Lorcaserin: From Also-Ran to Holy Grail in the NEJM

Back in July, we told you about a landmark cardiovascular outcomes study with lorcaserin. We only had topline results at that point, but we knew that this would be big. Today, we have a publication in the New England Journal of Medicine, an editorial, and lots of hyperbolic buzz in headlines all over the world.

That’s pretty good for a drug that was viewed as a disappointment just one year ago.

Why Is This a Big Deal?

Suddenly, people get it. This really is a big deal. Unfortunately, they don’t seem to know exactly why. It’s featured in the NEJM, so it must be big. That seems to be the thinking. So, they zoom in on the drug itself. “Holy grail diet pill could help millions lose weight in middle age,” says the Telegraph.

But they’ve got it wrong. What’s really important is the milestone that that this study marks for obesity care. For the first time ever, we have solid data that one of these drugs offers much more benefit than harm for people with obesity – over the long term.

This is a five-year study. With 12,000 patients randomly assigned to lorcaserin or placebo. Lorcaserin helped people maintain a lower weight, improve their cardiac risk factors, and avoid progressing to diabetes. Most importantly, though, the cardiovascular safety of the drug was the same as placebo.

Holy Grail?

So, it’s pretty clear that lorcaserin is safe and effective for long-term obesity treatment. This is not really about weight loss. Most all of the weight loss occurs in the first six months. The real point is not losing weight, but gaining better health. Maintaining a healthier weight over time is what yields the health benefits seen in this study.

And yet, these results don’t make lorcaserin a holy grail. Just a solid choice for obesity care. Some people will respond very well and enjoy big benefits. Others might not respond at all and they’ll need to move on to other options.

Julie Ingelfinger and Clifford Rosen take a more cautious tone in the editorial that accompanies this study. They suggest that liraglutide might do a better job of preventing diabetes than lorcaserin does. It’s a reasonable thought, but we don’t have a direct comparison to back it up. And, though we have a big long-term cardiovascular study for liraglutide in diabetes, we don’t have it for the higher doses used in obesity.

So we would say that Ingelfinger and Rosen missed the point, too. This is great news, but not because we’ve found the Holy Grail. It’s great news because it’s a major step toward building a solid evidence base for obesity care.

Much more will follow from this success. We need further progress. But for now, we hope that the folks who worked hard to make this success will enjoy the fruits of their labor.

Click here for the study and here for the editorial. For further perspective from Medscape, click here.

Maiden Carries in The Holy Grail, illustration by Arthur Rackham / WikiArt

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August 27, 2018