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Orlistat 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
Orlistat is the saturated derivative of lipstatin, a potent natural inhibitor of pancreatic lipases isolated from the bacterium Streptomyces toxytricini.
The effectiveness of orlistat in promoting weight loss is definite but 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.
Benefits aside, however, orlistat is notorious for its gastrointestinal side effects (sometimes referred to as treatment effects ), which can include steatorrhea (oily, loose stools). They decrease with time, however, and are the most frequently reported adverse effects of the drug.
Contents
1 Medical uses
2 Contraindications
3 Side effects
3.1 Long-term
3.2 Precautions
3.3 Interactions
4 Mechanism of action
5 Legal status
5.1 Australia and New Zealand
5.2 United States
5.3 European Union
5.4 Generic formulations
6 Society and culture
6.1 Cost
6.2 Counterfeit products
7 See also
8 References
9 Further reading
Medical uses
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.
Contraindications
Orlistat is contraindicated in:
Malabsorption
Hypersensitivity to orlistat
Reduced gallbladder function (e.g. after cholecystectomy )
Pregnancy and breastfeeding
Anorexia and Bulimia
Use caution with: obstructed bile duct, impaired liver function, and pancreatic disease
Side effects
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.
Side effects are most severe when beginning therapy and may decrease in frequency with time;
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.
Long-term
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
Fecal fat excretion promotes colon carcinogenesis. In 2006 the results of 30-day study were published indicating that orlistat at a dosage of 200 mg/kg chow administered to rats consuming a high-fat chow and receiving two 25 mg/kg doses of the potent carcinogen 1,2-dimethylhydrazine produced significantly higher numbers of aberrant crypt foci (ACF) colon lesions than did the carcinogen plus high-fat chow without orlistat.
Precautions
Absorption of fat-soluble vitamins and other fat-soluble nutrients is inhibited by the use of orlistat. A multivitamin tablet containing vitamins A,
Interactions
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.
Mechanism of action
Crystallographic structure of human fatty acid synthase (rainbow color, N-terminus = blue, C-terminus = red) inhibited by orlistat ( space-filling model ; carbon = grey, oxygen = red, nitrogen = blue).
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 instead are excreted unchanged. 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.
Legal status
Packaging of orlistat (Xenical) 120 mg capsules, as sold in Canada
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 has been available as a ” Pharmacist Only Medicine since 2000.
United States
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 / ˈ æ l aɪ / by GlaxoSmithKline.
Consumer advocacy organization Public Citizen opposed over-the-counter approval for orlistat.
Alli became available in the U.S. in June 2007. It is sold as 60 mg capsules—half the dosage of prescription orlistat.
European Union
On 21 January 2009, the European Medicines Agency granted approval for the sale of orlistat without a prescription.
Generic formulations
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,
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 Austria, orlistat is available under the brand name Slimox. In Malaysia, orlistat is available under the brand name Cuvarlix and is marketed by Pharmaniaga.
Society and culture
Cost
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.
Counterfeit products
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.
See also
Pharmacy and Pharmacology portal
Discovery and development of gastrointestinal lipase inhibitors

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