For referral information, please see adult weight management pathway:

• Eastern locality
• Northern locality

NICE CG43 Obesity (December 2006) provides strategic guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. It provides key priorities for implementation that includes public health support, drug therapy and surgery.

Drug therapy would only be considered after dietary, exercise and behavioural approaches have been started and evaluated. Drug therapy is not recommended in children under 12 years of age and only in certain circumstances in children 12 years and older by a multidisciplinary team experienced in prescribing for this age group. For adults, drug therapy would be considered for those who have not reached their target weight loss, who have reached a plateau or who are being considered for surgery. Drug therapy should only be prescribed as part of an overall plan for managing obesity. The use of drug therapy without an overall strategy for managing obesity may detract from patients making longer-term healthy lifestyle changes.

Naltrexone-bupropion

• NICE TA494: Naltrexone-bupropion is not recommended for managing overweight and obesity in adults alongside a reduced-calorie diet and increased physical activity (December 2017)

Lipase inhibitors

Orlistat

• Capsules 120mg (£24.42 = 84 capsules)

Notes

1. Orlistat should only be prescribed in adults who meet one of the following criteria:
   • A BMI of 30kg/m² or more.
   • A body mass index (BMI) of 28kg/m² or more with associated risk factors.
2. Continuation of therapy beyond 12 weeks should continue only if the patient has lost at least 5% of their initial body weight from the start of drug therapy.
3. Health care professionals will need to decide whether the anticipated weight loss (generally 5%) is of clinical significance to their patients. If prescribed, the patient should be counselled on the adverse effect profile associated with orlistat, particularly in connection with gastrointestinal adverse effects.
4. Orlistat 60mg capsules are now available OTC at approximately £50 for 28 days treatment.

Melanocortin 4 receptor agonist

Setmelanotide

• Solution for injection vial 10mg/1ml

Notes

• NICE HST21: Setmelanotide (Imcivree) is recommended, within its marketing authorisation, as an option for treating obesity and controlling hunger caused by pro-opiomelanocortin (POMC) deficiency, including proprotein convertase subtilisin/kexin type 1 or leptin receptor (LEPR) deficiency in people 6 years and over, only if the company provides setmelanotide according to the commercial arrangement (July 2022).
• NICE HST31: Setmelanotide (Imcivree) is recommended as an option for treating obesity and hyperphagia in genetically confirmed Bardet-Biedl syndrome (BBS) in people aged 6 years and over, only if they are aged between 6 and 17 years when treatment starts. These people can carry on having setmelanotide as adults until they need to stop. Setmelanotide is only recommended if the company provides it according to the commercial arrangement (May 2024).

Glucagon-like peptide-1 receptor agonists (GLP-1 mimetics)

Saxenda

(Liraglutide)

• Solution for injection 3ml pre-filled pen 6mg/ml

Indications

• As an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults who meet the criteria in NICE TA664 (see note 3)

Notes

1. For information on referral to adult weight management service, please see links at top of page.
2. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients and / or have different licensed indications and dosing regimens):
   1. Saxenda is licensed for weight management
   2. Victoza is licensed for the treatment of type 2 diabetes mellitus and should not be prescribed for weight management, see section 6.1.2 Antidiabetic drugs
3. NICE TA664: Liraglutide (Saxenda) is recommended as an option for managing overweight and obesity alongside a reduced-calorie diet and increased physical activity in adults (December 2020), only if:
   1. they have a body mass index (BMI) of at least 35kg/m² (or at least 32.5kg/m² for members of minority ethnic groups known to be at equivalent risk of the consequences of obesity at a lower BMI than the white population) and
   2. they have non-diabetic hyperglycaemia (defined as a haemoglobin A1c level of 42 mmol/mol to 47 mmol/mol [6.0% to 6.4%] or a fasting plasma glucose level of 5.5 mmol/litre to 6.9 mmol/litre) and
   3. they have a high risk of cardiovascular disease based on risk factors such as hypertension and dyslipidaemia and
   4. it is prescribed in secondary care by a specialist multidisciplinary tier 3 weight management service and
   5. the company provides it according to the commercial arrangement
4. The safety and efficacy of liraglutide for weight management have not been established in the following patients. Use in these patients is not recommended; aged 75 years or more, treated with other products for weight management, with obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain, with severe renal impairment, with severe hepatic impairment (see SmPC for more details)
5. For use of liraglutide (Victoza) in the treatment Type 2 diabetes mellitus, see section 6.1.2 Antidiabetic drugs.
6. MHRA Drug Safety Update (November 2023): Ozempic (semaglutide) and Saxenda (liraglutide): vigilance required due to potentially harmful falsified products
   1. Falsified Ozempic and Saxenda products have been found in the UK, including falsified pens containing insulin. Ozempic and Saxenda from legitimate supply chains are unaffected.
   2. Remain vigilant for symptoms linked to hypoglycaemia in patients who may have obtained a falsified product.
   3. Remind patients using these products to always obtain prescription medicines from a qualified healthcare provider and not to use products they suspect are falsified. The legitimacy of a pharmacy, including those on-line, can be verified by referring to the GPhC website pharmacy registry.
   4. Refer to the safety update for additional advice to patients.

Wegovy

(Semaglutide)

• FlexTouch solution for injection in pre-filled pen 0.25mg/0.37ml (1.5ml), 0.5mg/0.37ml (1.5ml), 1mg/0.75ml (3ml), 1.7mg/0.75ml (3ml), 2.4mg/0.75ml (3ml)

Indications

• As an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults who meet the criteria in NICE TA875 (see note 3)

Notes

1. For information on referral to adult weight management service, please see links at top of page.
2. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients and / or have different licensed indications and dosing regimens):
   1. Wegovy is licensed for weight management
   2. Ozempic and Rybelsus are licensed for the treatment of type 2 diabetes mellitus and should not be prescribed for weight management, see section 6.1.2 Antidiabetic drugs
3. NICE TA875: Semaglutide (Wegovy) is recommended as an option for weight management, including weight loss and weight maintenance, alongside a reduced-calorie diet and increased physical activity in adults (March 2023), only if:
   1. it is used for a maximum of 2 years, and within a specialist weight management service providing multidisciplinary management of overweight or obesity (including but not limited to tiers 3 and 4), and
   2. they have at least 1 weight-related comorbidity and:
      1. body mass index (BMI) of at least 35.0kg/m², or
      2. BMI of 30.0kg/m² to 34.9kg/m² and meet the criteria for referral to specialist weight management services in NICE's guideline on obesity: identification, assessment and management and
   3. the company provides it according to the commercial arrangement.
   4. Use lower BMI thresholds (usually reduced by 2.5kg/m²) for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family backgrounds
   5. Consider stopping semaglutide if less than 5% of the initial weight has been lost after 6 months of treatment
4. No dose adjustment needed in elderly patients, hepatic impairment, or those with mild to moderate or severe renal impairment. Semaglutide is not recommended for use in patients with end-stage renal disease (see SmPC for more details).
5. For use of semaglutide (Ozempic or Rybelsus) in the treatment Type 2 diabetes mellitus, see section 6.1.2 Antidiabetic drugs.