2020-10-29 OMA Agenda - Board of Trustees

Prior to initiation of phentermine, an appropriate history and physical should be performed to the extent possible by telemedicine and the consideration of contraindications should be documented. Vitals obtained with home devices, at a pharmacy or at a recent medical visit should be documented. To assess patients’ appropriateness for phentermine through telemedicine, it may be helpful to classify patients into risk categories. Lower risk patients include those who are 18 to 64 years old, have previously tolerated phentermine, have few active medical conditions, and have normal vital signs documented in the last 6 months. Higher risk patients for telehealth initiation include patients 65 years or older and with medical conditions listed in table 1. This age range was chosen as it is the age range for a major study demonstrating safety in longer-term phentermine use (5). Other risk factors were determined by the consensus of the group given standard recommendations, clinical experience and considerations for conditions that may add a unique dynamic to evaluation by telehealth. These factors may influence the provider’s decision about initiating phentermine by telehealth, but it is important to note that these risk factors by themselves are not absolute contraindications. Higher risk patients may actually benefit the most from treatment of obesity. Consistent with standard practices, monthly follow-up for the first three months after initiation should be arranged, then follow-up at least every three months is recommended (2). Side effects and treatment effectiveness should be assessed in order to decide whether to continue the medication. The provider’s decision to continue follow up care by telehealth will depend on the patient’s risk and ability to provide data such as blood pressure, pulse, and weight measurements. Continuation of phentermine through telemedicine Once a patient has been seen for at least one in-person follow-up after phentermine initiation, we consider them a stable, established patient. We agree with recommendations that AOMs are best utilized long-term (2,6). Established patients should be reevaluated for refills by telemedicine at least every three months. Patients should demonstrate medication efficacy with no concerning symptoms or abnormal vital signs to continue care by telemedicine. It is reasonable for providers to continue refilling phentermine by telemedicine for such stable patients for 6 months without an in-person appointment. However, there is no clear timeframe beyond which use of phentermine without an in-person visit becomes unsafe. Continuing phentermine with regular telehealth appointments may even be reasonable up to 12 months, depending on patients’ baseline risk and ability to report health data such as blood pressure, pulse and weight measurements. Conclusion We believe that the treatment of obesity is well suited to telemedicine and this should be encouraged to minimize the effects of COVID-19. Safe prescribing of phentermine by telehealth is possible, ideally when a patient can self-report weight, blood pressure, and heart rate. For established patients with historically stable vital signs, extended periods of prescribing phentermine by telemedicine may be reasonable. We hope this perspective will help providers safely continue the care of patients with obesity throughout the pandemic and beyond.