Pharmacotherapy for obesity management in adults: 2025 clinical practice guideline update.

BACKGROUND

Pharmacotherapy is a key component of comprehensive obesity management, alongside behavioural therapy and metabolic and bariatric surgery. In this guideline, we update the pharmacotherapy recommendations in the 2020 Canadian clinical practice guideline on obesity in adults and in the 2022 pharmacotherapy for obesity management revision to provide current recommendations for clinicians on the efficacy, safety, and appropriate use of pharmacotherapy in the management of obesity in adults.

METHODS

This guideline update follows the same methodology as the 2020 Canadian guideline on obesity in adults, adhering to the Appraisal of Guidelines for Research and Evaluation instrument and using the Shekelle framework to assess and grade evidence and to formulate recommendations. Building on the search conducted for the 2022 pharmacotherapy revision, we conducted a systematic literature review (search dates January 2022 to July 2024), supplemented by relevant trials published through May 2025, to identify studies assessing the efficacy of pharmacotherapy for weight management. We also conducted 13 targeted searches on the management of weight-related complications in 13 subpopulations with important adiposity-related health issues. We engaged primary care physicians, obesity medicine specialists, and people with lived experience of obesity to provide feedback on the recommendations.

RECOMMENDATIONS

This update includes 6 new and 7 revised recommendations since the 2022 pharmacotherapy guideline revision (all 2020 pharmacotherapy recommendations are updated). Measures of central adiposity, in addition to ethnicity-specific body mass index and adiposity-related complications, should be used to guide the decision to initiate pharmacotherapy. Obesity pharmacotherapy should be used in conjunction with health behaviour changes and individualized based on a person's specific health needs and in keeping with their values and preferences. Recommendations support long-term use of obesity pharmacotherapy for sustained weight loss and maintenance of weight loss. We provide recommendations for use of specific obesity pharmacotherapies with proven benefit in specific subpopulations - atherosclerotic cardiovascular disease, heart failure with preserved ejection fraction, metabolic dysfunction-associated steatohepatitis, prediabetes, type 2 diabetes, obstructive sleep apnea, osteoarthritis - and for those with certain specific monogenic causes of obesity. We recommend against the use of compounded medications or medications other than those approved for weight loss in people with excess adiposity.

INTERPRETATION

Pharmacotherapy in obesity facilitates clinically meaningful weight loss and important improvements in obesity-related health complications. Clinicians who treat people with obesity with or without obesity-related health complications should appropriately use pharmacotherapy as an integral part of their treatment paradigm.