2020-10-29 OMA Agenda - Board of Trustees

Comments. 1. There is no description of the process used select the expert consensus members or details of how the process was conducted. This is important to include to lend credibility to the conclusions presented. Some of the opening remarks in the Perspective can be deleted to stay within the word count restrictions. Thank you. After feedback we have decided calling ourselves a working group. Our group already meets as part of an obesity advocacy group for a specialty organization and this issue became of interest to us when the pandemic started and telehealth became more widely utilized. We had several phone and video calls and used an electronic shared document to craft our opinions between calls. We have added this information to the perspective. 2. It is unclear why the focus of the Perspective is on phentermine alone. Prescription of any anti-obesity medication (AOM) requires the same process of evaluation and monitoring. I realize that controlled substances are more tightly regulated – but Qsymia® is also a controlled substance and is inexplicably not included in the practice guideline. The Perspective would have more value if it took an expansive view of the field. We felt that Qsymia was included in the original language “Our opinions on prescribing by telemedicine include all recommended doses of phentermine, including combination formulations” However we have taken the opportunity to clarify this and specifically add diethylpropion. We elected not to specifically address phendimetrazine or benzphetamine for three reasons- one they are not included in the guidance Pharmacological Management of Obesity by Apovian, et al, the major reference for AOM prescribing. Secondly, the majority of our group did not utilize these medications enough to feel comfortable giving opinions on them. Finally, these two medications are schedule 3 medications as opposed to schedule 2 medications and this may dictate different prescribing patterns for some clinicians. 3. It would be interesting to include any available data on the number of phentermine and other AOM prescriptions since March, 2020 compared to same time period from 2019. Analysis of this data can be included in the Perspective, particularly if the number of prescriptions has diminished, thus adding importance for establishing practice guidelines. Agreed this would be wonderful information to have! Unfortunately we are unable to provide this information at this time. We are hopeful that telehealth and article supporting safe telehealth prescribing like this will keep prescribing patterns stable. We also feel if this data was present it would have many confounders- for example- patients may be following up less due to lack of income or lack of insurance, patients may be seeking more obesity care due to weight fluctuations as a result of COVID19 stress, etc. This is an opinion piece from Obesity Medicine specialists in a variety of clinical settings including academic, large hospitals, and clinics outlining specifications for prescribing phentermine via telehealth, a practice that until recently was not permitted. I applaud the authors for addressing this timely and very important issue, given that video visits have supplanted live visits in many obesity medicine practices. While I agree with the authors that this issue needs to be resolved I would like to comment on several aspects of the manuscript. This is an opinion, with minimal data on the safety of phentermine quoted. This is likely because not much safety data exists. How then was the age of 65 determined to be the cut point between high and low risk? I asked several obesity medicine physicians who are doing this and they responded that they would prescribe phentermine by video visit to a maximum age of between 45-60. A reference from guidelines, a position paper, or a similar respected source would be helpful. The authors note that CV risk factors including known CV disease and others like DM would preclude this type of intervention and follow-up, which is appropriate, but I’m not sure when age becomes a risk. We have added the reference Safety and Effectiveness of Longer-Term Phentermine Use: Clinical Outcomes from an Electronic Health Record Cohort by Lewis, et al. This study of longer term phentermine use had age cut offs of 18-64 in the study, which demonstrated phentermine safety when used for a year or longer. As such we have increased our age range to 18. The dose of phentermine which is reasonable to be prescribed via video visit is not addressed. A paper by Hendricks and colleagues noted that “the mean high dose” of phentermine prescribed by obesity specialists is 56 mg, a dose which some physicians feel should not be prescribed for anyone at any time until safety is proven, no less via video visit. On the other hand, low doses of phentermine, 4 mg - 18.75 mg daily may be reasonable with remote monitoring prior to a live visit in low risk patients. I think a statement about appropriate and safe dosing is required.