Table 1.

Step-by-Step Guide for Utilization of Weight Loss Medications After Bariatric Surgery

Step 1. Ascertain whether there is anatomic reason for weight regain with a thorough history and physical and upper GI study (if needed).

Step 2. If there is no anatomic reason for inadequate weight loss or weight regain, ensure that lifestyle factors (diet quality, physical activity, sleep, and stress level) have been optimized.

Step 3. Add topiramate 25 mg at bedtime as soon as weight loss halts (once the patient reaches a plateau) or once weight regain has begun as adjuct to an optimal lifestyle.

Step 4. Ascertain if there are any side effects associated with the use of topiramate. If there are minimal side effects with good patient weight loss response, consider changing the topiramate to an extended release formulation OR consider a transition to zonisamide 100 mg in the evening.

Step 5. Titrate the medication up slowly, as needed (when weight loss halts), to reduce the likelihood of side effects. It is preferable to increase the dose of topiramate by 25 mg at each increase. If side effects ensue with topiramate, but the patient has achieved weight loss, one might consider transitioning to an extended release topiramate first before a switch to an alternate agent such as zonisamide. If zonisamide is used, we recommend to titrate up by 100 mg. If a patient begins to experience side effects, reduce the dose back to the previous dose and maintain the patient at that dose

Step 6. If the patient has additional weight loss to be conferred, consider the addition of a second medication (i.e. phentermine, bupropion, liraglutide, etc.) in addition to the first medication. It is important to use agents that are from different classes (e.g. phentermine/topiramate, bupropion/naltrexone, bupropion/zonisamide, liraglutide/topiramate).

Step 7. If more weight loss is desirable, one might consider the addition of phentermine in the morning. We choose to utilize an extended release of phentermine with an initial starting dose of 15 mg in the morning and an increase to 30 mg if the patient does not have side effects. If the patient has a desirable weight loss outcome from the addition of phentermine but notes side effects, one might consider the switch to a smaller dose of phentermine of 8 mg in the morning with titration to 8 mg a day, three times daily, as needed.

Step 8. For patients who have a history of psychotropic induced weight gain, one might consider the addition of metformin. Unlike the other medications where we use the lowest effective dose, we will most often titrate the patient to metformin 1000 mg by mouth twice daily. If the patient has GI side effects, consider a switch to an extended release format.