|Systematic (IUPAC) name|
|Trade names||Xenical, alli|
|Licence data||EMA: , US FDA:|
|Pregnancy cat.||B1 (AU) X (US)|
|Legal status||Pharmacist Only (S3) (AU) P (UK) OTC (US)|
|Metabolism||In the GI tract|
|Half-life||1 to 2 hours|
|Mol. mass||495.735 g/mol|
|(what is this?)|
Orlistat (also known as tetrahydrolipstatin) is a drug designed to treat obesity. It is marketed as a prescription drug under the trade name Xenical by Roche in most countries, and is sold over-the-counter as Alli by GlaxoSmithKline in the United Kingdom and the United States. Its primary function is preventing the absorption of fats from the human diet by acting as a lipase inhibitor, thereby reducing caloric intake. It is intended for use in conjunction with a healthcare provider-supervised reduced-calorie diet.
Orlistat is the saturated derivative of lipstatin, a potent natural inhibitor of pancreatic lipases isolated from the bacterium Streptomyces toxytricini. However, due to its relative simplicity and stability, orlistat was chosen over lipstatin for development as an anti-obesity drug.
The effectiveness of orlistat in promoting weight loss is definite, though modest. Pooled data from clinical trials suggest that people given orlistat in addition to lifestyle modifications, such as diet and exercise, lose about 2–3 kilograms (4.4–6.6 lb) more than those not taking the drug over the course of a year. Orlistat also modestly reduces blood pressure, and appears to prevent the onset of type 2 diabetes, whether due to weight loss itself or to other effects; in a large randomized controlled trial, orlistat was found to reduce the incidence of diabetes by nearly 40% in obese people.
Orlistat is notorious for its gastrointestinal side effects (sometimes referred to as treatment effects), which can include steatorrhea (oily, loose stools). These decrease with time, however, and are the most frequently reported adverse effects of the drug. In the United States, the European Union, and Australia, orlistat is available for sale without a prescription. Over-the-counter approval was controversial in the United States, with consumer advocacy group Public Citizen repeatedly opposing it on safety and efficacy grounds. Generic formulations of orlistat are available in some countries.
At times, such as in spring 2012, orlistat has come into short supply, with consequent price increases because of nonavailability of one of the drug's components.
Orlistat is used for the treatment of obesity. The amount of weight loss achieved with orlistat varies. In one-year clinical trials, between 35.5% and 54.8% of subjects achieved a 5% or greater decrease in body mass, although not all of this mass was necessarily fat. Between 16.4% and 24.8% achieved at least a 10% decrease in body fat. After orlistat was stopped, a significant number of subjects regained weight—up to 35% of the weight they had lost.
The incidence of type 2 diabetes in an obese population over four years is decreased with orlistat (6.2%) compared to placebo (9.0%). Long-term use of orlistat also leads to a modest reduction in blood pressure (mean reductions of 2.5 and 1.9 mmHg in systolic and diastolic blood pressure respectively).
- Hypersensitivity to orlistat
- Reduced gallbladder function (e.g. after cholecystectomy)
- Pregnancy and breastfeeding
- Use caution with: obstructed bile duct, impaired liver function, and pancreatic disease
The primary side effects of the drug are gastrointestinal-related, and include steatorrhea (oily, loose stools with excessive flatus due to unabsorbed fats reaching the large intestine), fecal incontinence and frequent or urgent bowel movements. GlaxoSmithKline recommends that all users be cautious of the possible side effects until they "have a sense of any treatment effects". To minimize these effects, foods with high fat content should be avoided; the manufacturer advises consumers to follow a low-fat, reduced-calorie diet. Oily stools and flatulence can be controlled by reducing the dietary fat content to somewhere in the region of 15 grams per meal. The manual for Alli makes it clear that orlistat treatment involves aversion therapy, encouraging the user to associate eating fat with unpleasant treatment effects.
According to Roche, side effects are most severe when beginning therapy and may decrease in frequency with time; this is supported by the results of the XENDOS study, which found that only 36% of people had gastrointestinal adverse effects during their fourth year of taking orlistat, whereas 91% of study subjects had experienced at least one GI-related side effect during the first year of treatment. It has also been suggested that the decrease in side effects over time may be associated with long-term compliance with a low-fat diet.
The side effect profile of orlistat led US consumer group Prescription Access Litigation (PAL) to award its first 2007 "Bitter Pill Award" to GlaxoSmithKline—the 'With Allies Like This, Who Needs Enemas?' Award.
On 26 May 2010, the U.S. Food and Drug Administration (FDA) approved a revised label for Xenical to include new safety information about cases of severe liver injury that have been reported rarely with the use of this medication.
An analysis of over 900 orlistat users in Ontario showed that their rate of acute kidney injury was more than triple that of non-users. The putative mechanism for this effect is postulated to be excessive oxalate absorption from the gut and its subsequent deposition in the kidney, with excessive oxalate absorption being a known consequence of fat malabsorption.
An April 2013 study published in the British Medical Journal  looked at 94,695 patients receiving orlistat in the UK between 1999 and 2011. This study showed no evidence of an increased risk of liver injury during treatment. They concluded:
- The incidence of acute liver injury was higher in the periods both immediately before and immediately after the start of orlistat treatment. This suggests that the observed increased risks of liver injury linked to the start of treatment may reflect changes in health status associated with the decision to begin treatment rather than any causal effect of the drug.
Despite a higher incidence of breast cancer amongst those taking orlistat in early, pooled clinical trial data—the analysis of which delayed FDA review of orlistat—a two-year study published in 1999 found similar rates between orlistat and placebo (0.54% versus 0.51%), and evidence that tumors predated treatment in 3 of the 4 participants who had them. There is evidence from an in vitro study to suggest that the introduction of specific varied preparations containing orlistat, namely the concurrent administration of orlistat and the monoclonal antibody trastuzumab, can induce cell death in breast cancer cells and block their growth.
Absorption of fat-soluble vitamins and other fat-soluble nutrients is inhibited by the use of orlistat. A multivitamin tablet containing vitamins A, D, E, K, and beta-carotene should be taken once a day, at bedtime, when using orlistat.
On 4 June 2009, the U.S. Food and Drug Administration released its quarterly list of drugs that are under investigation for potential safety issues or new safety information. Orlistat was included in the list as having a "Potential Signal of Serious Risk" of liver toxicity, meaning that a potential risk of liver toxicity was identified based on reports to the FDA Adverse Event Reporting System between October and December 2008. Isolated cases of orlistat-associated liver problems have been reported before. On 24 August, the FDA reported that it would investigate 30 cases of liver damage reported between 1999 and October 2008 in patients taking orlistat, including six cases of liver failure.
Orlistat may reduce plasma levels of ciclosporin (also known as "cyclosporin" or "cyclosporine", trade names Sandimmune, Gengraf, Neoral, etc.), an immunosuppressive drug frequently used to prevent transplant rejection; the two drugs should therefore not be administered concomitantly. Orlistat can also impair absorption of the antiarrhythmic amiodarone.
Mechanism of action
Orlistat works by inhibiting gastric and pancreatic lipases, the enzymes that break down triglycerides in the intestine. When lipase activity is blocked, triglycerides from the diet are not hydrolyzed into absorbable free fatty acids, and are excreted undigested instead. Only trace amounts of orlistat are absorbed systemically; the primary effect is local lipase inhibition within the GI tract after an oral dose. The primary route of elimination is through the feces.
Orlistat was also recently found to inhibit the thioesterase domain of fatty acid synthase (FAS), an enzyme involved in the proliferation of cancer cells but not normal cells. However, potential side effects of Orlistat, such as inhibition of other cellular off-targets or poor bioavailability, might hamper its application as an effective antitumor agent. One profiling study undertook a chemical proteomics approach to look for new cellular targets of orlistat, including its off-targets. Orlistat also show potential activities mycobacteria and Trypanosoma brucei parasite (See further reading).
At the standard prescription dose of 120 mg three times daily before meals, orlistat prevents approximately 30% of dietary fat from being absorbed, and about 25% at the standard over-the-counter dose of 60 mg. Higher doses do not produce more potent effects.
Orlistat has historically been available by prescription only, and this situation continues in Canada. In Australia, the European Union, and the United States, certain formulations of orlistat have been approved for sale without a prescription.
Australia and New Zealand
In Australia and New Zealand, orlistat is currently[update] available over-the-counter in 120 mg size (84 capsules to the pack). Initially available only with a prescription, it was reclassified as a "Pharmacist Only Medicine" in October 2003. In late 2006, the Australian Consumers' Association complained that Roche was inappropriately advertising the drug to teenagers, and Roche was forced to withdraw its ads. The Association filed further complaints with the Therapeutic Goods Administration—TGA, Australia's regulatory authority for healthcare products—and the TGA's Scheduling Committee agreed to convene on 20 February 2007, to discuss possible revoking of orlistat's over-the-counter status. The Committee ultimately decided to keep orlistat as a Schedule 3 drug, but withdrew its authorization of direct-to-consumer Xenical advertising, stating this "increased pressure on pharmacists to provide orlistat to consumers...this in turn had the potential to result in inappropriate patterns of use". Xenical has recently[when?] began being advertised direct-to-customers again.
On 23 January 2006, a U.S. Food and Drug Administration advisory panel voted 11 to 3 to recommend the approval of an OTC formulation of orlistat, to be marketed under the name alli // by GlaxoSmithKline. Approval was granted on 7 February 2007, and alli became the first weight loss drug officially sanctioned by the U.S. government for over-the-counter use. Consumer advocacy organization Public Citizen, through its Health Research Group, opposed over-the-counter approval for orlistat, calling it "the height of recklessness" and "a dangerous mistake" due to questionable benefits and possible adverse effects. Public Citizen had already called for a ban of orlistat in April 2006.
U.S. patent protection for Xenical, originally to end on 18 June 2004, was extended by five years (until 2009) by the U.S. Patent and Trademark Office. The extension was granted on 20 July 2002, and expired on 18 June 2009.
Generic orlistat is available in Iran under the brand Venustat manufactured by Aburaihan Pharmaceutical co., in India, under the brands Orlean (Eris), Vyfat, Olistat, Obelit, Orlica and Reeshape. In Russia, orlistat is available under the brand names Xenical (Hoffmann–La Roche), Orsoten/Orsoten Slim (KRKA d. d.) and Xenalten (OBL-Pharm). In Malaysia, orlistat is available under the brand name Cuvarlix and is marketed by Pharmaniaga.
In January 2010, the U.S. Food and Drug Administration issued an alert stating that some counterfeit versions of Alli sold over the Internet contain no orlistat, and instead contain the weight-loss drug sibutramine. The concentration of sibutramine in these counterfeit products is at least twice the amount recommended for weight loss.
- Zhi J, Melia AT, Eggers H, Joly R, Patel IH (1995). "Review of limited systemic absorption of orlistat, a lipase inhibitor, in healthy human volunteers". J Clin Pharmacol 35 (11): 1103–8. doi:10.1002/j.1552-4604.1995.tb04034.x. PMID 8626884.
- Stylized with a lowercase a on the packaging, and a bar over the i (that is, "allī"), but capitalized conventionally in the manual.
- Bodkin J, Humphries E, McLeod M (2003). "The total synthesis of (−)-tetrahydrolipstatin". Australian Journal of Chemistry 56 (8): 795–803. doi:10.1071/CH03121.
- "What are the benefits?". Retrieved 13 July 2013.
- Barbier P, Schneider F (1987). "Syntheses of tetrahydrolipstatin and absolute configuration of tetrahydrolipstatin and lipstatin". Helvetica Chimica Acta 70 (1): 196–202. doi:10.1002/hlca.19870700124.
- Pommier A, Pons M, Kocienski P (1995). "The first total synthesis of (-)-lipstatin". Journal of Organic Chemistry 60 (22): 7334–7339. doi:10.1021/jo00127a045.
- Padwal R, Li SK, Lau DC (2004). "Long-term pharmacotherapy for obesity and overweight". In Padwal, Raj S. Cochrane Database Syst Rev (3): CD004094. doi:10.1002/14651858.CD004094.pub2. PMID 15266516.
- Torgerson J, Hauptman J, Boldrin M, Sjöström L (2004). "XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients". Diabetes Care 27 (1): 155–61. doi:10.2337/diacare.27.1.155. PMID 14693982.
- "Orlistat Side Effects".
- Schmid, Randolph E (9 February 2007). "FDA OKs First Nonprescription Diet Pill". USA Today. Retrieved 9 June 2009.
- Jeanne Whalen (20 April 2012). "Glaxo Sells Bulk of Over-the-Counter Drugs". The Wall Street Journal. "Glaxo said the issue wasn't a lack of interested buyers, but manufacturing problems that have led to shortages of the diet pill and forced the company to delay the product's sale."
- "Xenical Pharmacology, Pharmacokinetics, Studies, Metabolism". RxList.com. 2007. Retrieved 16 March 2007.
- Siebenhofer A, Horvath K, Jeitler K, et al. (July 2009). "Long-term effects of weight-reducing drugs in hypertensive patients". In Siebenhofer, Andrea. Cochrane Database Syst Rev 8 (3): CD007654. doi:10.1002/14651858.CD007654.pub2. PMID 19588440.
- Roche Pharmaceuticals (July 2008). "Xenical". Roche. Retrieved 19 February 2007.
- "Treating Obesity". NHS. Retrieved 13 July 2013.
- "myalli.com – what are treatment effects?". Archived from the original on 25 June 2007. Retrieved 24 June 2007.
- Hall, Carla (15 June 2007). "New diet drug touches off a feeding frenzy". Los Angeles Times. Retrieved 20 June 2007.[dead link]
- "FDA Approves alli (orlistat 60 mg capsules) Over-The-Counter" (Press release). PRNewswire. 7 February 2007. Archived from the original on 24 August 2007. Retrieved 8 April 2007.
- From page 12 of the Alli Companion Guide, 2007 edition: "They can be an incentive to keep from eating more fat than you really intend to."
- Mancini MC, Halpern A (2006). "Pharmacological treatment of obesity". Arq Bras Endocrinol Metab 50 (2): 377–89. doi:10.1590/S0004-27302006000200024. PMID 16767304. Free full text with registration
- Cohen, Deborah (25 September 2007). "A bitter pill for slimmers?". The Guardian (London). Retrieved 22 January 2009.
- "PAL Announces First Bitter Pill Award of 2007 to GlaxoSmithKline: 'With Allies Like This, Who Needs Enemas?' Award" (Press release). Prescription Access Litigation. 7 June 2007. Retrieved 22 January 2009.
- Douglas, Ian J; Julia Langham; Krishnan Bhaskaran; Ruth Brauer; and Liam Smeeth (2013). "Orlistat and the risk of acute liver injury: self controlled case series study in UK Clinical Practice Research Datalink". BMJ. doi:10.1136/bmj.f1936.
- Kolata, Gina (20 January 1999). "Obesity Drug Can Lead to Modest Weight Loss, Study Finds". The New York Times. Retrieved 11 December 2007.
- Davidson MH, Hauptman J, DiGirolamo M, et al. (1999). "Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial". JAMA 281 (3): 235–42. doi:10.1001/jama.281.3.235. PMID 9918478.
- J. A. Menendez, L. Vellon and R. Lupu (2005). "Antitumoral actions of the anti-obesity drug orlistat (XenicalTM) in breast cancer cells: blockade of cell cycle progression, promotion of apoptotic cell death and PEA3-mediated transcriptional repression of Her2/neu (erbB-2) oncogene". Annals of Oncology 16 (8): 1253–1267. doi:10.1093/annonc/mdi239. PMID 15870086.
- Garcia S, da Costa Barros L, Turatti A, Martinello F, Modiano P, Ribeiro-Silva A, de Oliveira Vespúcio M, Uyemura S (2006). "The anti-obesity agent Orlistat is associated to increase in colonic preneoplastic markers in rats treated with a chemical carcinogen". Cancer Lett 240 (2): 221–4. doi:10.1016/j.canlet.2005.09.011. PMID 16377080.
- Takayama T, Katsuki S, Takahashi Y, Ohi M, Nojiri S, Sakamaki S, Kato J, Kogawa K, Miyake H, Niitsu Y (1998). "Aberrant crypt foci of the colon as precursors of adenoma and cancer" (PDF). N Engl J Med 339 (18): 1277–84. doi:10.1056/NEJM199810293391803. PMID 9791143.
- "Vitamin A".
- "Potential Signals of Serious Risks/New Safety Information Identified from the Adverse Event Reporting System (AERS) between October - December 2008". U.S. Food and Drug Administration. 4 June 2009. Retrieved 8 June 2009.
- Filippatos TD, Derdemezis CS, Gazi IF, Nakou ES, Mikhailidis DP, Elisaf MS (2008). "Orlistat-associated adverse effects and drug interactions: a critical review". Drug Saf 31 (1): 53–65. doi:10.2165/00002018-200831010-00005. PMID 18095746.
- "U.S. probes Roche, Glaxo diet drug over liver injury". ABC News. 24 August 2009. Retrieved 24 August 2009.
- Zhi J, Moore R, Kanitra L, Mulligan TE (2003). "Effects of orlistat, a lipase inhibitor, on the pharmacokinetics of three highly lipophilic drugs (amiodarone, fluoxetine, and simvastatin) in healthy volunteers". J Clin Pharmacol 43 (4): 428–35. doi:10.1177/0091270003252236. PMID 12723464.
- PDB 2PX6; Pemble CW, Johnson LC, Kridel SJ, Lowther WT (August 2007). "Crystal structure of the thioesterase domain of human fatty acid synthase inhibited by Orlistat". Nat. Struct. Mol. Biol. 14 (8): 704–9. doi:10.1038/nsmb1265. PMID 17618296.
- 2006 Physicians' Desk Reference (PDR). Thomson PDR. 2006. ISBN 1-56363-527-5.
- "myalli.com – frequently asked questions". GlaxoSmithKline. 2007. Archived from the original on 12 July 2007. Retrieved 18 August 2007.
- Parker-Pope, Tara. "Weighing the Pros and Cons Of New Fat-Blocking Drug Alli", The Wall Street Journal, 19 June 2007, pp. D1. Retrieved on 2007-08-18.
- "Chemists to provide obesity pill". BBC News Online. 21 January 2009. Retrieved 22 January 2009.
- ClinicalTrials.gov NCT00940628
- "Drug advertising: Xenical". CHOICE. February 2007. Retrieved 16 February 2007.
- Bissett, Kelvin (5 February 2007). "Weight drugs danger revealed". The Daily Telegraph. Retrieved 16 February 2007.
- "Scheduling of orlistat" (Press release). Australian Therapeutic Goods Administration. 22 February 2007. Retrieved 3 March 2007.
- "Panel Supports Offering Diet Pill Orlistat Over the Counter". The Washington Post. 24 January 2006. pp. A02. Retrieved 10 August 2006.
- "FDA Approves Orlistat for Over-the-Counter Use" (Press release). U.S. Food and Drug Administration (FDA). 7 February 2007. Retrieved 7 February 2007.
- Saul, Stephanie (7 February 2007). "Weight-Loss Drug to Be Sold Over the Counter". The New York Times. Retrieved 10 February 2007.
- Press Release. Public Citizen Petitions FDA to Ban Xenical (orlistat). Public Citizen.
- "GlaxoSmithKline receives European Commission approval to market alli (orlistat 60mg)" (Press release). GlaxoSmithKline. 21 January 2009. Retrieved 22 January 2009.
- Rogan, James E. (30 July 2002). "Certificate Extending Patent Term Under 35 U.S.C. § 156". United States Patent and Trademark Office. Retrieved 8 April 2007.
- "Drug Patent Expirations in June 2009". DrugPatentWatch.com, in "Drug Patent Expirations in June 2009". Biotech Blog. 1 June 2009. Retrieved 20 June 2009.
- Devarajan, Uma (1 March 2009). "Fatty issues". The Deccan Chronicle. Retrieved 26 November 2009.
- "Fake Alli diet pills can pose health risks". CNN. 23 January 2010. Retrieved 24 January 2010.
- Boehm, Marcus F.; McClurg, Michael R.; Pathirana, Charles; Mangelsdorf, David; White, Steven K.; Hebert, Jonathan; Winn, David; Goldman, Mark E.; Heyman, Richard A. (1994). "Synthesis of high specific activity tritium-labeled [3H]-9-cis-retinoic acid and its application for identifying retinoids with unusual binding properties". Journal of Medicinal Chemistry 37 (3): 408–14. doi:10.1021/jm00029a013. PMID 8308867.
- Hanessian, Stephen; Tehim, Ashok; Chen, Ping (1993). "Total synthesis of (-)-tetrahydrolipstatin". The Journal of Organic Chemistry 58 (27): 7768. doi:10.1021/jo00079a022.
- Peng-Yu, Yang; Kai, Liu; Hong Ngai, Mun; J.Lear, Martin; R.Wenk, Markus; S.Qin, Yao (2010). "Activity-based proteome profiling of potential cellular targets of Orlistat−an FDA-approved drug with anti-tumor activities". Journal of the American Chemical Society 132 (2): 656. doi:10.1021/ja907716f. PMID 20028024.
- Peng-Yu, Yang; Min, Wang; Kai, Liu; Omar, Sheriff; J.Lear, Martin; Siu Kwan, Sze; Cynthia Y., He; S.Qin, Yao; Yao, Shao Q. (2012). "Parasite-based screening and proteome profiling reveal orlistat, an FDA-approved drug, as a potential anti Trypanosoma brucei agent". Chemistry-A European Journal 18 (27): 8403–13. doi:10.1002/chem.201200482. PMID 22674877.
- Official US Alli site from GlaxoSmithKline
- Official UK Alli site from GlaxoSmithKline
- Official Xenical site from Roche
- Official Philippines (Asia) Xenical site from Roche
- FDA Consumer Info at the Wayback Machine (archived January 26, 2008)