Weight Loss Medications for New Nurse Practitioners (Part 2)
Choosing a medication for weight management can feel overwhelming—especially when you’re trying to figure out who is a candidate, which medication makes the most sense, what contraindications to look for, and how to monitor treatment over time.
In this episode, I walk through the weight-loss medications I was using most often in primary care at the time of recording, including liraglutide, orlistat, and phentermine. I talk through how they work, common side effects and contraindications, cost and access considerations, and how I followed patients after starting treatment.
2026 Update: Obesity pharmacotherapy has changed substantially since this episode was recorded. Several newer medications are now available, including semaglutide and tirzepatide, and the way we think about medication selection and duration of treatment has evolved. The general principles of shared decision-making, considering cost and access, reviewing contraindications and adverse effects, and following patients over time are still useful—but do not use the medication hierarchy in this episode as a current prescribing algorithm. See the Clinical Updates below and the current Weight Loss Medication Cheat Sheet inside the Digital NP Binder for updated guidance.
Listen
Watch
What I Cover in This Episode
Who I considered a candidate for weight-loss medication (at the time of recording)
The role of lifestyle interventions alongside medication
Liraglutide, including dosing, GI effects, and contraindications
Orlistat, including how it works, GI effects, and fat-soluble vitamin considerations
Phentermine, including its stimulant effects, cardiovascular considerations, and monitoring
How I approached cost, medication access, treatment goals, and follow-up
Clinical Updates as of 2026
The anti-obesity medication landscape has changed substantially since this episode was recorded. The episode focuses on liraglutide, orlistat, and phentermine. Current U.S. guidelines include several additional options, with semaglutide and tirzepatide now preferred pharmacologic treatments for many adults who are candidates for anti-obesity medication.
Correction: Semaglutide is now FDA-approved for chronic weight management. In this episode, I describe semaglutide as an off-label option for weight loss. It is now FDA-approved for chronic weight management and also has an indication to reduce cardiovascular death, MI, and stroke in adults with established cardiovascular disease and overweight or obesity.
Tirzepatide is another major treatment option that wasn't available when this episode was recorded. It is FDA-approved for chronic weight management and for moderate-to-severe obstructive sleep apnea in adults with obesity.
Correction: The BMI threshold I give for patients with weight-related comorbidities is too low. In the episode, I describe medication eligibility as BMI 25–29.9 with a weight-related condition. FDA-approved chronic weight-management medications are generally indicated at BMI ≥30, or BMI ≥27 with at least one weight-related condition.
Anti-obesity medications are generally considered chronic therapy when effective and tolerated. In the episode, I describe using medication until a patient reaches their goal weight. Current guidance recognizes obesity as a chronic, relapsing disease and recommends continuing chronic pharmacotherapy beyond achievement of weight-loss goals when appropriate, because discontinuation commonly results in weight recurrence and loss of cardiometabolic benefits.
Medication selection has changed. The 2026 ACP guideline conditionally recommends semaglutide or tirzepatide as first-line pharmacotherapy for adults with obesity, with other medications selected based on efficacy, comorbidities, contraindications, adverse effects, cost/access, and patient preferences.
For an updated point-of-care quick reference, check out the Weight Loss Medications Cheat Sheet inside the Digital NP Binder.
Key Takeaways as of 2026
Start with a comprehensive assessment. Review weight history and trajectory, obesity-related conditions, medications that may contribute to weight gain, prior treatments, reproductive plans, contraindications, and relevant baseline testing.
Choose the medication for the patient in front of you. Efficacy matters, but so do comorbidities, contraindications, adverse effects, route, cost, insurance coverage, availability, and patient preference.
Medication and behavioral treatment work together. Nutrition, physical activity, behavioral support, and pharmacotherapy can all be components of comprehensive obesity treatment.
Set expectations before prescribing. Discuss how the medication works, likely adverse effects, what you're monitoring, cost/access, and what long-term treatment may look like.
Think of obesity treatment longitudinally. Follow patients regularly to assess response, tolerability, health outcomes, barriers to treatment, and whether the plan needs to be adjusted.
When to Consider referral: RDN for individualized nutrition therapy, obesity medicine for complex/refractory treatment, bariatric/metabolic surgery evaluation when appropriate, behavioral health/eating-disorder specialist when disordered eating/eating disorder is suspected.
Don't assume medication ends when the patient reaches a particular weight. For medications intended for chronic treatment, continuing effective and tolerated therapy may help maintain both weight reduction and associated health benefits.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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So in this week's video, I'm going to be talking about weight loss medications.
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And I want to say that if you haven't watched last week's video, which is the real true
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foundation of weight loss medication discussions with your patients, definitely go back and
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do that.
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Anyway, when it comes to weight loss medications, after you've had the conversation about
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their lifestyle management, you can talk about weight loss medications with them.
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So full transparency, I work in a federally qualified health center setting and a lot
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of my patients are under resourced.
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So the weight loss medication options that we have available may or may not be covered
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by their insurance, and if they're not, they can be quite expensive.
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So I'm going to talk about the top three recommended options.
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There are other options available, but there's less data, there's more side effects,
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and they tend to also be expensive.
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So I tend to start with the first three options, and most of the time those are
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effective for what we're going for.
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I really do have to say it's not necessarily even about the medication, it's about
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the whole picture that helps them in their weight management journey.
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OK, before I jump into the three kind of like top options, I want to say a couple
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things.
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When it comes to medicine, all of the information and data and algorithms that
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we have and guidelines, those are all based on research, research studies and
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the best available research that we have.
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We take all those studies, we bring them together in a meta analysis, all that stuff,
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right?
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You know that, but I'm just the reason I'm saying that is because there's some
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limitations when it comes to weight loss medications.
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The studies that we have available for all weight loss medication options,
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there are small studies, there's some attrition where patients don't complete
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the full study, they can be short in length, the participants can be
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heterogeneous, meaning that it is not a diverse, inclusive, large
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population that you can extrapolate the results to a larger population of
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diverse patients and people.
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And then there has been variable reporting in the clinical outcomes in terms
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of how this affects the medical comorbidities potentially, right?
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So just keeping that in mind, all the recommendations are based on like not
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great data.
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OK, so who can be prescribed weight loss medications?
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The general guiding principles, again, going back to last week's video, if
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you haven't watched it already about the kind of caveats about BMI, body
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mass index as an actual tool, is typically, generally speaking,
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patients who have a BMI greater than 30 are candidates with lifestyle
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modification as well.
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However, it is also indicated for patients who have a BMI of 25 to 29.9
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who have medical comorbidities like diabetes and hypertension that would be
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improved with weight loss medications and or they've already been doing
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the weight loss lifestyle modifications and it is not allowing them to
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reach their goals of weight loss.
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I am not hard and fast about the rules with that because I really want to
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support patients with their health outcomes and the real world is messy.
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The real world is not tidy, right?
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However, I'm not going to give a medication necessarily if they haven't
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already started lifestyle modifications.
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I will consider doing it adjunctively at the same time, depending on
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where they are in terms of contemplation, pre-contemplation like
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that, what stage of decision making they're in, because the solution is
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to throw medications at somebody and then that's going to magically
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solve their problems.
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It doesn't work like that.
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Again, go back and watch last week's video.
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But anyway, so those are generally speaking, who is a candidate for it.
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Let's get into the medications, right?
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So top three options.
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Number one is a GLP receptor agonist, laryngotide.
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There are many GLP-1 receptor agonists.
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However, that is the only one that is FDA approved specifically for
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weight loss.
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So this is an injectable diabetes medication, but again, approved for
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weight loss.
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So once a day injectable, we start at the lowest dose and we titrate up
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until we get to the maximum, until they reach their weight loss goals
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with the adjunctive lifestyle modifications.
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Pros of this medication are that there's no time limitation.
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The patients can continue on it as long as they're tolerating it until
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they meet their weight loss goals.
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Cons are side effects and the fact that it's injectable and it's daily.
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The main side effects are anorexia, a loss of appetite, stomach pain,
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nausea, it really reduces appetite and that can be very
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uncomfortable for patients.
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The good news is that when you start it, you start at the lowest
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dose and the side effects tend to improve the longer you take it.
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And if they're not tolerating a higher dose, you just go
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back down to the other dose.
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So that is kind of the first line option because of the data, again,
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the amount of research we have in terms of efficacy.
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It also has potential benefit for protect like cardiovascular
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protection and patients who have diabetes.
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It's been studied a lot for a medication in general.
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There is another medication.
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I'm not going to pronounce it right.
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Semaglutide, semaglutide, that is the generic name and it is
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off label use for weight loss.
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I'm not going to talk too much about it here.
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If you want to know more about all the GLP-1 receptor agonists, I
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talk about all of them in the context of diabetes management inside
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the diabetes workshop.
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If you want to check that out, it's at realworldnp.com.
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However, when it comes to GLP-1 semaglutide, however one says
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that, I don't want to use brand names in these videos, that
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is actually more efficacious in terms of the amount of weight
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loss and it is also once a week.
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It is my personal favorite when it comes to diabetes, choosing
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a GLP-1 receptor agonist because of the ease of use for patients
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and its efficacy.
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However, it is not FDA approved, so it might be less covered by
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insurance.
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I have not prescribed this for weight loss personally.
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What are the next two options?
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The next one is Orlistat and this is kind of also in that
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first line, second line, third line option.
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Generally speaking, because of the data that we have and
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because it's single use medications that have combination
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medication, because the more medications you add in
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combination, the more risk of side effects, those kinds of
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single use agents, generally speaking, are preferable.
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That's expert opinion, level of evidence.
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But anyway, in terms of second line options, Orlistat is
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really the next one.
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So Orlistat is the generic name.
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It basically boiled down, prevents the absorption of
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fat.
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So the fat in a person's meal is the highest caloric
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density of carbohydrate protein's fats.
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Fat has the highest caloric density.
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And so when you reduce the amount of fat absorbed, there's
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less calories consumed.
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So it's taken three times a day with three meals a day,
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prevents that fat absorption.
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But as you can imagine, that will lead you to what the
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side effects are.
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So the main side effects are GI distress.
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The fat goes instead of being absorbed and broken down by
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the body, it's excreted in stool.
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And so you can have oily stools, which can be very
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concerning for patients.
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So I always warn them about that and allow them, always
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allow them the choice to choose that one or not.
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Right.
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Maybe that's not the good option for them because
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they're at work and they can't risk rushing to the bathroom
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because they have to urgently have a stool that is very
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fatty. Right.
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This is like a weird thing to be talking about on the
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internet, but here we are.
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Most it's like not everybody has that though, because I
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prescribed this one a fair amount.
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The pros to this one are that you can use it for
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longer periods of time.
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I believe research has studied it up to three to
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four years of use.
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However, I believe the FDA indication is for 12 months
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to 24 months.
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Don't quote me on that one, but it's a longer, it's
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more appropriate for long-term use.
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Most of the patients that I've had on it have really
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only done it for about a year and then they're kind
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of chilling like they're done.
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The main goal is to use it until they're at their
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adequate goal weight that you have discussed.
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And then the side effects, we've already talked about
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that, the other considerations is that you want to
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make sure that they're taking a fat solid, they're
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reducing their ability to absorb fat soluble vitamins
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so that they really should be taking a multivitamin so
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that they don't reduce those vitamins.
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And yeah, I think that those are the main ones
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that I really talk to about patients is that we
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don't know if you're going to have that side
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effect, but you can use it for a longer term.
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And that's like the main thing.
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And some people have no side effects at all.
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The main way to reduce that side effect is to
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reduce the amount of fat in your diet.
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So if you're having a very fatty meal, you're
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going to excrete a lot of fat.
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So anyway, moving on option number three, I'm
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going to stop at the option number three.
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There are two other ones, but I've never
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prescribed them and they have more side effects
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and less data.
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So I'm not even going to talk about them.
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Fentermine is technically a single agent, but you
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can also use it in combination.
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And I'm forgetting what it's combined with.
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Here we are.
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I'm an imperfect human.
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And again, I've never prescribed that one.
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Fentermine alone is more affordable and so
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that's why I tend to use it.
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If I do, however, there are limitations.
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So Fentermine is basically, I believe it's
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a sympathomimetic, don't quote me on that
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actually.
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It is a stimulant and it reduces appetite and
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patients really love it, honestly, because it
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gives them energy.
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It reduces their appetite.
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They feel super great.
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Potential contraindications are if they
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have any cardiac history at all, it can
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elevate the blood pressure.
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It can cause tachycardia because again, it's
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a stimulant.
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So in those patients, it's not recommended
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and contraindicated and it's only indicated
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for 12 weeks of use, FDA.
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So I tell that to patients, it's really
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just a short-term medication.
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And the way that I phrase it is that it's
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an adjunct to what you're currently doing to
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kind of jumpstart the weight loss.
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Because as soon as you take away that
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medication, the appetite is going to go back
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to what it used to be.
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And the goal kind of, it's not that your
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stomach necessarily shrinks, but your
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stomach gets physically used to smaller
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portion sizes.
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And so portion size after being off of
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the medication will hopefully sustain because
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your body has acclimatized to that.
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So that's kind of how I phrase it for
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patients.
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I also let them know if they have any
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chest pain or dizziness or things like
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that to let me know.
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And then we stop that medication.
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When it comes to monitoring for
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Fentermine, I usually do monthly visits
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for any medication.
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I actually usually do monthly visits to
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not to make their life harder, but to
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measure their, especially for Fentermine
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because it's a short-term use medication.
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I'll measure their blood pressure,
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their heart rate and how it's going.
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Do they have any side effects?
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How, what is their weight?
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Typically what we expect to see with
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Fentermine is a four to 5% weight loss
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over the course of those 12 weeks.
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And so we want to see if it's, if
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it's efficacious, right?
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Is it working?
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Is it meeting their goals?
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And I actually want to pop back to,
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um, contraindications for GLP-1 for
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low-riglutide.
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If they have a personal history of
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pancreatitis, family history of
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thyroid medullary cancer, or multiple
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endocrine neoplasia, I think it's
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types 2A and 2B, which is like super
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random, but if somebody has that in
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their history, it's MEN, multiple
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endocrine neoplasia.
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Those are absolute contraindications
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for GLP-1 agonists.
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Anyway, so those are the main
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medications and their main side
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I don't really have any contraindications
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off the top of my head that I know
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of for Orlistat.
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It's a pretty safe medications.
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The approach is generally speaking,
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we want to see, we want to establish
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what their goal weight is and it's
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expected to have about a four to
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5% weight loss over the course
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of three to six months, maintain
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that and then continue on the
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path forward.
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It's cause I think a lot of people
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think they're going to drop a
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whole bunch of weight.
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They're going to drop a hundred
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pounds right away, and then they're
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going to just arrive and stay there.
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And that's not how that works.
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So that's the general guidelines
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of practice, but the reason
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for having those periodic visits
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either monthly or every three
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months, just checking in, because
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again, this, if you go back to
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last week's video, this is a
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chronic kind of condition
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that are not even a condition.
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It just takes time.
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It takes consistency.
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It takes time and it doesn't
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matter if we get here tomorrow,
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if we get here in two years,
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we're still going to arrive.
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Right. And so that's my thing
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with patients is that like slow
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and steady wins the race.
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So like, let's just do this
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together. I'm here to support
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you. So hopefully this video is
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helpful. I'm trying to be a little
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bit more off the cuff and
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hopefully this was helpful.
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But let me know what questions
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you have and thank you so
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much for watching.
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Hang in there and I'll talk to you
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soon.
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That's our episode for today.
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00:13:10.950 --> 00:13:12.710
Thank you so much for listening.
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00:13:13.070 --> 00:13:14.450
Make sure you subscribe,
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00:13:14.790 --> 00:13:16.270
leave a review and tell all
322
00:13:16.270 --> 00:13:18.210
your NP friends so together
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00:13:18.210 --> 00:13:19.710
we can help as many nurse
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practitioners as possible, give
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the best care to their patients.
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00:13:23.370 --> 00:13:24.950
If you haven't gotten your copy
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00:13:24.950 --> 00:13:26.410
of the ultimate resource guide
328
00:13:26.410 --> 00:13:28.650
for the new NP, head over to
329
00:13:28.650 --> 00:13:31.070
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00:13:31.490 --> 00:13:33.070
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00:13:34.390 --> 00:13:36.070
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333
00:13:36.470 --> 00:13:37.730
patient stories and extra
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00:13:37.730 --> 00:13:39.230
bonuses I really just don't
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00:13:39.230 --> 00:13:40.330
share anywhere else.
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00:13:40.730 --> 00:13:41.930
Thank you so much again for
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00:13:41.930 --> 00:13:43.410
listening. Take care and talk
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00:13:43.410 --> 00:13:43.670
soon.
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