Obesity medications: what does the future look like?

Multi-Target Drugs Against Metabolic Disorders

BACKGROUND

Metabolic disorders are a major cause of illness and death worldwide. Metabolism is the process by which the body makes energy from proteins, carbohydrates, and fats; chemically breaking these down in the digestive system towards sugars and acids which constitute the human body's fuel for immediate use, or to store in body tissues, such as the liver, muscles, and body fat.

OBJECTIVE

The efficiency of treatments for multifactor diseases has not been proved. It is accepted that to manage multifactor diseases, simultaneous modulation of multiple targets is required leading to the development of new strategies for discovery and development of drugs against metabolic disorders.

METHODS

In silico studies are increasingly being applied by researchers due to reductions in time and costs for new prototype synthesis; obtaining substances that present better therapeutic profiles.

DISCUSSION

In the present work, in addition to discussing multi-target drug discovery and the contributions of in silico studies to rational bioactive planning against metabolic disorders such as diabetes and obesity, we review various in silico study contributions to the fight against human metabolic pathologies.

CONCLUSION

In this review, we have presented various studies involved in the treatment of metabolic disorders; attempting to obtain hybrid molecules with pharmacological activity against various targets and expanding biological activity by using different mechanisms of action to treat a single pathology.

Anti-obesity activity of OBEX is regulated by activation of thermogenesis and decreasing adiposity gain

The incidence of obesity has been increasing dramatically worldwide over the past decades, thus requiring novel and effective therapeutic approaches. OBEX is an oral nutritional supplement composed of antioxidants with antiobesity activity. The effects of OBEX have been tested in vivo and in vitro. In vivo, OBEX reduces weight gain by decreasing adiposity gain and increasing energy expenditure in high fat diet-fed mice through the activation of thermogenesis in brown adipose tissue (BAT) independent of eating behaviors. In vitro analysis with 3T3-F442A cells revealed anti-proliferative and anti-differentiation effects of OBEX. In addition, OBEX induced a clear reduction of the lipid load in mature adipocytes obtained from 3T3-F442A cells. Overall, our findings suggest that OBEX has a protective effect against an obesogenic environment.

Transient receptor potential (TRP) channels: a metabolic TR(i)P to obesity prevention and therapy

Cellular transport of ions, especially by ion channels, regulates physiological function. The transient receptor potential (TRP) channels, with 30 identified so far, are cation channels with high calcium permeability. These ion channels are present in metabolically active tissues including adipose tissue, liver, gastrointestinal tract, brain (hypothalamus), pancreas and skeletal muscle, which suggests a potential role in metabolic disorders including obesity. TRP channels have potentially important roles in adipogenesis, obesity development and its prevention and therapy because of their physiological properties including calcium permeability, thermosensation and taste perception, involvement in cell metabolic signalling and hormone release. This wide range of actions means that organ-specific actions are unlikely, thus increasing the possibility of adverse effects. Delineation of responses to TRP channels has been limited by the poor selectivity of available agonists and antagonists. Food constituents that can modulate TRP channels are of interest in controlling metabolic status. TRP vanilloid 1 channels modulated by capsaicin have been the most studied, suggesting that this may be the first target for effective pharmacological modulation in obesity. This review shows that most of the TRP channels are potential targets to reduce metabolic disorders through a range of mechanisms.

The combination of obesity and hypertension: a highly unfavorable phenotype requiring attention

PURPOSE OF REVIEW

Body habitus is a key lifestyle characteristic whose current status and future projections are disconcerting. The percentage of the global population who are either overweight or obese has substantially increased, with no indication that any country has a solution to this issue. Hypertension is a key unfavorable health metric that, like obesity, has disastrous health implications if left uncontrolled. Poor lifestyle characteristics and health metrics often cluster together to create complex and difficult to treat phenotypes. Excess body mass is such an example, creating an obesity-hypertension phenotype, which is the focus of this review.

RECENT FINDINGS

An increased risk for hypertension is clearly linked to obesity, indicating that the two conditions are intimately linked. The cascade of obesity-induced pathophysiologic adaptations creates a clear path to hypertension. Adopting a healthy lifestyle is a primary intervention for the prevention as well as treatment of the obesity-hypertension phenotype.

SUMMARY

The obesity-hypertension phenotype is highly prevalent and has disastrous health implications. A primordial prevention strategy, focused on lifelong healthy lifestyle patterns, is the optimal approach for this condition. For those individuals already afflicted by the obesity-hypertension phenotype, interventions must aggressively focus on weight loss and blood pressure control.

US health policy and prescription drug coverage of FDA-approved medications for the treatment of obesity

OBJECTIVE

Obesity is now the most prevalent chronic disease in the United States, which amounts to an estimated $147 billion in health care spending annually. The Affordable Care Act (ACA) enacted in 2010 included provisions for private and public health insurance plans that expanded coverage for lifestyle/behavior modification and bariatric surgery for the treatment of obesity. Pharmacotherapy, however, has not been included despite their evidence-based efficacy. We set out to investigate the coverage of Food and Drug Administration-approved medications for obesity within Medicare, Medicaid and ACA-established marketplace health insurance plans.

METHODS

We examined coverage for phentermine, diethylpropion, phendimetrazine, Benzphentamine, Lorcaserin, Phentermine/Topiramate (Qysmia), Liraglutide (Saxenda) and Buproprion/Naltrexone (Contrave) among Medicare, Medicaid and marketplace insurance plans in 34 states.

RESULTS

Among 136 marketplace health insurance plans, 11% had some coverage for the specified drugs in only nine states. Medicare policy strictly excludes drug therapy for obesity. Only seven state Medicaid programs have drug coverage.

CONCLUSIONS

Obesity requires an integrated approach to combat its public health threat. Broader coverage of pharmacotherapy can make a significant contribution to fighting this complex and chronic disease.

Pharmacotherapy for Patients with Obesity

BACKGROUND

Although pharmacotherapy is not the cornerstone of obesity treatment, it is a valuable tool that could be considered for patients who have not had adequate benefit from lifestyle interventions or who have difficulty maintaining initial weight loss over longer periods.

CONTENT

This review focuses on the role of antiobesity drugs, the mechanisms by which the drugs work, potential pharmacological targets in the neural control of food intake and regulation of body weight, the history of antiobesity drugs, a summary of efficacy and safety data from clinical trials, and the clinical application of pharmacotherapy. Currently, 5 approved drug therapies are available in the US for long-term weight management, with only 2 of these meeting the stronger Food and Drug Administration (FDA) criteria of 5% weight loss relative to a placebo after 1 year and others receiving approval based on the categorical criterion of the proportions of patients achieving 5% weight loss. Interpretation of the results of clinical trials conducted before regulatory agency approval is limited by high dropout rates; thus, the results might not be replicable in clinical practice settings. Many patients who are suitable candidates for pharmacotherapy are not using the new drugs due to lack of insurance coverage and high out-of-pocket costs.

SUMMARY

With the availability of 4 new drugs since 2012, clinicians in the US now have more tools for long-term weight management. The quality of pharmacotherapy clinical investigations needs considerable improvement. Future research should focus on examining the mediators and moderators of response.

Bombesin receptor subtype-3-expressing neurons regulate energy homeostasis through a novel neuronal pathway in the hypothalamus

OBJECTIVES

Bombesin receptor subtype-3 (BRS-3) has been suggested to play a potential role in energy homeostasis. However, the physiological mechanism of BRS-3 on energy homeostasis remains unknown. Thus, we investigated the BRS-3-mediated neuronal pathway involved in food intake and energy expenditure.

MATERIALS AND METHODS

Expression of BRS-3 in the rat brain was histologically examined. The BRS-3 neurons activated by refeeding-induced satiety or a BRS-3 agonist were identified by c-Fos immunostaining. We also analyzed expression changes in feeding-relating peptides in the brain of fasted rats administered with the BRS-3 agonist.

RESULTS

In the paraventricular hypothalamic nucleus (PVH), dorsomedial hypothalamic nucleus (DMH), and medial preoptic area (MPA), strong c-Fos induction was observed in the BRS-3 neurons especially in PVH after refeeding. However, the BRS-3 neurons in the PVH did not express feeding-regulating peptides, while the BRS-3 agonist administration induced c-Fos expression in the DMH and MPA, which were not refeeding-sensitive, as well as in the PVH. The BRS-3 agonist administration changed the Pomc and Cart mRNA level in several brain regions of fasted rats.

CONCLUSION

These results suggest that BRS-3 neurons in the PVH are a novel functional subdivision in the PVH that regulates feeding behavior. As the MPA and DMH are reportedly involved in thermoregulation and energy metabolism, the BRS-3 neurons in the MPA/DMH might mediate the energy expenditure control. POMC and CART may contribute to BRS-3 neuron-mediated energy homeostasis regulation. In summary, BRS-3-expressing neurons could regulate energy homeostasis through a novel neuronal pathway.

The burden of obesity in the current world and the new treatments available: focus on liraglutide 3.0 mg

The prevalence of obesity increases worldwide. Treating obesity and its associated health problems has a significant economic impact on health care systems. The unsatisfactory long-term outcomes observed in the obesity treatment are due to its complex pathophysiology and the inherent difficulties associated with maintenance of lifestyle modifications. Determined by genetic and environmental factors, obesity has been officially recognized as a chronic disease, an action that allowed the recognition of anti-obesity drugs as legitimate therapeutic options to address the growing obesity endemic. Like other chronic diseases, obesity requires long-term treatment. Pharmacological interventions, when used as an adjunct to lifestyle changes, are useful to facilitate clinically meaningful weight loss, which may impact on obesity-associated comorbid conditions. In the past, medications for weight reduction were limited. However, the landscape has changed and new drugs provide additional options for weight management. Among the new drugs, liraglutide is the most studied, especially regarding its effects on the limbic system. As an adjunct to a reduced-calorie diet and increased physical activity, treatment with liraglutide 3.0 mg provides a statistically significant and clinically meaningful weight loss. Liraglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist that shares 97% homology to native GLP-1. Receptor agonists of GLP-1, including liraglutide, have emerged as effective therapies for type 2 diabetes and obesity. This review will address the major findings concerning the central regulation of appetite and the main studies that evaluated new drugs for obesity treatment, with a greater focus on liraglutide 3.0 mg.

Daesiho-Tang Is an Effective Herbal Formulation in Attenuation of Obesity in Mice through Alteration of Gene Expression and Modulation of Intestinal Microbiota

Background

Obesity has become a major global health challenge due to its increasing prevalence, and the associated health risk. It is the main cause of various metabolic diseases including diabetes, hypertension, cardiovascular disease, stroke and certain forms of cancer.

Methods and Results

In the present study we evaluated the anti-obesity property of Daesiho-tang (DSHT), an herbal medicine, using high fat diet (HFD)-induced obese mice as a model. Our results showed that DSHT ameliorated body weight gain, decreased total body fat, regulated expression of leptin and adiponectin genes of adipose tissue and exerted an anti-diabetic effect by attenuating fasting glucose level and serum insulin level in HFD-fed animals. In addition, DSHT-treatment significantly reduced total cholesterol (TC), triglycerides (TG) and increased high density lipoprotein-cholesterol (HDL), glutamic pyruvic transaminase (GPT) and glutamic oxaloacetic transaminase (GOT) levels in serum and reduced deposition of fat droplets in liver. DSHT treatment resulted in significantly increased relative abundance of bacteria including Bacteroidetes, Bacteroidetes/Firmicutes ratio, Akkermansia Bifidobacterium., Lactobacillus, and decreased the level of Firmicutes. Using RT2 profiler PCR array, 39 (46%) genes were found to be differentially expressed in HFD-fed mice compared to normal control. However, normal gene expressions were restored in 36 (92%) genes of HFD-fed mice, when co-exposed to DSHT.

Conclusion/Major Findings

The results of this study demonstrated that DSHT is an effective herbal formulation in attenuation of obesity in HFD-fed mice through alteration of gene expressions and modulation of intestinal microbiota.

The Fto Gene Regulates the Proliferation and Differentiation of Pre-Adipocytes in Vitro

The highly regulated differentiation and proliferation of pre-adipocytes play a key role in the initiation of obesity. Fat mass and obesity associated (FTO) is a novel gene strongly associated with the risk of obesity. A deficiency of FTO may cause growth retardation in addition to fat mass and adipocyte size reduction in vivo. To investigate the potential role of Fto gene on the proliferation and differentiation of pre-adipocytes, we generated Fto-knockdown and overexpressed 3T3-L1 cells. Using numerous proliferation assays our results suggest that Fto knockdown leads to suppression of proliferation, lower mitochondrial membrane potential, less cellular ATP, and decreased and smaller intracellular lipid droplets compared with controls (p < 0.05). Western blot analysis demonstrated that Fto knockdown can significantly suppress peroxisome proliferator-activated receptor gamma (PPARγ) and glucose transporter type 4 (GLUT4) expression and inhibit Akt phosphorylation. By contrast, overexpression of Fto had the opposing effect on proliferation, mitochondrial membrane potential, ATP generation, in vitro differentiation, Akt phosphorylation, and PPARγ and GLUT4 expression. Moreover, we demonstrated that Wortmannin, a phosphoinositide 3-kinase (PI3K) inhibitor, could inhibit phospho-Akt in Fto overexpressed 3T3-L1 cells. Taken together, the results suggest that Fto regulates the proliferation and differentiation of 3T3-L1 cells via multiple mechanisms, including PPARγ and PI3K/Akt signaling.