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Phentermine therapy for obesity does not elevate blood pressure

To the Editor: The report by Kang et al. [1] of a clinical trial with a new diffuse-controlled release of phentermine for obesity is timely because phentermine is currently one of the few remaining approved drugs for obesity pharmacotherapy. We agree that the study data supports the authors’ conclusions that this formulation of phentermine is a safe and effective treatment adjunct for treating obesity. We also agree that further longterm studies of phentermine should be undertaken. In our opinion, phentermine pharmacotherapy for obesity is much safer than is commonly assumed. Phentermine offers a high potential of substantial benefit to obese patients, particularly those with moderate elevations of blood pressure, and it should be the first choice medicine when pharmacotherapy is considered for most obese patients. Kang et al. mentioned that phentermine may elevate blood pressure, even though they observed the opposite effect. Other than a few anecdotes, there is little or no evidence in the peer-reviewed medical literature to support the often repeated conjecture that phentermine, when chronically administered, can elevate blood pressure. The clinical trial reports cited by Kang et al. either did not report blood pressures or reported that phentermine-treated subjects had declines in blood pressure. The meta-analyses cited discuss elevations of blood pressure as adverse effects but provide no supporting data. Average blood pressures are known to decline when obese patients lose weight without pharmacotherapy [2]. Obesity treatment specialists experienced with phentermine have known for some time that average blood pressures also decline in patients when phentermine is added to weight loss therapy. These observations have recently been confirmed in two observational reports from private practices, one short term [3] and the other long term [4]. In clinical trials for Qnexa, a combination of phentermine and topiramate, investigators also observed that the blood pressure declined in treated patients with the most pronounced declines occurring in patients with preexisting hypertension [5]. The long-term phentermine study mentioned above [4] found that phentermine-treated patients with preexisting hypertension had the greatest declines in blood pressure, patients with preexisting prehypertension had lesser declines, while patients with initial optimum blood pressures (<120/80) had no significant blood pressure changes. Long-term phentermine-treated patients had better success with weight loss maintenance and had blood pressure declines that were persistent so long as weight loss was maintained.