Efficacy of Add-On Topiramate Therapy in Psychiatric Patients with Weight Gain

Medication-induced weight gain and advanced therapies for the child with overweight and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details medication-induced weight gain and advanced therapies for the child with overweight or obesity.

Methods

The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement addresses medication-induced weight gain and advanced therapies for the child with overweight or obesity.

Conclusions

This OMA Clinical Practice Statement on medication induced-weight gain and advanced therapies for the child with overweight or obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations. This section is designed to help the provider with clinical decision making.

The use of anti-obesity medications in people with mental illness as an adjunct to lifestyle interventions - Effectiveness, tolerability and impact on eating behaviours: A 52-week observational study

OBJECTIVE

The increasing prevalence of obesity and metabolic syndrome in people with mental illness (MI) is a global health priority. Anti-obesity medications (AOMs) may help with reducing medication induced hunger and weight gain when lifestyle changes are insufficient. Our aim is to evaluate the effectiveness, tolerability, impact on eating behaviours and psychiatric safety of AOMs in this population.

METHODS

We conducted an observational study of 244 adults with MI with at least two risk factors for metabolic syndrome attending an obesity management clinic. Participants received standardised diet, exercise and psychological care, in addition to AOMs tailored to each participant's circumstances. Baseline and 12-month assessments encompassing physical, metabolic and psychological parameters were compared.

RESULTS

Over the course of the study, the average weight loss was 11.79 kg (12.1%), decrease in BMI was 3.90 kg/m² and reduction in waist circumference was 12.6 cm. Participants with good glycaemic control increased from 28.6% to 80.7%, hypercholesterolaemia reduced from 85.2%-29.9% and hypertension rates reduced from 88.9%-52.0%. Depression, anxiety and stress levels for the sample decreased significantly (all p < .01). Eating behaviours improved (all p < .001) at follow-up. Psychiatric side effects including deterioration of mood (28.2%) and suicidality (30.8%) were primarily experienced by those on topiramate.

CONCLUSIONS

AOMs can be effective in achieving clinically meaningful weight loss, improved metabolic co-morbidities and eating behaviours in people living with MI, when combined with a comprehensive lifestyle program. The majority of AOMs are well tolerated but topiramate appears more likely to negatively impact mental health.

Efficacy and safety of adjunctive topiramate for schizophrenia: a meta-analysis of randomized controlled trials

OBJECTIVE

To systematically examine the randomized controlled trial (RCT) evidence regarding efficacy and tolerability of topiramate cotreatment with antipsychotics in schizophrenia-spectrum disorders.

METHODS

Random-effects meta-analysis of RCTs of topiramate cotreatment with antipsychotics vs. placebo/ongoing antipsychotic treatment in schizophrenia-spectrum disorders. Standardized or weighted mean difference (SMD/WMD), risk ratio (RR) ±95% confidence intervals (CIs), and number needed to harm (NNH) were calculated.

RESULTS

Across 16 RCTs (n = 934, duration = 11.8 ± 5.6 weeks), topiramate outperformed the comparator regarding change/endpoint of total (SMD: -0.58, 95% CI: -0.82, -0.35, P < 0.00001), positive (SMD: -0.37, 95% CI: -0.61, -0.14, P = 0.002), negative (SMD: -0.58, 95% CI: -0.87, -0.29, P < 0.0001), and general symptoms (SMD: -0.68, 95% CI: -0.95, -0.40, P < 0.00001). Furthermore, topiramate was superior regarding body weight (WMD: -2.75 kg, 95% CI: -4.03, -1.47, P < 0.0001), body mass index (BMI) (WMD: -1.77, 95% CI: -2.38, -1.15, P < 0.00001), triglycerides (P = 0.006), and insulin levels (P < 0.00001). Superiority regarding psychopathology and body weight/BMI was consistent across Chinese/Asian and Western RCTs, double-blind and open designs, clozapine and non-clozapine cotreatment, augmentation and co-initiation RCTs, and higher and lower quality RCTs. In meta-regression analyses, topiramate's efficacy for total symptoms was moderated by shorter illness duration (P = 0.047), while weight loss was greater in prevention/co-initiation vs. intervention/augmentation RCTs (-4.11 kg, 95% CI: -6.70, -1.52 vs. -1.41 kg, 95% CI: -2.23, -0.59, P < 0.001). All-cause discontinuation was similar between topiramate and comparators (RR: 1.28, 95% CI: 0.91, 1.81, P = 0.16). While topiramate led to more concentration/attention difficulties (P = 0.03, NNH = 8, 95% CI=4-25), psychomotor slowing (P = 0.02, NNH = 7, 95% CI = 4-25), and paresthesia (P = 0.05, NNH = 2, 95% CI = 4-33), it led to less ≥7% weight gain (P = 0.0001, NNH = 2, 95% CI = 2-3) and constipation (P = 0.04, NNH = 9, 95% CI = 5-100) than the comparator.

CONCLUSIONS

These results indicate that adjunctive topiramate to antipsychotics is an effective and safe treatment choice for symptomatic improvement and weight reduction in patients with schizophrenia-spectrum disorders.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

What are the risks and the benefits of current and emerging weight-loss medications?

Obesity is epidemic; new medications and therapeutic options are urgently needed to reduce the associated health care burden. The initial clinical strategy for weight loss is lifestyle modification involving a combination of diet, exercise, and behavior change. However, it is difficult for many to achieve and maintain weight loss solely through this approach. Only two drugs, orlistat and sibutramine, have been approved by the US Food and Drug Administration (FDA) to treat obesity long term, and both medications have undesirable side effects, leaving an enormous unmet need for efficacious and safe therapy for obesity. Other medications with weight-loss effects have been approved by the FDA for short-term treatment of obesity or for disorders other than obesity, but these also have potential adverse effects. This article discusses the perceived benefits and risks of these approved medications along with emerging drugs that have shown weight-loss effects.