2020-10-29 OMA Agenda - Board of Trustees

Revised Manuscript – October 26, 2020 Perspectives on Phentermine Prescribing for Obesity Treatment via Telemedicine With a public health emergency such as the COVID-19 pandemic, the risks and benefits of in-person medical visits must be heavily weighed. Risk is particularly important to consider in patients seeking obesity treatment, given that obesity is associated with COVID-19 complications and mortality. (1) Obesity is a disease, and thus its treatment is an essential medical service that should continue in an emergency (2). Telemedicine is now an integral part of the healthcare system and it is increasingly recognized that many conditions can be treated in this manner (3). Our goal is to advise providers treating obesity on how to prescribe phentermine safely utilizing telemedicine. Phentermine is the most prescribed anti-obesity medication (AOM). It is well tolerated and has high efficacy for total body weight loss of 5-10% . Phentermine may be associated with elevations in blood pressure and pulse and is a Schedule IV controlled substance, so careful monitoring has been advised (2). There are currently no guidelines for prescribing phentermine through telemedicine. As a group Diplomates of the American Board of Obesity Medicine*, from diverse practices, whom are known to each other through a preexisting obesity advocacy group, we recognized an urgent need amongst our colleagues for discussion regarding prescribing phentermine by telehealth. As such, we offer this perspective, which was achieved as a working group over several phone calls and utilizing shared documents to draft this perspective. We utilized evidence and existing guidelines where possible, supplemented with discussion based on our combined clinical experiences. We believe phentermine can be prescribed safely through telemedicine visits for both initiation and continuation of therapy. Patients who are benefitting or could benefit from phentermine should not have it withheld and should not be required to attend an in-person visit unnecessarily. However, if the benefit outweighs the risk, patients seeking obesity care should not be prohibited from in-person visits. Providers are best suited to decide if it is safer for the patient to have an in-person or telemedicine appointment. Our opinions here include all recommended doses of phentermine, including the combination formulation (Phentermine/Topiramate ER). While studied less, it is reasonable to consider diethylpropion with the same considerations. Other AOMs could also be prescribed by telehealth, but due to the popularity, effectiveness but also the stigma often associated with phentermine, we chose to focus on this medication. Our goal is not a complete review on the prescribing of phentermine or to change providers’ usual practice, but to highlight additional considerations when this medication is initiated or continued through telemedicine and improve providers’ comfort with doing so. Initiation of phentermine through telemedicine Historically, controlled substances could not be initiated in the US without an in-person encounter. Given the current declaration of a public health emergency, the DEA has temporarily waived the need for an in-person visit prior to an initial prescription (4). Consistent with usual practice, phentermine should be used for the treatment of obesity in conjunction with lifestyle change counseling, including nutrition, physical activity and behavioral recommendations. (2) Providers should be aware of specific requirements by locale for anti-obesity medications and controlled substances.