Varenicline, as the tartrate salt, is a powder which is a white to off-white to slightly yellow solid .. Patients in this study (n=) were treated with open-label. ISMP released numerous reports detailing Chantix adverse effects, The boxed warning that was added to the Chantix label in and. his colleagues decided to study the off-label use of varenicline after the results Since the launch of varenicline as Chantix, Pfizer, the drug.

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The global pandemic of obesity and overweight now affects between 2. Treatment for what is now recognized as a chronic disease includes pharmacotherapy, considered an essential component of comprehensive therapy.

New drug discovery is robust, but the pace of the US Food and Drug Administration approval for obesity drugs has been glacial, and only a handful of approved drugs are available for treating obesity. In the last 20 years, the US Food and Drug Administration has approved drugs for cancer, for cardiovascular diseases, for neurological diseases, and endocrinologic drugs, but only 6 for obesity, 2 of which have been taken off market.

Currently, there are only 9 drugs approved by the FDA for obesity treatment.

US physicians have turned to off-label drug use in their effort to care for increasing numbers of patients with excess adiposity. Phentermine is the most commonly used drug for treating obesity. Offlabwl approved only for short-term use, US physicians have used it successfully for long-term since its initial approval in This drug, used off-label for long-term, has proven to be safe and effective, far safer than the disease it is used to treat.

Phentermine and diethylpropion, an equally offlabwl but somewhat less effective drug, are both generic and therefore inexpensive.

These drugs have been maligned inappropriately because their two-dimensional structure diagrams resemble amphetamine and also because of unproven presumptions about their potential adverse effects. In the face of an increasing epidemic, worldwide obese and overweight patients deserve effective treatment that prescribing these drugs could provide, if rehabilitated and used more frequently. US physicians will likely continue to use any drug proven useful off-label for this illness until such time as more effective drugs are approved.

The extent of the pandemic of obesity and overweight has been seriously underestimated since most assessments do not include perhaps as many as 2.

These overfat patients are not classified as either overweight or obese. Significant progress has been achieved in understanding the pathophysiologic processes qnd in excess adiposity. Noteworthy advances in knowledge in this field include the discoveries that mammalian fat stores are not just inert repositories of energy but dynamic organs metabolically active in producing hormones, and that excess adipose tissue releases a storm of molecules that incite protean systemic inflammatory processes.

Lifestyle modification is an important component of comprehensive obesity treatment. One facet of such treatment is improvement and abatement of harmful eating behaviors. Regulation of appetite has been a focus of obesity drug effects but there is now also evidence that chantiz obesity drugs induce beneficial changes in eating behavior.

Additional research in this arena is needed. Development of new drugs to combat excessive adiposity has been very slow and there have been prolonged delays in approval of new drug by the US Food and Drug Administration FDA. Currently available anti-obesity drugs include 5 approved for long-term use and 4 for short-term use.

The acceptance of these new obesity drugs by Offlzbel physicians has been far below acceptance rates of wnd new drugs. Novo Nordisk has said they intend to market Saxenda long-term but they chantiix have reduced their sales force marketing the drug to physicians.

Zafgen announced they had halted research on their obesity-drug candidate beloranib in July after two deaths during trials. Meanwhile, other companies continue searching for other effective weight management drugs. There are 2 slightly differing chantiz approaches for weight management in the US. Great treatment emphasis is placed on lifestyle modification, and pharmacotherapy is considered a treatment modality ancillary to behavior modification.

No emphasis is placed on treating patients with excess adiposity but with a BMI below the thresholds and pharmacotherapy for such patients is off-label. On the other hand, private obesity medicine practitioners led by the year-old American Society of Bariatric Physicians ASBPrecently renamed the Obesity Medicine Association, have taken a pragmatic ovflabel to treatment. Offlable physicians prescribe obesity medicines not only for patients with Chanrix above conventional cutoffs but also often prescribe obesity drugs off-label for patients who have excess adiposity with BMIs below orthodox thresholds.

Thus, when in the FDA abruptly required all labels for obesity drugs to include BMI thresholds as indications for prescribing, the practitioners found that they were using the obesity drugs off-label for many of their patients.


The use of BMI thresholds for diagnosis and treatment decisions is controversial. It is known that a BMI of 30 as a test for indicating the treatment chantxi excess adiposity has a very chantixx specificity, but has a very low sensitivity. Body weight or indices of body weight are only indirect assessments of adiposity.

Body fat can be measured directly by a variety of methods, including skin calipers, biologic impedance, underwater weighing, and dual-energy X-ray absorptiometry DXAwhich is the most accurate.

BMI offoabel a measurement of adiposity compares unfavorably with the various direct measures of body fat. Other arguments advanced for drug treatment according to excess adiposity as opposed to using BMI include the fact that excess adipose tissue accumulation is associated with an immune response that results in widespread systemic inflammatory changes that damage distant tissues and induce a host of complicating diseases.

An immune process appears at a very early stage of adipose accumulation, 13 which then induces slowly progressive systemic inflammation. The pragmatic approach, which acknowledges that excess adiposity is most often progressive, is to treat with pharmacotherapy early while the patient is overfat but not yet overweight or obese, whereas the orthodox approach delays treatment withholding pharmacotherapy until adipose-induced inflammatory processes are irreversible.

Cjantix following either approach agree that obesity is a chronic disease and oflabel treatment must be long term. However, in the orthodox approach, the older sympathomimetic drugs, approved before the FDA required long-term trials for obesity medicine approval, are restricted to short-term use, whereas physicians using anr pragmatic approach are comfortable using these drugs long term in an off-label manner.

Adherents to the pragmatic approach argue that short-term restrictions were added when the older drugs were approved the second time in a political compromise move with no scientific justification. Use of the older drugs for patients with a BMI below conventional cutoffs and long-term use are two of the most common ways in which phentermine and the other older drugs are used off,abel, but there are others that will be discussed subsequently.

One focus of such treatment is offlqbel and mitigation of harmful eating behaviors. Recent data suggest that at least some obesity drugs induce reductions in energy intake by generating beneficial changes in cravings and eating behaviors. Off-label drug use OLDU generally means that a odflabel is being used for an unapproved indication, population or at an unapproved dosage.

In addition to these unapproved uses, antiobesity may be also employed for longer than recommended durations, when contraindicated, or in other ways contrary to the US FDA-approved label. Countries other than the USA typically have their own drug approval processes, but their labels commonly include language similar to that of the FDA label.

The uses of drugs that are approved for other diseases that have weight loss as a side effect and that are used in treating overweight or obese patients with the indicated diseases are not discussed. While, in general, OLDU is neither illegal nor unethical, some jurisdictions may limit the use of specific medications for specific situations. Penalties may include forfeiture of medical license. In addition, the state chantixx may charge an offending doctor who dispenses medications with felony, drug trafficking and money laundering.

Physicians should not presume off-label use of controlled substance antiobesity medicines is freely permitted in their own location but should investigate local regulations and laws carefully before prescribing these drugs off-label.

Drug labels are information documents produced after marketing approval but prior to marketing and are infrequently updated as new knowledge emerges from experience with the drug except when unexpected adverse effects surface. The longer a drug has been in use, the more the likelihood of its uses and benefits being discovered that were not contemplated prior to or during the approval process.

Long-term usage may demonstrate that initial safety concerns that prompted warnings in the chqntix are unfounded, but such warnings may not be removed from the label. Hence, dhantix contained in labels of older drugs may be outdated due to unavailability of more recent research and clinical experience at offlabwl time the warnings were added to the label. Drugs commonly used off-label for weight offlabeo are discussed in the following section. snd

Methamphetamine desoxyephedrine was first approved in by the FDA for treating narcolepsy, abd depression, postencephalitic Parkinson syndrome, chronic alcoholism, cerebral arteriosclerosis, and hay fever.

Later, inmethamphetamine was also approved as the first drug for treating obesity. Both approvals were made chantx a time when when US law required the FDA to only consider whether new drugs were safe without consideration of their ane.

Later, inthe US congress amended the Food Drug and Cosmetic Act requiring the FDA to approve new drugs based on their safety but only if the new drug demonstrated proven effectiveness for the stipulated indication. Methamphetamine is a category II controlled substance and although today this drug is apparently rarely used for treating obesity, such usage is not off-label.


Physicians used 5 mg methamphetamine tablets up to 3 times daily before meals in the s and s for treating obesity, but then turned toward using sympathomimetic amines as these became available beginning with phenmetrazine in ; phentermine, diethylpropion and phendimetrazine in ; and benzphetamine in Phentermine became the most frequently prescribed medicine for treating obesity. The originally approved indication was obesity; and the drug was used on-label until when it, along with all other drugs approved for treating obesity, were approved a second time after an amendment to the Food Drug and Cosmetic Act required that the FDA approve new drugs based on efficacy as well as safety.

There was protracted opposition to re-approval from those who maintained the sympathomimetic obesity drugs that had dangerous addiction potential. No evidence of addiction had appeared during 18 years of increasingly frequent use, but the FDA re-approved them all, having silenced the opposition by announcing the drugs would be approved for short-term use only.

US physicians treating obesity, well aware of these statuary boundaries, continued to use phentermine and the other sympathomimetic amine anorectic drugs off-label chantkx personal communication; WL Asher, Denver, Colorado, USA, May Surveys of prescribing practices among physicians treating obesity have confirmed that a majority of these physicians continue to prescribe the sympathomimetics off-label in this manner. Phentermine is also used off-label in several ways other than long-term.

Phentermine is, and has long been, prescribed for patients whose excess adiposity is below the conventional BMI cutoffs.

Prescribed phentermine doses higher than the limit suggested are common. The label lists The phenomenon cnantix to may be related both to intra-species variability of drug metabolism and dose—time induction of more rapid drug metabolism.

Whatever the theoretical explanation, doses higher than Current treatment recommendations for attention deficit call for a starting dose of amphetamine of 0. The variation in dose required for effective treatment is thought to be due to intra-individual variability in drug metabolism and plasma clearance.

Whitewashing a black box warning: The Chantix story that didn’t get told

A study in baboons 25 found that intravenous ad and phentermine produced equivalent plasma levels of norepinephrine. This suggests that oral doses of these drugs would have equivalent effects in humans on plasma norepinephrine levels. These doses are comparable with the doses of amphetamine used to treat attention deficit with respect to norepinephrine plasma levels and are not excessive.

Some of these chantixx are being treated for attention deficit, but many are not. It is common knowledge among obesity medicine practitioners that obese patients with attention deficit often experience clinical improvement when treated with phentermine, particularly if they are not currently being treated for their attention deficit.

FDA, drug companies clash over off-label uses – STAT

Effective dosages for weight loss or maintenance for these patients vary widely but most require or tolerate higher phentermine doses than patients without attention deficit. Phentermine was used safely for treating overweight children by pediatricians chwntix it became unpopular in the s. There are no reports of harm from phentermine treatment in either very young or elderly patients.

The surveys of obesity medicine physicians cited above indicate that a majority use phentermine in treating adolescents. The same surveys suggest that these physicians do not recognize an upper age limit for treatment. However, observational reports have included patients safely treated with phentermine as young as 3 years 27 and as old as 88 years.

Although there are no published data on the frequency of use, phentermine is occasionally prescribed for patients with label contraindications.

Coronary artery disease, stroke, arrhythmias, congestive heart failure, and uncontrolled hypertension are listed specifically. In the absence of controlled data supporting these contraindications, there is no unambiguous evidence that suggests these conditions are absolute contraindications. However, US obesity medicine specialists, based on the known mechanism of action of phentermine, and the pathophysiology of the illness, would consider congestive heart failure, uncontrolled hypertension, untreated clinically significant arrhythmias, and severe advanced coronary artery disease to be absolute contraindications.

This viewpoint is supported by reduced mortality observed in the Sibutramine Cardiovascular Outcomes SCOUT trial for patients with cardiovascular disease who had moderate weight loss. Other contraindications include hyperthyroidism, glaucoma and history of drug abuse. Most physicians would likely agree that phentermine not be used until hyperthyroidism has been treated but most would also agree a history of successful treatment of hyperthyroidism is not a contraindication.

As with other medications that have anticholinergic side effects, phentermine is contraindicated in patients with narrow-angle glaucoma.