Ask the Pharmacist

Q) I’ve started taking a medication to help with my mental health which is helping but I am concerned with the weight that I have put on. What can I do about this?

A) Last week, we talked about how antidepressants and the atypical antipsychotics (also known as 2nd generation antipsychotics, a class of drugs that includes olanzapine, quetiapine, risperidone, aripiprazole and others) can cause weight gain in some (but certainly not all) people who take them. Like many things in life, it’s all fine and dandy to understand the principals behind this, but it is far more useful to have some practical strategies to combat this problem should it arise.  When you’re already struggling with self-esteem, packing on extra pounds around your midsection is just one more kick to the ego.

One potential strategy is to switch to a different member of the same class of drugs. When it comes to antidepressants, fluoxetine (Prozac), bupropion (Wellbutrin) and fluvoxamine (Luvox) tend to be the drugs that are least likely to lead to long-term weight gain whereas paroxetine (Paxil) and mirtazapine (Remeron) are the biggest offenders.

With respect to the atypical antipsychotics, ziprasidone (Zeldox) tends to be fairly weight neutral whereas most of the other members, and in particular olanzapine and clozapine are likely to cause both weight as well as an increased risk of diseases such as diabetes and heart disease. Aripiprazole is an interesting option that has caused significant weight gain in some patients but has also, conversely, been added on to other antipsychotics and caused substantial weight loss as well as added therapeutic benefits.

Switching to an alternative agent is a viable option if you’re putting on weight with your current therapy and it’s just not working well enough. However, it becomes a much more challenging decision if the offending drug is really making a positive difference in how you are coping with life.

Although many of these drugs work by very similar mechanisms to elevate your mood (i.e. increasing neurotransmitters such as serotonin, noradrenaline and dopamine), switching to a similar agent with a lower potential for weight gain does not necessarily mean it’s going to work just as well. It’s a bit of a Pandora’s box. There is the chance that it might work even better, minus the weight gain, but there is also the risk that it will be less effective and still cause you to gain extra weight.

For a person who has battled the nightmare of clinically significant depression, that is a substantial risk to take on. As such, there are strategies to reverse/ prevent the weight gain without changing your therapy.

The first option makes intuitive sense but needs to be stated since there is strong scientific evidence supporting it. The doctors from the Wharton Medical Clinics in Toronto looked at the records of over 17,000 patients and compared the health records of those who took psychiatric medicines versus those who didn’t. They found that the patients who were entered into a formal weight loss program, as opposed to just being told to eat right and exercise more, actually did lose weight. These findings applied to all sub-groups of patients.

In other words, a formalized program benefitted male and female, young and old and worked no matter which drug the patient was taking. And this weight loss was substantial. Over an average of 16 months, patients lost about 7.5 pounds which was equivalent to about 2.9% of their body weight. Of course, this is an average with some people doing better than others. 27.6% of patients lost 5% or more of their baseline weight and 10.1% lost twice that amount or more.

A program such as this does not have to be either a financial or schedule burden. In the case of the Wharton program, a trained weight management educator simply gave suggestions regarding eating strategies and physical activity. In general, participants were taught to reduce their usual diet by about 500 calories a day and then were asked to return to the clinic for ongoing dietary guidance every 3 to 4 weeks. While this is a simple, safe and effective strategy, the reality is that even a fairly modest diet such as this one is not everyone’s cup of tea.

There are other options out there, one of which is taking the diabetic drug metformin. Metformin has been the mainstay of type 2 diabetes for decades now and has a well established track record of safety, even when used by people who are not diabetic. It is also incredibly inexpensive (well under $30 for a 3 month-supply). We believe that metformin works by reducing insulin resistance and via the suppression of our appetite. It also increases the levels of glucagon-like peptide which might contribute to this effect. At a dose of 750 to 1,500mg a day, metformin caused, on average, a reduction in weight of about 7 pounds. Its main side effects are gas and diarrhea, often of a temporary nature and has no potential to lower your blood sugars to a point that would be hazardous to your health.

The much newer diabetic drug semaglutide (Ozempic) has not been studied yet for its effect on antidepressant induced weight gain but is a very promising agent due to its high standard of safety and the much more substantial weight loss it seems to produce relative to metformin.

Other drugs that can be added to psychotropic drugs to help with weight loss include:

· Topiramate– an antiepileptic drug which has substantial evidence supporting this effect and can also exert positive effects on psychotic states (it has long been used in the treatment of bipolar disorder) but does come with a greater risk of side effects

· Amantadine– a drug long used to help Parkinson’s and the treatment of the flu which also seems to work well but often leaves you feeling kind of lousy while you are on it

· H2 receptor antagonists such as famotidine (Pepcid) are usually taken to reduce stomach acid (i..e. heartburn) and are super safe and well tolerated even in the very young and have a little (emphasis on the word little) evidence that they may be helpful.

· Betahistine– is a drug commonly given out to treat dizziness and has been studied in conjunction with olanzapine and produced impressive results. It also has the added benefit of reducing the “sleepiness” that many people with depression often feel

This is far from an exhaustive list so the good news here is that there is a really strong chance for a positive outcome for those who need to stay on their mental health therapy but are struggling with the weight gain these drugs can sometimes produce. For more information about this or any other health related questions, contact your pharmacist.