2020-10-29 OMA Agenda - Board of Trustees

Our perspective states “Our opinions on prescribing by telemedicine include all recommended doses of phentermine” We believe the term “recommended” indicates FDA approved dosing and certainly would preclude phentermine doses of 56mg! The length of time without a live visit is addressed, but is not based on data or formal consensus. Phentermine is approved for short-term use, 12 weeks or less, though it is widely used for longer periods of time. Longer treatment is off-label, and could 12 weeks define the outer limit of time permitted without visit? yes, we agree that 12 weeks is generally considered the outer limit without a visit. We have decided to Pharmacological Management of Obesity by Apovian, et al which recommends monthly appointments for the first three months then at up to three month intervals. Our position is that this is the case for telehealth as well. How was consensus reached? Was a consensus meeting held, or did one author write the paper and ask the others to sign on? An "expert consensus" includes interested parties in many fields, not just those who practice in a particular way. The inclusion and agreement of cardiology and neurology colleagues on this manuscript would make the conclusions more believable to those physicians who are not phentermine prescribers. Thank you. After feedback we have decided on 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. Although I understand the interest in singling out phentermine with the use of telemedicine, it appears as if there are a few competing topics the authors raise in this perspective: (1) The use of telemedicine in obesity care in the COVID-19 pandemic, (2) the management of obesity using pharmacological agents, like phentermin, in treating obesity , and (3) patient risk assessment when prescribing phentermine. There are several paragraphs introducing the above themes that does water down their important perspective, which is, I think, to consider risk stratifying patients when prescribing phentermine as a standard of care in the setting of telemedicine. I would suggest the authors consider choosing one of the topics above, and provide a slightly more detailed perspective, providing their clinical expertise. In general, I’m concerned that articles like this only exacerbate the misconceptions (more dangerous, for short term use only etc) about phentermine, that is that this drug, for well-known reasons, should be singled out from the rest of the anti-obesity medications because of its history. Why do the authors chose to do so? I wouldn't necessarily recommend it here. The last thing we want to do is add to misconceptions about phentermine. In response to this concern we have clarified why we focused on phentermine (widely used, effective, but stigma present) as well as clarified we support long-term use and have cited references for long-term use. If there is interest, I suggest considering a more general perspective piece on the use of AOMs for obesity care in the setting of telemedicine. However, it appears as if the authors would like to share their perspective specifically on phentermine, specifically risk stratification. The risk categories when considering phentermine leave the reader without any insight why the authors chose these categories. For example, why is a 16 year old considered low 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. We believe this supports our age range suggestion. Are all women, that is those in the childbearing years who are “at risk of pregnancy” considered high risk? Please keep in mind this is considered only higher risk for telehealth. The labeling for combination phentermine/topimax ER recommends pregnancy test at baseline and monthly. While a patient could do a pregnancy test themselves, and this may be appropriate, we believe this puts the patient in the higher risk tier where the provider should more heavily consider if in person appointment to confirm patient is not pregnant before initiation of medication should be considered. Why does this need to be done with phentermine, why other AOMs this is not considered. Is it to overcome the bias that exists and the lack of reimbursement? I believe the authors are trying to introduce a novel way to persuade insurers to allow for controlled substances like phentermine to be prescribed via telemedicine, but further explanation is require, if indeed, this is the major point the authors want to make.