First, do no harm

By Victor Sierpina
The father of medicine, Hippocrates, gave us the dictum, “Primum non nocere” meaning “First, do no harm.” The challenge is that many modern medical treatments, while offering benefits, also have a substantial potential list of risks.For example, let me just take a couple of recent weight loss drugs and give you a sense of the warnings. Qysmia, approved in 2012, is a combination of phentermine/topiramate and costs $160 a month, lists potential kidney stones, cardiac damage, and risk of fetal malformation. Side effects are insomnia, irritability, numbness, constipation and dry mouth. The latest player, Contrave, was just approved in September, and is a combination of naltrexone/bupropion. Major warnings include risks of suicidal thoughts, seizures, blood pressure and cardiac problems, liver toxicity, eye damage from glaucoma, and low blood sugar. Other adverse reactions are nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth and diarrhea.
With friends like these, who needs enemies?
There is a big market for these products so other options include: prescription Xenical or Orlistat approved by the FDA in 1999. It costs $470 a month and basically causes you to poop out high fat in your diet. The over-the-counter variety, Alli, was approved in 2007 and is about $50 a month. Belviq or lorcaserin is about $213 a month and even Consumer Reports says to skip it. The cheapest of the pack is phentermine at $16 a month, basically a mild form of speed. All have significant side effects if you review the accompanying package handouts.
Let me tell you about my overall impression of these products. Phooey.
I must acknowledge the significant risks of obesity and the tremendous challenges those who have gotten obese. Those with a BMI over 35 have great difficulty in losing substantial weight with diet and exercise alone.
On the other hand, there is the siren song that a pill can help offset years of Twinkies, soft drinks, cheeseburgers and inactivity. Drug companies know this as do supplement manufacturers.
Unscrupulous weight loss doctors will offer a cocktail of substances, usually including thyroid, diuretics and some appetite suppressant to desperate patients, not advising them of the risks. I have seen some serious problems from such misadventures.
One reason I don’t like to prescribe any of these products is that despite potential and actual harms, they just don’t help much if at all. Weight loss is modest, usually 10 pounds or less. Though some products claim to offer 10 percent of body weight reduction, I have never seen this in practice.
Back in the ’60s and ’70s, mothers little helper for weight loss was a drug called Benzedrine or other types of amphetamine with the street name of speed. You all know how well that worked. Lots of side effects and abuse issues.
Supplements and natural products available over the counter don’t have much better of a track record for effectiveness, though their safety is generally better.
I had a personal experience with one of my patients that further soured me on this whole class of drugs. About 10 years ago, I helped manage a patient’s pregnancy and delivery of a healthy baby, despite some blood pressure problems. A few months after delivery, she was having trouble losing her baby fat and begged me to prescribe Fen/Phen, then a popular weight loss product.
I initially declined because I had seen little benefit, many side effects, and because she had hypertension. She insisted that she would go to another doctor to get it if I didn’t give it to her.
I figured if I prescribed it, I could at least monitor her. A month later, she had gained 5 pounds on Fen/Phen and her blood pressure was up. I did not renew it. Fen/Phen was subsequently taken off the market for safety reasons.
About 6 months later, I got a notice that I was named in a class-action lawsuit because I had prescribed this to her. Even though she had experienced no harm from the medicine, she joined the lawsuit lottery. My name was dropped once her lawyers reviewed my medical records, but it left a bad taste in my mouth and an ache in my heart from a long-term and previously dear patient.
More recently, a scientist who had done his research on Qysmia pleaded with me to prescribe it. After clearing all the legal and insurance hurdles to getting a script for it, he quit it after a couple months because of bad dreams and other psychiatric side effects. Oh, and he didn’t lose any weight.
All the advertisements say, “Talk to your doctor” before trying any of these. They may be helpful in select cases, but beware and watch your body, as well as your wallet. Do no harm is still good advice a few millennia after Hippocrates.
Dr. Victor S. Sierpina is the WD and Laura Nell Nicholson Family Professor of Integrative Medicine and Professor of Family Medicine at UTMB.