Obesity Treatments

Dr Carmen Munteanu will offer you face to face consultations in the clinic and tailored follow up visits to monitor your progress, adjust lifestyle factors and medication with ongoing practical support.

As you become established on medication and an expert in managing your weight loss, the follow ups will become less frequent but nevertheless, you can feel confident that you are not alone on this journey.

You will have an initial consultation to develop together an overall weight loss management plan. This lasts between one to one and a half hours.

A plan including dietary information , physical activity goals , screening for low mood and depression , a review of your regular medication and suggestions for starting weight loss medication that is most appropriate for you.

Contrary to popular beliefs, there is no miracle diet. When it comes to obesity a simple calorie count is not enough or effective. We will discuss eating patterns, explore specific times of the day when you are most likely to overeat, triggers, how do you experience the feeling of fullness after a meal, where do you eat and much more. This will help to develop the overall management plan.

Once stabilised on the medication, I will continue to support you with follow up visits and prescriptions according to results. We can organise that the medication is delivered directly to your home address.

Like with other chronic conditions, treatment for obesity is for life.
There is no quick cure, it is likely that you may need some form of medication for life, depending on the initial body weight.

If you agree and decide to start treatment, I will be writing to your GP with the name of the medication prescribed, simply for the safety reasons: any other drugs prescribed by your doctor can be checked for interactions against the weight loss medication.

I will also recommend that you have blood tests in your practice to assess presence of any complications associated with obesity and in the long term to assess the improvement in your metabolic health with the treatment.

The available treatments for weight loss prescribed in the clinic:

Mysimba (tablets)
Orlistat (tablets)
Saxenda ( daily injections)
Wegovy ( weekly injections) - Watch out soon – the newly NICE approved Wegovy will be soon available in the clinic following its UK launch.

1. Mysimba ( Naltrexone -Bupropion)

Mysimba is a prescription-only weight loss medicine that works by reducing your appetite and cravings for foods. Mysimba is not designed to be used as a standalone treatment but should be part of a treatment plan which includes a calorie-controlled diet and exercise.

2. Saxenda (liraglutide) also known as the ( ‘skinny injection’)

Saxenda is a prescription-only, daily injection medicine used to aid weight loss. Our bodies produce a hormone called GLP-1 which helps regulate blood sugar levels following any food we eat. Saxenda works similarly to GLP-1. It also works by reducing the amount of glucagon your body produces. Glucagon is a hormone which works by inhibiting the action of insulin. As a result, it makes you feel less hungry, slows down the emptying of your stomach and makes you feel ‘fuller’ for longer

3. Orlistat ( Xenical)

Orlistat is a prescription-only medicine that comes in capsule form. It works directly in your stomach by preventing as much as 30% of the fat consumed per meal from being absorbed by your body. Reducing absorption of fat can be effective in weight loss when used in conjunction with a calorie-controlled diet and exercise.

How do I take Mysimba?

Mysimba is a prescription-only weight-loss medication containing naltrexone and bupropion. You take 1-2 tablets once or twice a day up to a maximum of 4 tablets per day.

Mysimba has two active ingredients that, although not fully understood, are thought to be complementary in the way they work.

Bupropion helps to reduce your appetite so that you do not feel as hungry and are satisfied with less food.

Naltrexone is thought to curb your food cravings which reduces your desire to eat.
The combination of these two actions works together to help you lose weight.

Although Mysimba is shown to be effective as a weight-loss treatment and was approved for use in Europe in 2015, it does not have a license for this use by the NHS in the UK so is only available on a private prescription

Your medicine should be taken as advised by our clinic.

When you take Mysimba you will gradually increase your dose over a four-week period until you reach what is called the maintenance dose. This is the dose at whichyou will continue to take Mysimba. You increase your dose as follows:

• Week 1 - ONE tablet to be taken in the MORNING
  
• Week 2 - ONE tablet to be taken in the MORNING & ONE tablet to be taken in the EVENING
  
• Week 3 - TWO tablets to be taken in the MORNING & ONE to be taken in the EVENING
  
• Week 4 - TWO tablets to be taken in the MORNING & TWO tablets to be taken in the EVENING
• Maintenance Dose – Same as week 4
  

You should swallow your tablets whole with plenty of water, with or immediately after food. They are a prolonged-release formulation, so you must never crush, chew or cut the tablets as this will affect the rate at which the active ingredients are released into your body.
The maximum recommended dosage of Mysimba is two tablets twice a day. If you do not lose at least 5% of your body weight after 16 weeks of treatment, we will evaluate if you should continue taking Mysimba.

Always take this medication exactly as your doctor tells you to.

Mysimba®
18 mg/90 mg
prolonged-release tablets
naltrexone hydrochloride / bupropion hydrochloride
Oral use
112 tablets

What information do we need to know about you?

Mysimba cannot be used if:

• you are pregnant, trying to become pregnant or are breastfeeding
  
• you are under 18 or over 75 years old
  
• you have any allergies to any of the ingredients in Mysimba or are taking any medicines that contain any of the active ingredients in Mysimba
• you have severe liver disease, end-stage renal disease, uncontrolled hypertension, history of seizures or fits, CNS tumour, opioid dependence, acute alcohol, opioid or benzodiazepine withdrawal, history of bipolar disorder, bulimia or anorexia nervosa
  
• you are taking monoamine oxidase inhibitors (MOI) – you must have at least a 14-day gap from stopping your MOI before starting Mysimba
  

you are taking any opiates or opiate-containing medicines (i.e. morphine, codeine, cough mixtures containing dextromethorphan, methadone) – you must have at least a 7-10-day gap before starting Mysimba

Mysimba should be used in caution if:

• you are aged 65-75 years
• you have liver or kidney problems
  
• you have depression, suicidal thoughts or any other mental health condition
  
• you have diabetes, high blood pressure or heart disease, have had a serious head injury, regularly drink alcohol or use sedatives, you have any drug addictions
  
• you are taking any medicine that may increase the risk of fits or seizures
  

You must tell us about all the medications that you are taking including those that are prescribed, bought over the counter and also herbal remedies and supplements as they may interact with Mysimba and you will need to be monitored for side effects

What are the possible side effects of taking Mysimba?

As with all medication, Mysimba can be associated with unwanted side effects. Although generally mild some of these can be more severe which may result in the treatment being discontinued.

Very common side effects (may affect more than 1 in 10 people):

1. Insomnia
2. Anxiety & agitation
3. Headache
4. Feeling restless
5. Abdominal pain & constipation
6. Nausea & vomiting
7. Joint & muscular pain
Common side effects (may affect up to 1 in 10 people):
1. Hypersensitivity reactions (e.g. rash, itch)
2. Reduction in lymphocyte cells count
3. Depression, irritability & increased energy
4. Dizziness, vertigo & tinnitus
5. Tremor
6. Headache
7. Tiredness, difficulty concentrating & lack of energy
8. Watery eyes
9. Palpitations, hot flushes & excessive sweating
10. Chest pain
11. Decreased appetite, diarrhoea
12. Taste disturbances, dry mouth & toothache
13. Delayed ejaculation
14. Fever & chills
15. Hair loss

Uncommon side effects (may affect up to 1 in 100 people):

• Cold sores
  
• Athlete’s foot
  
• Swollen glands in the neck, armpit or groin
  
• Excessive loss of body waterj dehydration
  
• Loss of appetite
  
• Increased appetite & weight gain
  
• Abnormal dreams, nightmares
  
• Flushing
  
• Feeling nervous, feeling spacey, tension, agitation, mood swings, hallucinations, confusion, severe suspiciousness (paranoia), disorientation
  
• Loss of sexual desire
  
• Tremor of the head or a limb which increases when trying to perform a particular function
  
• Balance disorder
  
• Loss of memory, mental impairment
  
• Almost fainting
  
• Motion sickness
  
• Ear pain, ear discomfort
  
• Visual disturbances, blurred vision, eye irritation, pain or swelling, increased sensitivity to light
  
• Nasal discomfort, congestion, runny nose, sneezing, sinus disorder
  
• Sore throat, increase in mucus that is coughed up, difficulty in breathing, disorder of the voice, cough, yawning
  
• Fluctuating or increased blood pressure
  
• Pain in the lower part of the abdomen
  
• Burping
  
• Swelling of the lips
  
• Passage of fresh blood through the anus usually in or with stool
  
• Hernia
  
• Passing wind (flatulence), haemorrhoids, ulcer, cavities
  
• Inflammation of the gallbladder
  
• A problem with the spine where supporting disc between two bones (vertebra) bulges out
  
• Jaw & groin pain
  
• A disorder characterised by a sudden compelling urge to urinate, abnormally frequent urination, painful urination
  
• Irregular menstrual cycle, vaginal bleeding, dryness of the female vulva & vagina
  
• Difficulty in getting or keeping an erection
  
• Feeling abnormal or weakness
  
• Thirst, feeling hot
  
• Coldness of extremities (hands, feet)
  
• Increased creatinine levels in the blood (indicating loss of kidney function)
  
• Increased liver enzymes and bilirubin levels, liver disorders, hepatitis
  
• Decreased haematocrit (indicating loss of red blood cell volume)
  
• Acne, oily skin
  

There are further rare and very rare side effects that occasionally people can experience when taking Mysimba, for complete details about all side effects always read the Patient Information Leaflet.

How to take Saxenda :

Saxenda comes in a 3ml pre-filled weight loss injection pen. The pen contains a clear and colourless or almost colourless solution.

All weight loss pens are supplied with the right quantity of needles you require for injecting. You will need to store your Saxenda pre-filled pen in a refrigerator (2°C to 8°C) before your first use. Once you start using the pen, you can keep it for 1 month either at room temperature (2 to 30°C) or in a refrigerator (2°C to 8°C). Do not freeze.

When you take Saxenda you need to gradually increase your dose in 0.6mg intervals, until you reach what is called the maintenance dose at 3mg daily. This is the dose at which you will continue to take Saxenda. You increase your dose as follows:

• Week 1 – 0.6mg as a once-daily injection
  
• Week 2 – 1.2mg as a once-daily injection
  
• Week 3 – 1.8mg as a once-daily injection
  
• Week 4 – 2.4mg as a once-daily injection
  
• Week 5 onwards – maintenance dose of 3.0mg as a once-daily injection
  

Increasing the dose slowly over time should minimise any unwanted side effects, such as nausea, vomiting and diarrhoea. As you increase your dose, if you find that you cannot tolerate your side effects, you should stay on the same dose for 2 continuous weeks. If after 2 weeks your side effects are still not tolerable, you should consider stopping treatment.
The maximum recommended daily dosage of saxenda is 3.0mg. Try to take it at the same time each day, picking a time that works for you, with or without food or drink.

You must continue with your new diet and exercise regime while you are taking Saxenda.
Always use Saxenda exactly how your prescriber has told you. Check with your doctor, pharmacist or nurse if you are unsure.

When you first start Saxenda, a single pen will last 17 days and the first full pack of five pens will last six weeks. Once you have achieved the maintenance dose, a pack of five pens will last 30 days.

How do I administer my Saxenda injection?

Saxenda is a self-administered subcutaneous injection that you inject under your skin. The best sites for injecting are the front of your waist (abdomen), the front of your thigh or the upper arm. You must take extra care not to inject into a vein or muscle.
If you accidentally use more Saxenda than you should, you must talk to a doctor or go to a hospital straight away. You may experience nausea or vomiting and may require medical treatment.

If you forget a dose, you can inject it as soon as you remember, as long as it is within 12 hours from when you usually take your dose. However, if more than 12 hours have passed since you should have used Saxenda, miss the dose and inject your next dose the following day at the usual time. Never use a double dose or increase the dose on the following day to make up for the missed dose. If there has been more than 72 hours (three days) between doses, you should return to the 0.6mg starting dose and work through the doses as you did when you first started treatment.

You cannot use Saxenda if you:

• are pregnant, breastfeeding or planning to become pregnant
  
• have any known allergies to any of the ingredients in Saxenda
  
• are under 18 years old or over 75 years old
  
• have diabetes and are taking other medicines that contain GLP-1 (such as exenatide or lixisenatide) or have issues with hypoglycaemia (low blood sugar)
  
• have severe heart failure
  
• have liver or severe kidney disease or are on dialysis
  
• have severe stomach or gut problems such as gastroparesis (delayed stomach emptying) or inflammatory bowel disease
  

If you have any of the following conditions you will need to speak with the doctor as Saxenda may not be appropriate for you:

• Diabetes
  
• Diseases of the pancreas
  
• Inflamed gall bladder or gallstones
  
• Thyroid diseases including thyroid nodules and enlargement of the thyroid gland
  
• Heart palpitations or a racing heart
  
• Mild to moderate liver or kidney disease
  
• A condition that requires you to take anticoagulants such as warfarin

You can expect to lose a minimum of 5% of your initial body weight after completing 12 weeks of treatment at 3.0mg liraglutide daily. If you have not lost 5% of your initial body weight after 12 weeks at 3.0mg, then treatment should be discontinued at this stage.

How long does a Saxenda pen last?

Saxenda comes in a 3ml pre-filled injection pen. When you first start Saxenda, a single pen will last 17 days and the first full pack of five pens will last six weeks.

Titration phase
1 pen= 17 days
5 pens = 6 weeks
At week 5 you reach the 3 mg/ day dose
At 3 my dose, one pen will last 6 days and therefore
6 pens = 30 days ( 1 month )

Where do I inject Saxenda?

Inject your dose under the skin (this is called a subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm. Do not inject into a vein or muscle. Saxenda is self-injectable in the upper arm, abdomen, or thigh.
What time of the day should I use my Saxenda medication?
Saxenda can be taken at any time of the day at a time that is convenient for you. For the best results stick to the same time each day.

Will I experience side effects using Saxenda?

All medication will have the potential of side effects and Saxenda is no different.
Nausea is the most common side effect experienced at the start of treatment. This will normally reduce in most cases as your body becomes used to the medication. You may experience an increase in side effects when you increase the dose, these should settle within a few days. There are some self-help tips you can try if you do suffer from nausea.

• Eat bland, low-fat foods, like cracker toast and rice
  
• Eat foods that contain water, like soups and gelatin
  
• Don't lie down after you eat
  
• Go outside to get some fresh air
  

The patient information leaflet sent with the treatment and a copy of this leaflet can be found here :https://www.medicines.org.uk/emc/files/pil.2313.pdf and also on www.saxenda.co.uk

How is Saxenda stored?

All new and unused Saxenda pens should be stored in a refrigerator between 2°C and 8°C. After first use, store in a refrigerator or at room temperature between 15°C and 30°C. Pens in use should be thrown away after 30 days even if they still have Saxenda left in them. Don’t freeze Saxenda. Saxenda that has been frozen must not be used.

Can I take my Saxenda medication abroad?

Yes you can. Always carry medicines in their original, correctly labelled packages. Carry your medicine in your hand luggage (although check your airline's regulations before travelling) with a copy of your prescription.

How do I take Xenical/Orlistat

Orlistat/Xenical is a prescription-only weight-loss medication. The usual dose is one 120mg capsule taken with each of your three main meals per day. It works by reducing the absorption of fat from your diet.

Orlistat/Xenical is approved to help you lose weight in conjunction with an active lifestyle and a calorie-controlled balanced diet.

The medication is available as the branded Xenical or generically as Orlistat; both medicines contain 120mg of Orlistat. Xenical/Orlistat is a prescription-only medication that works in your stomach by preventing digestion of about a third of the fat you eat in each meal. It does this by attaching itself to the enzymes that usually breakdown fat. Any undigested fat is passed through your system when you go to the toilet. It does not affect the hormonal balance of your brain or affect the way you think about food.
When combined with a healthy diet and exercise you could lose around 1kg (2lb) more for every 2kg (4lb) you lose from dieting alone.

If you miss a meal or have a meal that has zero fat in it, you do not need to take your dose of Xenical/Orlistat as it only works in the presence of fat in your diet.
We will discontinue the treatment with Xenical/Orlistat after 12 weeks if you have not lost at least 5 % of your body weight as measured at the start of treatment. .
You must take a daily multivitamin supplement alongside Xenical/Orlistat. Some of the vitamins and minerals that your body needs to function are fat-soluble, so if you do not digest all the fat in your diet you may become deficient.

What are the possible side effects of taking Xenical/Orlistat?

As with all medicines, Xenical/Orlistat can cause some side effects, although not everyone will experience these. You may notice changes to your bowel movements due to increased levels of fat passing through your digestive system. These changes are quite normal, often mild and usually occur in the first few weeks of starting Xenical/Orlistat. Typical symptoms can include increased flatulence (wind), an increase in the number of bowel movements with the potential for an oily discharge. If you eat meals that contain a higher level of fat than the recommended 30%, you may experience problems in controlling bowel movements. Over time these symptoms may reduce or disappear, especially if you keep to the recommended diet advice.
Always tell a doctor or pharmacist as soon as possible if you do not feel well while you are taking Xenical/Orlistat.

Very common side effects (affects more than 1 user in 10)

• Headache
  
• Abdominal pain or discomfort
  
• Urgent or increased need to open the bowels
  
• Flatulence (wind) with discharge
  
• Oily discharge, oily or fatty stools
• Liquid stools
  
• Low blood sugar levels (experienced by some people with type 2 diabetes)
  
• Upper respiratory infections
  
• Flu (influenza)
  

Common side effects (affects 1 to 10 users in 100)

• Rectal pain or discomfort
  
• Soft stools
  
• Incontinence (stools)
  
• Bloating (experienced by some people with type 2 diabetes)
  
• Tooth or gum disorders
  
• Irregularity of menstrual cycle
  
• Tiredness
  
• Anxiety
  
• Lower respiratory infections
  
• Urinary tract infections
  

The following side effects have also been reported but their frequency cannot be estimated from the available data:

• Allergic reactions. The main symptoms are itching, rash, wheals (slightly elevated, itchy skin patches that are paler or redder than surrounding skin), severe difficulty in breathing, nausea, vomiting and feeling unwell
  
• Skin blistering (including blisters that burst)
  
• Diverticulitis
  
• Bleeding from the back passage (rectum)
  
• Increases in the levels of some liver enzymes may be found in blood tests
  
• Hepatitis (inflammation of the liver). Symptoms can include yellowing skin and eyes, itching, dark coloured urine, stomach pain and liver tenderness (indicated by pain under the front of the rib cage on your right-hand side), sometimes with loss of appetite. Stop Xenical/Orlistat if such symptoms occur and tell your doctor
  
• Gallstones
  
• Pancreatitis (inflammation of the pancreas)
  
• Oxalate nephropathy (build-up of calcium oxalate which may lead to kidney stones)
  Xenical/Orlistat can also affect other medications that you are taking such as anticoagulants. Always tell the doctor about all your medicines and read the patient information leaflet fully before you start taking Xenical/Orlistat.
  

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