPELLETTI ET AL.

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 TABLE 5 (Continued)

Drug
Central action
Short term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
CAPPELLETTI ET AL.

constipation, dysgeusia,
and other functional GI
disorders.
- Allergies: Urticaria, rash,
ecchymosis, erythema.
- Endocrinological:
Impotence, changes in
libido, gynecomastia,
menstrual disorders.
- Hematological: Bone
marrow depression,
agranulocytosis,
leukopenia, dyspnea,
hair loss, myalgia,
dysuria, diaphoresis
polyuria.
DRUG
Central Action
Long Term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
Phentermine– - Topiramate is a mood ≥18 years old for long- Initial treatment dose: Phentermine - Pregnancy. - Progressively titrate the
topiramate26,32–37 stabilizer and term use. 3.75 mg of ER - Allergies: Urticaria. - Glaucoma. dose.
anticonvulsant drug. It Initial BMI ≥ 30 kg/m2 phentermine/23 mg of - Cardiovascular: - Hyperthyroidism. - Monitor heart rate and
indirectly inhibits the (obesity) or topiramate per day for Increased blood - During the 14 days blood pressure.
neurotransmission of BMI ≥ 27 kg/m2 14 days; then, 14 days pressure. following the - Avoid high doses in
orexigenic neurons (overweight) in the increased to the - Central nervous system: administration of patients with
NPY/AgRP in the presence of at least one recommended dose of Euphoria, psychosis, monoaminoxidase depression (doses of
arcuate nucleus of the weight-associated 7.5 mg/46 mg of tremors. inhibitors. 15/92 mg/day).
hypothalamus, via comorbidity. phentermine– - Reproductive: Changes - Known hypersensitivity - In case of history of
independent gamma- Adolescents: ≥12 years topiramate once a day in libido, impotence. or idiosyncrasy to seizures, taper the dose
aminobutyric acid old for long-term use in the morning with or - Ophthalmological: sympathomimetic progressively.
(GABA) signaling. with a BMI of the 95th without food intake. Glaucoma. amines. - May reduce the effect of
Its association with percentile or greater Then, the dose may be Topiramate - Severe renal failure. oral contraceptives.
phentermine when standardized for increased to 15/92 mg - Dermatological: Bullous - Psychosis. - Potentiates the effect of
potentiates the age and sex. of phentermine– skin reactions (including - Non-controlled cardiac loop diuretics with risk
anorexigenic effect, and topiramate. erythema multiforme, arrythmias. of hypokalemia.
lower doses of both Stevens-Johnson - Renal lithiasis (calcium - Potentiates the carbonic
drugs reduce the syndrome, toxic phosphate). anhydrase inhibitors,
adverse effects. epidermal necrolysis, increasing the risk of
pemphigus).

(Continues)
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 TABLE 5 (Continued)
8 of 21

DRUG
Central Action
Long Term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
- Gastrointestinal: renal lithiasis and
Pancreatitis. metabolic acidosis.
- Metabolic:
Hyperammonemia,
hypothermia.
- Ophthalmic:
Maculopathy glaucoma
dose-dependently.
Naltrexone– Naltrexone is an opioid ≥18 years of age for long- 16 mg of naltrexone and - Frequent: Nausea, - Pregnancy and lactation. - Should not be used in
bupropion26,38–44 receptor antagonist; as term use. 180 mg of oral constipation, diarrhea, - Uncontrolled association with high-
a single drug, it is Initial BMI ≥ 30 kg/m2 bupropion morning and headache, dizziness, hypertension. fat foods.
indicated for the (obesity) or afternoon (at least 8 h vomiting, insomnia, dry - Bulimia–anorexia. - Watch for any
treatment of addictions BMI ≥ 27 kg/m2 between each dose). mouth. - Epilepsy or seizures or behavioral changes or
to opiates or alcohol. (overweight) in the The initial dose is 8 mg of - Severe (require anticonvulsant therapy. suicidal ideation.
Bupropion is a presence of at least one ER naltrexone and discontinuation of - Treatment with other
noradrenalin and weight-associated 90 mg of ER bupropion treatment): Seizures, bupropion-containing
dopamine reuptake comorbidity. (1 tablet) once per day suicidal ideation or medications.
inhibitor, it has an for 1 week; the dose is injuring others, maniac - Recent abrupt
antidepressant effect, progressively increased episodes, increased BP discontinuation of
and it is also indicated weekly up to two or HR, visual problems, alcohol use.
for smoking cessation. tablets am and 2 tablets liver injury or hepatitis, - Opiates treatments,
Bupropion stimulates pm. severe allergic reaction, methadone or opiate
the hypoglycemia in withdrawal syndrome.
proopiomelanocortin patients with diabetes - Abrupt discontinuation
(POMC)-producing mellitus type 2 treated of benzodiazepines or
neurons, precursor of with sulfonylureas or anticonvulsants.
anorexigenic peptides, insulin. - MAO inhibitors
such as alpha treatment.
melanocyte-stimulating - Allergy to naltrexone or
hormone, and of β bupropion.
endorphins that activate - Treatment with CYP2B6
the μ receptor to inducers (ritonavir,
opioids, limiting lopinavir,
bupropion activity. The carbamazepine,
synergistic effect of phenobarbital).
bupropion and - Treatment with
naltrexone, which levodopa or
antagonizes the μ amantadine.
receptors, results in an - Narrow angle glaucoma.
increased anorexigenic
effect.
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 TABLE 5 (Continued)

DRUG
Central Action
CAPPELLETTI ET AL.

Long Term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
26,45–59
Liraglutide Liraglutide is a glucagon- ≥18 years old with initial 3 mg once a day - Very frequent: Nausea, - Pregnancy and lactation. - Its use is not
like peptide 1 (GLP-1) BMI ≥ 30 kg/m2 subcutaneous (pre-filled vomiting, diarrhea, - Hypersensitivity to recommended in
with 97% sequence (obesity) or pen). constipation. liraglutide or any of its association with
alignment to the BMI ≥ 27 kg/m2 The initial dose is 0.6 mg/ - Frequent: Other GI excipients. another GLP-1 receptor
endogenous GLP-1, (overweight) in the day for 1 week; it is effects, cholelithiasis, - Personal or family agonist.
which causes weight presence of at least one increased weekly by insomnia, dizziness, history of bone marrow - Pancreatitis: Suspicious
loss via reduced food weight-associated 0.6 mg until a dose of injection site reactions, or thyroid cancer or pancreatitis leads to
reduced. comorbidity, such as 3.0 mg/day for fatigue. type 2 multiple liraglutide of 3 mg
Liraglutide at a dose of high blood sugar (pre- enhanced GI endocrine neoplasms. treatment
1.8 mg is indicated for diabetes and type 2 tolerability. discontinuation; if acute
the treatment of diabetes mellitus), Liraglutide therapy should pancreatitis is
diabetes mellitus type 2. hypertension, be discontinued after confirmed, treatment
It increases satiety and dyslipidemia, or 12 weeks at a dose of should not be
reduces appetite due to obstructive sleep 3.0 mg/day if the reinitiated. Use with
its action on the arcuate apnea. patient has not lost at caution in patients with
nucleus of the - Adolescents > 12 years least 5% of the initial a history of pancreatitis.
hypothalamus. There, it old with an initial body weight. - Type 2 diabetes mellitus:
directly stimulates the BMI ≥ 30 kg/m2 Liraglutide of 3 mg
anorexigenic neurons (obesity) and body should not be used to
POMC/CART and weight over 60 kg. replace insulin. Patients
indirectly inhibits the with type 2 diabetes
neurotransmission of mellitus receiving
orexigenic neurons liraglutide of 3 mg in
NPY/AgRP via GABA- combination with
dependent signaling. insulin and/or
sulfonylurea may be at
increased risk of
hypoglycemia; the risk
may be lowered by
adjusting the insulin or
sulfonylurea dose.
- The efficacy and safety
of liraglutide of 3 mg
has not been
established in
- congestive heart failure
class IV (NYHA) and
- treatment with other
weight control agents.

(Continues)
9 of 21

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 10 of 21

TABLE 5 (Continued)

DRUG
Central Action
Long Term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
26,60–67
Semaglutide Semaglutide is a GLP-1 (≥18 years old) with initial Initial dose: 0.25 mg/ - Very frequent: Nausea, - Hypersensitivity to - Its use is not
analogue with 94% BMI ≥ 30 kg/m2 week during the 1st vomiting, diarrhea, semaglutide or to any recommended in
sequence alignment (obesity) or month; 2nd month constipation. of its excipients. combination with
with human GLP-1. It BMI ≥ 27 kg/m2 0.50 mg/week; 3rd - Frequent: Other GI - Personal or family another GLP-1 agonist
only differs in two (overweight) in the month 1 mg/week; 4th effects, cholelithiasis, history of bone marrow or DDP4 blocker.
amino acids. It has an presence of at least one month 1.7 mg/week; insomnia, dizziness, cancer, thyroid cancer, - Pancreatitis: Suspicious
18-carbon fatty acid weight-associated 5th month 2.4 mg/ injection site reactions, or multiple endocrine pancreatitis should lead
chain attached to amino comorbidity. week maintenance fatigue. neoplasms (MEN2). to discontinuation of
acid 26 of the molecule, dose. - Pregnancy and lactation. semaglutide treatment;
which provides a strong if acute pancreatitis is
albumin bond and confirmed, treatment
facilitates extended shall not be reinitiated.
activity. Use with caution in
Semaglutide at 0.5–2 mg/ patients with a history
week is indicated for of pancreatitis.
the treatment of type 2 - Diabetes mellitus type 2:
diabetes mellitus. Semaglutide should not
be used to replace
insulin. Patients with
type 2 DM receiving
semaglutide in
combination with
insulin and/or
sulfonylurea may be at
higher risk of
hypoglycemia; the risk
may be lowered by
adjusting the insulin or
sulfonylurea dose.
- The efficacy and safety
of semaglutide of 2 mg
has not been
established in
- congestive heart failure
class IV (NYHA) and
- patients treated with
other weight control
products.
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 TABLE 5 (Continued)

DRUG
Central Action
Long Term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
CAPPELLETTI ET AL.

68–73
Sibutramine Sibutramine promotes Age > 18 years old. Recommended initial - Dry mouth, insomnia, - Pregnancy and lactation. - Caution should be used
This drug was officially satiety blocking the BMI ≥ 30 kg/m2 (in Brazil, dose: 110 mg/day oral constipation, GI - Patients with a history in patients with
removed from the reuptake of it is only authorized for capsule in the morning, disorders, tremors, of coronary artery - glaucoma,
market and is only noradrenalin and patients with obesity with or without food, palpitations, anxiety, disease (angina, history - epilepsy,
approved for patients serotonin, hence for 2 years maximum). swallowed with water. headache, dizziness, of myocardial - predisposition to
with obesity in Brazil. reducing food intake. If the patient fails to lose tachycardia, infarction), congestive hemorrhage,
Therefore, it at least 2 kg over the hypertension, nausea, heart failure, - concomitant use of
underwent a second first 4 weeks, consider abdominal pain. tachycardia, peripheral medications affecting
iteration for inclusion increasing the dose to obstructive arterial hemostasis and platelet
in the Latin American 15 mg/day or disease, arrythmia, or function, and
therapy regimens. discontinue cerebrovascular disease - level of risk during
sibutramine. (stroke or TIA). pregnancy: C.
Treatment should be - Patients with
discontinued in patients uncontrolled
failing to respond to the hypertension.
15 mg/day dose (at - Patients with a history
least 2 kg in 4 weeks). or existing eating
disorders, such as
bulimia and anorexia.
- Patients receiving other
central action weight
loss medications or
medications for
psychiatric disorders.
- Patients receiving
monoaminoxidase
receptor inhibitors.
Drug
Peripheral
action
Short term Mechanism of action Indications Dosing Adverse reactions Contraindications Warnings
Orlistat26,71,74– Orlistat is a reversible gastrointestinal >12 years One 120 mg capsule three - Frequent: Oily spots, - Pregnancy, chronic - Drug interactions and reduced vitamin
78
lipase inhibitor that prevents the old times per day with each flatulence with malabsorption syndrome absorption: Orlistat may interact with
absorption of 30% of fat intake, fat-containing meal discharge. Fecal or with cholestasis; concomitant medications, such as
which is excreted in the feces. (during or up to 1 h urgency, fatty known hypersensitivity to ciclosporin, levothyroxine, warfarin,
Inhibiting fat digestion reduces the after eating). feces, increased orlistat or any of its amiodarone, anti-epileptic
formation of mixed micelles and the Patients should be advised defecation, fecal constituents; pregnancy medications, and anti-retroviral
absorption of long-chain fatty acids, to follow a nutritionally incontinence. or lactation. medications.
cholesterol, and certain liposoluble balanced diet and a - Other frequent - Liver damage: Patients should be
vitamins. reduced calorie intake, reactions: instructed to report any liver
Abdominal pain/ dysfunction symptoms (anorexia,
11 of 21

(Continues)

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12 of 21 CAPPELLETTI ET AL.

TABLE 6 Obesity-associated comorbidities.

Cardiovascular • Hypertension

upper right quadrant) while taking

Abbreviations: BP, blood pressure; CART, cocaine- and amphetamine-regulated transcript; DDP4, dipeptidyl peptidase 4; DM, diabetes mellitus; ECG, electrocardiogram; GI, gastrointestinal; HR, heart rate;
itching, jaundice, dark color urine,
light-colored feces, or pain in the
• Coronary artery disease
• Heart failure
•

- Increased urinary oxalate.

Venous insufficiency
• Dyslipidemia
Endocrine • Metabolic syndrome
• Type 2 diabetes mellitus

- Cholelithiasis.
• Dyslipidemia
• Polycystic ovary syndrome
orlistat.
Warnings

• Amenorrhea
• Infertility
• Menstrual disorders
• Vitamin D deficiency
• Thyroid cancer
Respiratory • Dyspnea
• Obstructive sleep apnea
Contraindications

• Hypoventilation syndrome
• Pickwick syndrome
• Bronchial asthma
Gastrointestinal • Gastroesophageal reflux disease
• Metabolic dysfunction-associated fatty
liver
rectal pain/malaise.
infectious diarrhea,

• Cholelithiasis
Adverse reactions
malaise, nausea,

• Hernias
• Esophageal, gastric cardia, colon and
rectum, pancreas, gallbladder, and liver
cancers
Genitourinary • Urinary incontinence
• Glomerulopathies
• Renal failure
with approximately 30%

Distribute the daily intake

•
of fats, carbohydrates,

Hypogonadism
of the calories as fat.

• Breast cancer (postmenopause), ovarian,

and proteins in the
three main meals.

endometrial, kidney, and prostate

MAO, monoamine oxidase; NYHA, New York Heart Association; TIA, transient ischemic attack.

• Pregnancy complications
Neurological • Cerebrovascular accident
• Idiopathic intracranial hypertension
Dosing

• Alzheimer's disease
• Meralgia paresthetica
Musculoskeletal • Hyperuricemia and gout
Indications

• Arthrosis—arthritis
• Degenerative arthropathy of weight-
bearing joints
• Lumbar pain
Skin, adnexal • Striae
structures, and soft • Ochre dermatitis
parts • Lymphedema
• Intertrigo
• Acanthosis nigricans and acrochordons
•
Mechanism of action

Suppurative hidradenitis
Psychological • Depression
• Body image disorders
• Eating disorders
• Poor quality of life
(Continued)

Source: Based on Garvey et al.,16 Balcázar et al.,78 Benziger et al.,79

Catenacci et al.,80 and Lauby-Secretan et al.81
Short term
Peripheral
TABLE 5

action

consider discontinuation, change of medication or association with

Drug

another drug in addition to reviewing, reinforcing, and maintaining

lifestyle changes.15,16,85,103–114
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CAPPELLETTI ET AL. 13 of 21

3.3 | Treatment success their initial weight after 12 weeks of treatment at optimal medication
doses.104
Treatment success should be defined as achievement of the following Evidence is limited, and further clinical trials are required for phar-
goals (LE: A; R: I):16,83,85 macological treatment for weight regain or insufficient weight loss
after bariatric surgery. However, it may be useful to prevent and treat
• sustained weight loss of 5%–10% over time; weight regain and increase weight loss when it becomes temporarily
• permanent lifestyle changes; stagnant using a multidisciplinary approach (LE: C; R: IIa).106–113
• improvement or prevention of comorbidities; and The following parameters are suggested for follow-up purposes
• improved quality of life. and to define treatment success:

In responders, medications improve weight loss and enhance the man- • quality of life;
agement of concomitant metabolic diseases. A responder or rapid • BMI;
responder patient is defined as a patient that loses 5% or more of • metabolic comorbidities; and
• functional comorbidities.
T A B L E 7 Cutoff points used for waist circumference in different
guidelines or studies.

Females Males 3.4 | Non-recommended therapies

European Group for the Study of Insulin ≥80 cm ≥94 cm
Resistance (EGIR, 1999) To establish which medications should not be prescribed for the treat-
III National Cholesterol Study Program ≥88 cm ≥102 cm ment of patients with obesity, experts state that the following medi-
(NCEP/ATP III, 2001–2004) cations are not considered anti-obesity and therefore should not be
International Diabetes Federation (IDF, 2005) ≥80 cm ≥90 cm prescribed for weight loss purposes (LE: B; R: III):18,83,88,90,115,116
based on ethnicity (Latin Americans)
Latin American Group for the Study of ≥90 cm ≥94 cm • thyroid hormones;
Metabolic Syndrome (GLESMO, 2011)
• human chorionic gonadotrophin;
Source: Based on Ross et al.,91 Batsis and Zagaria,92 and Aschner et al.93 • growth hormone;

F I G U R E 2 Algorithm for pharmacological therapy in obesity. BMI, body mass index; CVD, cardiovascular disease; CVR, cardiovascular risk;
DM2, diabetes mellitus type 2; HBP, high blood pressure; KD, kidney disease; NAFLD, non-alcoholic fatty liver disease; OSAS, obstructive sleep
apnea syndrome; PCOS, polycystic ovary syndrome; SEL, socioeconomic level.
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14 of 21 CAPPELLETTI ET AL.

• diuretics; T A B L E 8 Medications associated with weight gain and

• laxatives; and therapeutic options.

• drugs that have not been approved or that have been recalled. Associated Neutral medications or
disease or Drugs that increase drugs that reduce body
Furthermore, some drugs may impact weight loss; however, the loss is comorbidity body weight weight

not significant; hence, they are not approved as anti-obesity medica- Hypertension Beta-adrenergic Inhibitors of the renin-
18,83,90,115,116 blockers angiotensin system
tions. These include (LE: B; R: III)
(propranolol, Calcium blockers
metoprolol, and If beta-blockers are
• metformin; atenolol) needed, carvedilol
• topiramate onotherapy; and nebivolol are less
associated with
• bupropion monotherapy;
weight gain
• anxiolytics; and
Diabetes mellitus Insulin GLP-1 receptor
• serotonin reuptake inhibitors.
type 2 Sulfonylureas agonists
Methylglycines SGLT2 inhibitors
Additionally, considering that obesity is a chronic disease, the panel of Glitazones Pramlintide
experts does not recommend the use of drugs that are exclusively Metformin
DDP4 inhibitors
approved for short-term use (LE: A; R: III).
Alpha-glycosidase
inhibitors
Depression Monoaminoxidase Bupropion
3.5 | Contraindications inhibitors Fluoxetine (short-term
Tricyclic use)
The general contraindications for anti-obesity drugs were as follows antidepressants Sertraline (<1 year)
Mirtazapine Venlafaxine
(LE: B; R: IIa):16,20,85,114,117
Paroxetine Desvenlafaxine
Doxepin Duloxetine
• renal failure with glomerular filtration rate < 30 mL/min; Citalopram
• heart failure; Escitalopram
Fluoxetine and
• liver failure;
sertraline (long
• untreated psychosis; term)a
• pregnancy and lactation; and Epilepsy Phenobarbital Topiramate
• alcohol abuse and other drug addictions. Valproic acid Zonisamide
Carbamazepine Lamotrigine
Gabapentin Levetiracetam
Specific contraindications for each drug are listed in Table 5. Women
Pregabalin
of childbearing age are recommended to use contraceptives during
Chronic Corticosteroids Non-steroidal anti-
anti-obesity drug therapy, and these medications should be discontin-
inflammatory inflammatory drugs
ued for at least four to five half-lives before trying to become disease (NSAIDs)
pregnant. Disease-modifying
Encouraging the use of natural or nutritional supplements to antirheumatic drugs
(DMARDs)
support weight loss is a widespread practice in Latin American
Psychosis Olanzapine Aripiprazole
countries, either because the patient decides to use them or
Clozapine Ziprasidone
through medical or paramedical recommendations. The literature
Risperidone Trazodone
review conducted by the experts in this consensus led them to con- Quetiapine
clude that there is insufficient evidence to support the use of natu- Thioridazine
ral products to treat patients with obesity (LE: C; R: IIb).118–129 Haloperidol
Lithium
These are some examples:
Mirtazapine

Abbreviations: DDP4, dipeptidyl peptidase 4; GLP-1, glucagon-like

• chromium picolinate;
peptide 1; SGLT2, sodium–glucose cotransporter 2.
• Indian nut; a
Controversial evidence about the effect of these drugs on body weight.
• Garcinia cambogia; Source: Based on Apovian et al.,18 Li et al.,82 Erlandson et al.,83 Bray
• Spirulina; and et al.,129 Verhaegen and Van Gaal,130 Gafoor et al.,131 and Arterburn
• white kidney bean extract. et al.132
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CAPPELLETTI ET AL. 15 of 21

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20 of 21 CAPPELLETTI ET AL.

APP E NDIX A: BASELINE QUESTIONS FOR CONSENSUS ON PHARMACOLOGICAL TREATMENT OF OBESITY IN LATIN AMERICA

Questions

I O
Intervention, exposure, risk C Clinical outcome, what it is intended to
P factor, test, medication, Comparison to another known accomplish, morbidity, mortality,
Patient problem description treatment agent complications
1. In whom is pharmacological weight loss treatment indicated?
In what type of patient living Pharmacological treatment In contrast to non- Improved outcomes
with obesity pharmacological treatment
2. Which are the clinical parameters to consider when prescribing pharmacological treatment for obesity?
In the patient living with What clinical and paraclinical Are useful in the evolution of In follow-up and treatment success
obesity with pharmacological data the therapeutic response
treatment
3. What are the time periods (minimum and maximum) for the use of pharmacological therapy?
In patient living with obesity Duration of pharmacological Comparing to non- Offer adequate results
treatment pharmacological
prescriptions
4. Under what circumstances should treatment be discontinued?
Patient living with obesity With pharmacological treatment What adverse reactions may That require treatment discontinuation
(monotherapy or combined be experienced
therapy)
5. What is considered a therapeutic success of this treatment?
The patient living with obesity What measures for his/her Should be adopted in contrast When is it considered successful
undergoing pharmacological comprehensive approach to non-pharmacological
therapy treatment
6. What indications should be considered for the comprehensive approach of obesity?
In the patient living with In pharmacological treatment In contrast to a patient not To optimize the treatment goal
obesity receiving pharmacological
treatment
7. What is the maximum age to indicate pharmacological treatment?
In adult patient living with Pharmacological treatment In contrast with non- May be used up to what age
obesity pharmacological therapy
8. What are the pharmacological alternatives that can be prescribed?
In the adult patient living with What are the therapeutic Applicable to fulfill the goal
obesity options
9. Which drugs should be prescribed or should not be considered as anti-obesity medications?
In the patient living with What are the drugs that should Versus those approved by the Contraindications
obesity undergoing NOT be prescribed regulatory agencies
pharmacological treatment
10. What are the contraindications of anti-obesity drugs?
The patient living with obesity What are the drugs that should In contrast with those At all times
in pharmacological treatment NOT be prescribed approved by the regulatory
agencies
11. What is the level of evidence for natural products in terms of prescription, ADR, and treatment success that justify their prescription, either alone
or in combination?
In the patient living with The use of nutritional adjuvants Is there any evidence as For the treatment of obesity
obesity and/or natural products compared to medications
 1467789x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13683, Wiley Online Library on [16/04/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CAPPELLETTI ET AL. 21 of 21

I O
Intervention, exposure, risk C Clinical outcome, what it is intended to
P factor, test, medication, Comparison to another known accomplish, morbidity, mortality,
Patient problem description treatment agent complications
12. What treatment regimens are available for each drug?
The treatment success of the Drug prescription, dose In contrast with conventional Achieves an adequate weight and
patient living with obesity treatment improves quality of life
13. Is there any special indication for the management of comorbidities while the patient is receiving pharmacological treatment for obesity?
The patient with comorbidities Treatment of these Is there any difference with To maintain adequate control
comorbidities regards to treatment
considerations
14. What is the role of drugs approved for short-term use in the treatment of obesity?
Patient living with obesity Treated with pharmacological Compared with conventional Long-term effect of the intervention
options therapy
15. What is the long-term follow-up once the treatment objective is achieved?
In the patient living with Treated with pharmacological Versus conventional therapy Which are the control parameters in the
obesity options long term
16. Is pharmacological treatment indicated in post-bariatric weight regain?
In the patient living with Pharmacological therapy In contrast to patients that do Is indicated to achieve control of the
obesity relapsing after not relapse disease
bariatric surgery