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ORIGINAL CONTRIBUTION
Effect of Rimonabant, a Cannabinoid-1
Receptor Blocker, on Weight and
Cardiometabolic Risk Factors
in Overweight or Obese Patients
RIO-North America: A Randomized Controlled Trial
F. Xavier Pi-Sunyer, MD
Louis J. Aronne, MD
Hassan M. Heshmati, MD
Jeanne Devin, MS
Julio Rosenstock, MD
for the RIO-North America
Study Group
R
OUGHLY TWO THIRDS OF US
adults meet the criteria for
overweight or obesity,
1
which
greatly increases the risk of
developing diabetes mellitus and
cardiovascular disease
2
and related
mortality.
3
In addition to weight loss,
obesity management should target
reduction in the cardiometabolic
risk factors of atherogenic dyslipid-
emia, excess abdominal obesity, and
elevated glucose. Modest (approxi-
mately 5% to 10% of body weight)
intentional nonpharmacological
weight loss improves obesity-related
cardiovascular and metabolic abnor-
malities
4
but diet and exercise inter-
ventions have limited long-term suc-
cess. As a result, long-term weight
management remains a challenge for
patients and clinicians.
The endocannabinoid system regu-
lates energy homeostasis through G pro-
tein–coupled cannabinoid-1 recep-
tors
5,6
located in the central nervous
system and in various peripheral
tissues, including adipose tissue, muscle,
For editorial comment see p 826.
Author Affiliations are listed at the end of this
article.
Corresponding Author: F. Xavier Pi-Sunyer, MD,
Obesity Research Center, St Luke’s-Roosevelt Hos-
pital, 1111 Amsterdam Ave, WH1020, New York, NY
10025 (fxp1@columbia.edu).
Context Rimonabant, a selective cannabinoid-1 receptor blocker, may reduce body
weight and improve cardiometabolic risk factors in patients who are overweight or obese.
Objective To compare the efficacy and safety of rimonabant with placebo each in
conjunction with diet and exercise for sustained changes in weight and cardiometa-
bolic risk factors over 2 years.
Design, Setting, and Participants Randomized, double-blind, placebo-
controlled trial of 3045 obese (body mass index ⱖ30) or overweight (body mass in-
dex ⬎27 and treated or untreated hypertension or dyslipidemia) adult patients at 64
US and 8 Canadian clinical research centers from August 2001 to April 2004.
Intervention After a 4-week single-blind placebo plus diet (600 kcal/d deficit) run-in
period, patients were randomized to receive placebo, 5 mg/d of rimonabant, or 20
mg/d of rimonabant for 1 year. Rimonabant-treated patients were rerandomized to
receive placebo or continued to receive the same rimonabant dose while the placebo
group continued to receive placebo during year 2.
Main Outcome Measures Body weight change over year 1 and prevention of weight
regain during year 2. Additional efficacy measures included changes in waist circum-
ference, plasma lipid levels, and other cardiometabolic risk factors.
Results At year 1, the completion rate was 309 (51%) patients in the placebo group,
620 (51%) patients in the 5 mg of rimonabant group, and 673 (55%) patients in the
20 mg of rimonabant group. Compared with the placebo group, the 20 mg of rimona-
bant group produced greater mean (SEM) reductions in weight (−6.3 [0.2] kg vs −1.6
[0.2] kg; P⬍.001), waist circumference (−6.1 [0.2] cm vs −2.5 [0.3] cm; P⬍.001), and
level of triglycerides (percentage change, −5.3 [1.2] vs 7.9 [2.0]; P⬍.001) and a greater
increase in level of high-density lipoprotein cholesterol (percentage change, 12.6 [0.5]
vs 5.4 [0.7]; P⬍.001). Patients who were switched from the 20 mg of rimonabant
group to the placebo group during year 2 experienced weight regain while those who
continued to receive 20 mg of rimonabant maintained their weight loss and favorable
changes in cardiometabolic risk factors. Use of different imputation methods to ac-
count for the high rate of dropouts in all 3 groups yielded similar results. Rimonabant
was generally well tolerated; the most common drug-related adverse event was nau-
sea (11.2% for the 20 mg of rimonabant group vs 5.8% for the placebo group).
Conclusions In this multicenter trial, treatment with 20 mg/d of rimonabant plus diet
for 2 years promoted modest but sustained reductions in weight and waist circumfer-
ence and favorable changes in cardiometabolic risk factors. However, the trial was lim-
ited by a high drop-out rate and longer-term effects of the drug require further study.
Clinical Trials Registration ClinicalTrials.gov Identifier: NCT00029861
JAMA. 2006;295:761-775 www.jama.com
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Figure 1. Flow Diagram of RIO-North America Trial
4604 Patients Screened
3500 Entered Placebo Run-in
214 Completed Study
Treatment Year 2
210 Completed Study
Treatment Year 2
215 Completed Study
Treatment Year 2
225 Completed Study
Treatment Year 2
257 Completed Study
Treatment Year 2
292 Included in Year 2
Primary Analysis
294 Included in Year 2
Primary Analysis
296 Included in Year 2
Primary Analysis
323 Included in Year 2
Primary Analysis
328 Included in Year 2
Primary Analysis
3045 Completed Placebo Run-in
1104 Excluded (Screening Failures)
930 Did Not Meet Inclusion/Met
Exclusion Criteria
2 Adverse Event
77 Withdrew Consent
24 Lost to Follow-up
71 Other
455 Excluded (Run-in Failures)
99 Did Not Meet Inclusion/Met
Exclusion Criteria
39 Adverse Event
184 Withdrew Consent
80 Lost to Follow-up
53 Other
607 Assigned to Receive
Placebo
607 Received Study
Drug as Assigned
1216 Assigned to Receive
5 mg of Rimonabant
1214 Received Study
Drug as Assigned
2 Withdrew Prior to
Receiving Study Drug
1222 Assigned to Receive
20 mg of Rimonabant
1219 Received Study
Drug as Assigned
3 Withdrew Prior to
Receiving Study Drug
298 Discontinued Study
Participation
34 Lack of Efficacy
49 Adverse Event
22 Poor Compliance
137 Patient’s Request
56 Lost to Follow-up
0 Recovery
0 Other
596 Discontinued Study
Participation
63 Lack of Efficacy
122 Adverse Event
58 Poor Compliance
263 Patient’s Request
85 Lost to Follow-up
0 Recovery
5 Other
549 Discontinued Study
Participation
35 Lack of Efficacy
169 Adverse Event
48 Poor Compliance
213 Patient’s Request
79 Lost to Follow-up
1 Recovery
4 Other
590 Included in Year 1
Primary Analysis
1191 Included in Year 1
Primary Analysis
1189 Included in Year 1
Primary Analysis
10 Discontinued Study
Participation After Year 1
18 Discontinued Study
Participation After Year 1
13 Discontinued Study
Participation After Year 1
309 Completed Study
Treatment Year 1
620 Completed Study
Treatment Year 1
673 Completed Study
Treatment Year 1
299 Continued to Receive
Placebo (Placebo/Placebo)
298 Received Study Drug
as Assigned
300 Assigned to Receive
Placebo (5 mg of
Rimonabant/Placebo)
300 Received Study Drug
as Assigned
302 Assigned to Continue
Rimonabant
(5 mg of Rimonabant/5 mg
of Rimonabant)
300 Received Study Drug
as Assigned
333 Assigned to Continue
Rimonabant (20 mg of
Rimonabant/20 mg of
Rimonabant)
333 Received Study Drug
as Assigned
327 Assigned to Receive
Placebo (20 mg of
Rimonabant/Placebo)
326 Received Study Drug
as Assigned
85 Discontinued Study
Participation
10 Lack of Efficacy
20 Adverse Event
7 Poor Compliance
34 Patient’s Request
13 Lost to Follow-up
1 Other
90 Discontinued Study
Participation
10 Lack of Efficacy
21 Adverse Event
0 Poor Compliance
46 Patient’s Request
13 Lost to Follow-up
0 Other
87 Discontinued Study
Participation
10 Lack of Efficacy
25 Adverse Event
5 Poor Compliance
34 Patient’s Request
13 Lost to Follow-up
0 Other
102 Discontinued Study
Participation
12 Lack of Efficacy
20 Adverse Event
5 Poor Compliance
51 Patient’s Request
14 Lost to Follow-up
0 Other
76 Discontinued Study
Participation
5 Lack of Efficacy
20 Adverse Event
7 Poor Compliance
30 Patient’s Request
14 Lost to Follow-up
0 Other
STUDY YEAR 1
3045 Randomized
602 Randomized 660 Randomized
STUDY YEAR 2
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
762 JAMA, February 15, 2006—Vol 295, No. 7 (Reprinted) ©2006 American Medical Association. All rights reserved.
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the gastrointestinal tract, and the liver.
7
While peripheral cannabinoid-1 recep-
tor activation decreases adiponectin pro-
duction in adipocytes,
8
central cannabi-
noid-1 receptor activation in preclinical
studies stimulates eating, decreases
muscle, and stimulates hepatic and adi-
pose tissue lipogenic pathways in ani-
mal models of obesity.
9
In genetic and
diet-induced obesity, rimonabant, a se-
lective cannabinoid-1 receptor blocker,
reduces overactivation of the central
8,10
and peripheral
11,12
endocannabinoid sys-
tem
8,10,13
and prevents weight gain and
associated metabolic disorders, thus re-
vealing a novel strategy for the treat-
ment of obesity and related cardiometa-
bolic disorders.
Table 1. Patient Characteristics at Baseline According to First Randomized Treatment Assignment*
Placebo
(n = 607)
5 mg of Rimonabant
(n = 1214)
P Value vs
Placebo
20 mg of Rimonabant
(n = 1219)
P Value vs
Placebo
Race
White 516 (85.0) 1010 (83.2)
.56
1027 (84.2)
.79
Black 67 (11.0) 140 (11.5) 132 (10.8)
Sex
Male 113 (18.6) 245 (20.2)
.43
230 (18.9)
.90
Female 494 (81.4) 969 (79.8) 989 (81.1)
Age, y
Overall, mean (SD) 44.8 (11.6) 44.4 (11.3) .16 45.6 (11.8) .47
18-44 277 (45.6) 624 (51.4) 560 (45.9)
45-64 304 (50.1) 540 (44.5) 594 (48.7)
ⱖ65 26 (4.3) 50 (4.1) 65 (5.3)
Body mass index
Overall, mean (SD) 37.6 (6.4) 38.0 (6.7) .16 37.2 (6.2) .35
ⱕ27 0 0 1 (⬍0.1)
⬎27-⬍30 16 (2.6) 25 (2.1) 27 (2.2)
ⱖ30-⬍35 207 (34.1) 397 (32.7) 465 (38.1)
ⱖ35-⬍40 189 (31.1) 378 (31.1) 347 (28.5)
ⱖ40 195 (32.1) 414 (34.1) 379 (31.1)
Weight, mean (SD), kg 105.0 (21.8) 105.5 (21.9) .06 103.0 (20.3) .65
Waist circumference, mean (SD), cm 106.0 (15.1) 106.5 (15.7) .13 104.9 (15.0) .48
Height, mean (SD), cm 167 (9) 166 (9) .24 166 (9) .55
Lipids, mean (SD), mg/dL
HDL cholesterol 49 (12) 48 (12) .58 49 (13) .72
Triglycerides 133 (73) 139 (78) .36 137 (80) .18
Ratio of total cholesterol to HDL cholesterol,
mean (SD)
4.18 (1.07) 4.26 (1.10) .86 4.19 (1.13) .12
Fasting glucose, mean (SD), mg/dL 92 (11) 92 (11) .52 92 (11) .89
Fasting glucose status
Normal (⬍110 mg/dL) 576 (95.2) 1158 (95.8)
1142 (94.0)
Impaired (110-⬍126 mg/dL) 24 (4.0) 39 (3.2) .68 58 (4.8) .53
Diabetic (ⱖ126 mg/dL) 5 (0.8) 12 (1.0) 15 (1.2)
Fasting insulin, mean (SD), µIU/mL 13.4 (10.0) 12.9 (11.0) .30 12.9 (9.8) .37
Insulin resistance derived from homeostasis
model assessment, mean (SD)
3.1 (2.7) 3.0 (3.5) .42 3.0 (2.7) .53
Blood pressure, mean (SD), mm Hg
Systolic 121.7 (12.4) 121.9 (12.7) .96 121.7 (12.7) .75
Diastolic 78.1 (7.8) 78.2 (8.1) .27 77.7 (8.2) .98
Disease/disorder
Hypertension† 168 (27.7) 367 (30.2) .26 390 (32.0) .06
Dyslipidemia‡ 388 (63.9) 767 (63.2) .76 749 (61.5) .31
The metabolic syndrome§ 192 (31.8) 438 (36.3) .06 419 (34.6) .23
Current smoker 64 (10.5) 102 (8.4) .09 118 (9.7) .30
Abbreviation: HDL, high-density lipoprotein.
SI conversion factors: HDL cholesterol to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply by 0.0113; glucose to mmol/L, multiply by 0.0555.
*Values are expressed as number (percentage) unless otherwise indicated. Continuous parameters were analyzed using analysis of variance and categorical parameters were
analyzed using the
2
test.
†Defined as systolic blood pressure of 140 mm Hg or higher and/or supine diastolic blood pressure of 90 mm Hg or higher.
‡Defined as low-density lipoprotein cholesterol level of 130 mg/dL or higher, HDL cholesterol level of less than 40 mg/dL, and/or triglycerides level of 150 mg/dL or higher.
§Defined as abdominal obesity (waist circumference) of greater than 102 cm for men and of greater than 88 cm for women; triglycerides level of 150 mg/dL or higher; HDL cho-
lesterol level of less than 40 mg/dL for men and less than 50 mg/dL for women; systolic blood pressure of 130 mm Hg or higher and diastolic blood pressure of85mmHgor
higher; and fasting glucose level higher than 110 mg/dL.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, February 15, 2006—Vol 295, No. 7 763
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Table 2. Placebo-Subtracted Changes From Baseline Body Weight and Cardiometabolic Risk Factors for Year 1*
Last Observation Carried Forward Baseline Imputed Repeated Measures
Weight, kg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −1.3 (0.3) −1.2 (0.3) −1.8 (0.4)
95% CI (−2.0 to −0.7) (−1.8 to −0.6) (−2.6 to −0.9)
P value ⬍.001 ⬍.001 ⬍.001
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −4.7 (0.3) −4.2 (0.3) −5.9 (0.4)
95% CI (−5.4 to −4.1) (−4.8 to −3.6) (−6.8 to −5.0)
P value ⬍.001 ⬍.001 ⬍.001
HDL cholesterol, %
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 2.3 (0.9) 1.8 (0.7) 2.4 (1.0)
95% CI (0.6 to 4.0) (0.4 to 3.2) (0.4 to 4.4)
P value .01 .01 .02
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 7.2 (0.9) 6.2 (0.7) 8.6 (1.0)
95% CI (5.6 to 8.9) (4.8 to 7.7) (6.6 to 10.6)
P value ⬍.001 ⬍.001 ⬍.001
Triglycerides, %
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −4.2 (2.3) −4.1 (2.0) −6.6 (2.8)
95% CI (−8.8 to 0.3) (−7.9 to −0.2) (−12.0 to −1.2)
P value .07 .04 .02
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −13.2 (2.3) −11.4 (2.0) −16.1 (2.7)
95% CI (−17.7 to −8.7) (−15.2 to −7.6) (−21.5 to −10.8)
P value ⬍.001 ⬍.001 ⬍.001
Ratio of total cholesterol to HDL cholesterol
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.14 (0.04) −0.10 (0.03) −0.15 (0.04)
95% CI (−0.21 to −0.07) (−0.15 to −0.04) (−0.24 to −0.07)
P value ⬍.001 ⬍.001 ⬍.001
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.28 (0.04) −0.22 (0.03) −0.32 (0.04)
95% CI (−0.35 to −0.21) (−0.28 to −0.16) (−0.40 to −0.23)
P value ⬍.001 ⬍.001 ⬍.001
Waist circumference, cm
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.6 (0.3) −0.6 (0.3) −0.9 (0.4)
95% CI (−1.3 to 0.1) (−1.2 to 0.1) (−1.8 to 0)
P value .08 .08 .05
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −3.6 (0.3) −3.2 (0.3) −4.5 (0.4)
95% CI (−4.3 to −2.9) (−3.9 to −2.6) (−5.4 to −3.7)
P value ⬍.001 ⬍.001 ⬍.001
Fasting glucose, mg/dL
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.38 (0.59) −0.12 (0.49) −0.31 (0.75)
95% CI (−1.54 to 0.77) (−1.09 to 0.84) (−1.78 to 1.16)
P value .52 .80 .68
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.65 (0.59) −0.48 (0.49) −0.69 (0.74)
95% CI (−1.80 to 0.51) (−1.44 to 0.49) (−2.14 to 0.77)
P value .27 .33 .36
Fasting insulin, µIU/mL
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −1.7 (0.7) −1.3 (0.6) −1.7 (0.8)
95% CI (−3.0 to −0.4) (−2.4 to −0.2) (−3.2 to −0.2)
P value .01 .02 .03
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −2.8 (0.7) −2.2 (0.6) −2.7 (0.8)
95% CI (−4.1 to −1.5) (−3.4 to −1.1) (−4.2 to −1.2)
P value ⬍.001 ⬍.001 ⬍.001
(continued)
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
764 JAMA, February 15, 2006—Vol 295, No. 7 (Reprinted) ©2006 American Medical Association. All rights reserved.
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The RIO-North America trial evalu-
ated the efficacy and safety of rimona-
bant in conjunction with a hypoca-
loric diet in promoting reductions in
body weight and waist circumference,
long-term weight maintenance, and
amelioration of cardiometabolic risk
factors in obese and higher-risk over-
weight patients.
METHODS
Patients
Men and women aged 18 years or older
were recruited at 64 US and 8 Cana-
dian clinical research centers between
September 2001 and April 2002
(F
IGURE 1 and TABLE 1). Entry criteria
included body mass index (calculated as
weight in kilograms divided by the
square of height in meters) of 30 or
greater (obese) or body mass index of
higher than 27 (overweight and treated
or untreated dyslipidemia or hyperten-
sion). Patients were excluded if they had
a body weight fluctuation of more than
5 kg in the previous 3 months; clini-
cally significant cardiac, renal, hepatic,
gastrointestinal tract, neuropsychiatric,
or endocrine disorders; drug-treated or
diagnosed type 1 or type 2 diabetes; use
of medications that alter body weight or
appetite; a history or current substance
abuse; or changes in smoking habits or
smoking cessation within the past 6
months. Women with childbearing po-
tential were required to use medically ap-
proved contraception. Determination of
race, a US Food and Drug Administra-
tion requirement, was by patient self-
identification.
Study Design
RIO-North America was a 2-year, ran-
domized, double-blind, placebo-
controlled trial. The institutional re-
view boards at each center reviewed and
approved the study protocol and pa-
tients provided written informed con-
sent before entry into the trial. Follow-
ing a 1-week screening period, patients
were instructed to follow a hypoca-
loric diet (approximately 600 kcal/d
deficit) that was continued during a
4-week placebo, single-blind, run-in pe-
riod and then throughout the double-
blind treatment period. The diet pre-
scription was adjusted to each patient’s
basal metabolic rate estimated by the
Harris-Benedict equation
14
and self-
reported physical activity at screening
and at weeks 24, 52, and 76. Patients
also were instructed to increase their
level of physical activity throughout the
study.
Patients who completed the run-in
period were randomly allocated to 1 of
3 double-blind treatment groups for 1
year: placebo, 5 mg/d of rimonabant, or
20 mg/d of rimonabant. A predefined
randomization schedule assigned pa-
tients using a block size of 5 and a ran-
domization ratio of 1:2:2 to ensure suf-
ficient numbers of rimonabant-
treated patients for a rerandomization
(1:1) for year 2. Rimonabant-treated pa-
tients were rerandomized to receive pla-
cebo or continued to receive the same
rimonabant dose while the placebo
Table 2. Placebo-Subtracted Changes From Baseline Body Weight and Cardiometabolic Risk Factors for Year 1 (cont)
Last Observation Carried Forward Baseline Imputed Repeated Measures
Insulin resistance derived from homeostasis model assessment
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.6 (0.2) −0.4 (0.2) −0.6 (0.3)
95% CI (−1.0 to −0.1) (−0.8 to −0.1) (−1.2 to −0.1)
P value .01 .02 .02
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.8 (0.2) −0.6 (0.2) −0.8 (0.3)
95% CI (−1.2 to −0.4) (−1.0 to −0.3) (−1.4 to −0.3)
P value ⬍.001 ⬍.001 .001
Systolic blood pressure, mm Hg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.2 (0.6) 0.2 (0.5) 0.2 (0.8)
95% CI (−0.9 to 1.4) (−0.9 to 1.2) (−1.3 to 1.7)
P value .69 .72 .81
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.2 (0.6) −0.3 (0.5) −0.3 (0.8)
95% CI (−1.4 to 1.0) (−1.3 to 0.8) (−1.8 to 1.2)
P value .75 .62 .66
Diastolic blood pressure, mm Hg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.5 (0.4) 0.3 (0.4) 0.2 (0.5)
95% CI (−0.3 to 1.3) (−0.5 to 1.0) (−0.8 to 1.2)
P value .24 .47 .73
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.2 (0.4) 0 (0.4) −0.2 (0.5)
95% CI (−0.6 to 1.0) (−0.8 to 0.7) (−1.2 to 0.8)
P value .66 .93 .65
Abbreviations: CI, confidence interval; HDL, high-density lipoprotein cholesterol.
SI conversion factors: HDL cholesterol to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply by 0.0113; glucose to mmol/L, multiply by 0.0555.
*Results shown according to method of imputation.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
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Table 3. Placebo-Subtracted Changes From Baseline in Weight and Cardiometabolic Risk Factors for Year 2 for Patients Who Received the
Same Treatment in Both Years*
Last Observation Carried Forward Baseline Imputed Repeated Measures
Weight, kg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.8 (0.3) −0.8 (0.3) −0.4 (0.8)
95% CI (−1.5 to −0.1) (−1.5 to −0.1) (−1.8 to 0.9)
P value .02 .02 .52
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −3.6 (0.3) −3.5 (0.3) −4.4 (0.7)
95% CI (−4.3 to −3.0) (−4.2 to −2.9) (−5.7 to −3.1)
P value ⬍.001 ⬍.001 ⬍.001
HDL cholesterol, %†
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.5 (1.0) −0.9 (0.8) 1.2 (1.5)
95% CI (−1.5 to 2.5) (−2.4 to 0.6) (−1.8 to 4.2)
P value .60 .25 .44
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 6.3 (1.0) 3.6 (0.8) 9.5 (1.5)
95% CI (4.3 to 8.3) (2.1 to 5.2) (6.6 to 12.4)
P value ⬍.001 ⬍.001 ⬍.001
Triglycerides, %†
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −2.6 (2.5) −1.7 (1.9) −5.1 (3.5)
95% CI (−7.5 to 2.2) (−5.4 to 2.1) (−12.0 to 1.8)
P value .29 .38 .15
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −8.5 (2.5) −5.4 (1.9) −7.4 (3.4)
95% CI (−13.4 to −3.7) (−9.2 to −1.6) (−14.0 to −0.8)
P value ⬍.001 .01 .03
Ratio of total cholesterol to HDL cholesterol
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.08 (0.04) −0.04 (0.03) −0.10 (0.06)
95% CI (−0.16 to 0) (−0.10 to 0.02) (−0.23 to 0.02)
P value .05 .23 .11
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.22 (0.04) −0.15 (0.03) −0.26 (0.06)
95% CI (−0.30 to −0.14) (−0.21 to −0.09) (−0.38 to −0.13)
P value ⬍.001 ⬍.001 ⬍.001
Waist circumference, cm
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.2 (0.4) 0.2 (0.3) −0.5 (0.7)
95% CI (−1.0 to 0.5) (−0.5 to 0.8) (−1.8 to 0.8)
P value .51 .64 .46
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −2.8 (0.4) −1.8 (0.3) −4.0 (0.6)
95% CI (−3.6 to −2.0) (−2.4 to −1.1) (−5.3 to −2.7)
P value ⬍.001 ⬍.001 ⬍.001
Fasting glucose, mg/dL
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.30 (0.68) 0.37 (0.53) 1.57 (1.11)
95% CI (−1.63 to 1.03) (−0.68 to 1.41) (−0.60 to 3.74)
P value .66 .49 .16
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.82 (0.68) −0.26 (0.53) −0.52 (1.06)
95% CI (−2.16 to 0.51) (−1.31 to 0.78) (−2.60 to 1.56)
P value .23 .62 .63
Fasting insulin, µIU/mL
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.2 (0.7) 0.3 (0.6) 0.5 (0.9)
95% CI (−1.2 to 1.7) (−0.9 to 1.4) (−1.2 to 2.2)
P value .77 .65 .58
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −1.8 (0.7) −1.2 (0.6) −1.7 (0.8)
95% CI (−3.3 to −0.4) (−2.4 to 0) (−3.4 to −0.1)
P value .01 .04 .04
(continued)
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
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group continued to receive placebo for
year 2. Randomization was balanced
within each center and stratified by
weight loss (ⱕ2kgor⬎2 kg) during
the run-in period. Medication compli-
ance, defined as consumption of 80%
or greater of tablets, was assessed by tab-
let counting at each specified visit.
Assessments
Initial screening included a medical his-
tory, physical examination, electrocar-
diography, clinical chemistry, thyroid
function, hematology, and urinalysis.
Body weight was measured using a cali-
brated digital or balance scale at screen-
ing, biweekly during the run-in pe-
riod, baseline (randomization), weeks
2 and 4, and then every 4 weeks. Waist
circumference was measured using a
spring-loaded measuring tape mid-
way between the lower rib and iliac
crest and followed the same measure-
ment schedule as body weight.
Fasting serum glucose and insulin
levels were measured at screening, base-
line, every 12 weeks until week 36, at
week 52, every 12 weeks between week
52 and week 88, and at week 104. Se-
rum glucose, insulin, and lipids were
assayed according to standard proce-
dures.
15,16
Low-density lipoprotein cho-
lesterol was measured directly by ul-
tracentrifugation. Metabolic syndrome
status was assessed according to the Na-
tional Cholesterol Education Program
Expert Panel on Detection, Evalua-
tion, and Treatment of High Blood Cho-
lesterol in Adults (Adult Treatment
Panel III) criteria
17
at baseline, year 1,
and year 2.
Safety Evaluations
Each safety evaluation included a physi-
cal examination with collection of vi-
tal signs and recording of adverse
events. Hematology and serum chem-
istry were evaluated every 3 months.
The hospital anxiety and depression
scale,
18
a validated tool for the evalua-
tion of mood and psychological traits
that includes depression and anxiety
subscales, was assessed at screening,
baseline, and at weeks 24, 52, 76, and
104. Electrocardiography screening was
performed every 3 months. Adverse
events were assessed by spontaneous re-
port at each visit.
Statistical Analysis
Sample Size. The sample size was cal-
culated based on the assumption that
the SD of weight change at year 1 would
be 10 kg. Thus 2800 randomized pa-
tients (560 patients in the placebo group
and 1120 patients in each rimonabant
dose group [to ensure sufficient pa-
tients for rerandomization at the end of
year 1]) provided 99% power to de-
tect a 3-kg difference between 1 dose
of rimonabant and placebo after 1 year.
We chose an ␣ level of .025 to ensure
Table 3. Placebo-Subtracted Changes From Baseline in Weight and Cardiometabolic Risk Factors for Year 2 for Patients Who Received the
Same Treatment in Both Years* (cont)
Last Observation Carried Forward Baseline Imputed Repeated Measures
Insulin resistance derived from homeostasis model assessment
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0 (0.2) 0.1 (0.2) 0.3 (0.2)
95% CI (−0.4 to 0.5) (−0.2 to 0.5) (−0.2 to 0.7)
P value .84 .46 .24
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.6 (0.2) −0.3 (0.2) −0.4 (0.2)
95% CI (−1.0 to −0.1) (−0.7 to 0) (−0.8 to 0)
P value .01 .05 .08
Systolic blood pressure, mm Hg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.3 (0.7) 0.7 (0.5) −0.2 (1.1)
95% CI (−0.1 to 1.6) (−0.3 to 1.7) (−2.3 to 1.9)
P value .63 .18 .86
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) −0.3 (0.7) 0.1 (0.5) −0.4 (1.0)
95% CI (−1.6 to 1.0) (−0.9 to 1.1) (−2.4 to 1.6)
P value .63 .87 .70
Diastolic blood pressure, mm Hg
5 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.7 (0.4) 0.8 (0.3) 0.5 (0.7)
95% CI (−0.1 to 1.6) (0.1 to 1.5) (−0.9 to 1.8)
P value .10 .03 .49
20 mg of Rimonabant vs placebo
Least-squares mean difference (SEM) 0.1 (0.4) 0.2 (0.3) −0.5 (0.7)
95% CI (−0.8 to 0.9) (−0.5 to 0.9) (−1.8 to 0.8)
P value .86 .61 .48
Abbreviations: CI, confidence interval; HDL, high-density lipoprotein cholesterol.
SI conversion factors: HDL cholesterol to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply by 0.0113; glucose to mmol/L, multiply by 0.0555.
*Results shown according to method of imputation. P values are for the mean difference between each rimonabant dose and placebo.
†Analyses were performed on percentage changes from baseline.
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an overall type I error rate of .05 ac-
cording to a modified Bonferroni pro-
cedure.
Analysis Populations. Efficacy
analyses were performed at the end of
years 1 and 2. The 1-year modified
intent-to-treat (ITT) population was
defined as all randomized patients
who received at least 1 dose of the
double-blind study drug during the
first year and had at least 1 postbase-
line trial assessment (T
ABLE 2 and
FIGURE 2). The 2-year modified ITT
population for the analysis of the
prevention of weight regain was com-
posed of all randomized patients who
completed year 1, received at least 1
dose of study drug in year 2, and
had at least 1 weight assessment after
rerandomization (T
ABLE 3 and
Figure 2). The modified ITT popula-
tion for the analysis of efficacy over 2
years included patients who received
the same double-blind study drug for
the entire study (including those
who discontinued study participation
during the first year).
Primary and Secondary Efficacy
Analyses. The primary efficacy vari-
able was weight loss over year 1. The
other primary efficacy variable was
prevention of weight regain between
the first and second years expressed as
the change in weight from the end of
the first year (rerandomization base-
line) to the end of year 2.
Other weight-related criteria were the
percentage of patients achieving weight
loss of 5% or greater and weight loss of
10% or greater from baseline to years
1 and 2 and changes in waist circum-
ference. Secondary efficacy end points
were changes in level of high-density
lipoprotein (HDL) cholesterol from
baseline to year 1 and the prevalence
of the metabolic syndrome. Addi-
tional secondary efficacy variables in-
cluded changes from baseline in sys-
tolic and diastolic blood pressure, levels
of fasting glucose and insulin, lipids,
and insulin resistance measured by ho-
meostasis model assessment
19
(HOMA-
IR), which is calculated by multiply-
ing fasting insulin by fasting glucose and
dividing by 22.5.
Primary efficacy analyses were ap-
plied to the ITT population with the last
Figure 2. Change From Baseline for Body Weight and Waist Circumference Over Years 1 and 2
0
–8
–6
–4
–2
–10
No. of Patients
Placebo
5 mg of Rimonabant
20 mg of Rimonabant
Weeks
Body Weight
Change From Baseline, kg
Yea r 1
0
590
1191
1189
12
496
1004
1017
36
347
711
750
24
413
833
863
52
309
619
672
Weeks
Yea r 2
Placebo
20 mg of Rimonabant
5 mg of Rimonabant
Placebo/Placebo
20 mg of Rimonabant/20 mg
of Rimonabant
20 mg of Rimonabant/Placebo
52
292
323
328
0
–8
–6
–4
–2
–10
No. of Patients
Placebo
5 mg of Rimonabant
20 mg of Rimonabant
Weeks
Waist Circumference
Change From Baseline, cm
1187
12
491
995
1013
36
343
706
748
410
830
857
24 52
305
611
667
Weeks
289
322
325
104
216
225
256
92
222
240
263
84
233
261
272
76
247
277
286
68
254
301
297
60
284
315
319
52 104
214
225
257
92
219
238
264
84
231
258
272
76
245
274
287
68
250
297
297
60
281
312
317
No. of Patients
Placebo/Placebo
20 mg of Rimonabant/Placebo
20 mg of Rimonabant/20 mg
of Rimonabant
No. of Patients
Placebo/Placebo
20 mg of Rimonabant/Placebo
20 mg of Rimonabant/20 mg
of Rimonabant
0
585
1187
Error bars indicate SEM.
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observation carried forward (LOCF;
FIGURE 3). Comparisons of the pri-
mary efficacy end point (weight change
from baseline) were conducted using
analysis of variance with the modified
Bonferroni procedure
20
to adjust for
multiple comparisons. The analysis of
variance model included treatment and
randomization stratum (weight loss of
ⱕ2kgor⬎2 kg during the run-in pe-
riod) as fixed effects. Similar analyses
were applied to the secondary efficacy
variables. Because this analysis ex-
cluded repeated measurements made
over the course of the study, a post-
hoc repeated-measures approach was
applied to changes in weight from base-
line using a model that included fixed
effects (randomization stratum, treat-
ment, days after randomization, and
treatment ⫻ days interaction) and a ran-
dom effect for patients. Similar meth-
ods were applied to other efficacy end
points.
The prevention of weight regain dur-
ing year 2 was analyzed using a 2-way
analysis of covariance model includ-
ing rerandomization treatment se-
quence and randomization stratum as
fixed effects and weight loss during year
1 as the covariate. Each rerandomized
dose group (ie, 20 mg of rimonabant
during year 1 and then 20 mg of ri-
monabant during year 2) was com-
pared with the same dose group that
was switched to placebo (ie, 20 mg of
rimonabant during year 1 and then pla-
cebo during year 2).
As an assessment of sensitivity, a
more conservative imputation method
than LOCF for handling missing data
was applied. For study dropouts with
efficacy data and improvement in an
end point, the imputed last value was
defined as a weighted average of the
baseline and LOCF values in which the
weights were defined as the propor-
tion of treatment duration during the
trial. If a study dropout had efficacy data
and showed no improvement in an end
point, the last value was not imputed
because the imputation method would
have provided a better result than the
LOCF. If a study dropout had no effi-
cacy data, the imputed value was set to
the baseline value and the change from
baseline was set to zero.
The percentage of patients losing at
least 5% or 10% of their baseline body
weight in the groups receiving either 20
mg or 5 mg of rimonabant and the per-
centage of patients meeting the Adult
Treatment Panel III criteria
17
for the
metabolic syndrome were compared
with the percentage of patients receiv-
ing placebo using logistic regression.
The estimates of responses in sec-
ondary end points to treatment that
could not be attributed to weight loss
alone were based on standard regres-
sion methods in which weight loss
(change in weight from baseline to 1
year) was introduced as a covariate
(analysis of covariance). The weight-
adjusted analysis of covariance model
for treatment effect was: Y=a ⫹T ⫹
␥W ⫹ e where Y is the efficacy vari-
able, T is the treatment indicator, and
W is weight loss. The weight-
independent portion of the total treat-
ment effect was calculated as the ratio
of the weight-adjusted treatment effect
 to the treatment effect 1 in the over-
all unadjusted analysis of variance
model: Y=a ⫹1T ⫹ e1.
21
This ratio
reflects the proportion of the total effect
size that cannot be explained by weight
loss. All statistical tests were 2-sided at
the .05 significance level except as
noted; all P values presented herein are
unadjusted. Unless otherwise noted, re-
sults are for the ITT population. Sta-
tistical analyses were performed using
SAS software version 8.2 (SAS Insti-
tute Inc, Cary, NC).
Figure 3. Last Observation Carried Forward, Baseline Imputed Measures, and Repeated
Measures for Body Weight and Waist Circumference Over Years 1 and 2
0
–8
–6
–4
–2
–10
Change From Baseline, kg
Last
Observation
Carried Forward
Baseline
Imputed
Repeated
Measures
Body Weight
Last
Observation
Carried Forward
Baseline
Imputed
Repeated
Measures
Year 1 Year 2
0
–8
–6
–4
–2
–10
Change From Baseline, cm
Last
Observation
Carried Forward
Baseline
Imputed
Repeated
Measures
Waist Circumference
Last
Observation
Carried Forward
Baseline
Imputed
Repeated
Measures
Placebo
20 mg of Rimonabant
5 mg of Rimonabant
Placebo/Placebo
20 mg of Rimonabant/20 mg
of Rimonabant
20 mg of Rimonabant/Placebo
Error bars indicate SEM.
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RESULTS
A total of 3045 patients completed the
4-week, placebo run-in and were ran-
domized to double-blind treatment
with placebo (n= 607), 5 mg of
rimonabant (n=1216), or 20 mg of
rimonabant (n=1222). Five random-
ized patients (2 in the group who
received 5 mg of rimonabant and 3 in
the group who received 20 mg of
rimonabant) did not receive double-
blind study medication. The disposi-
tion of patients over 2 years appears
in Figure 1. The characteristics of the
study population at randomization
were similar in the 3 treatment groups
(Table 1).
Year 1 was completed by 51% of pa-
tients (n = 309) in the placebo group,
51% (n =620) in the 5 mg of rimona-
bant group, and 55% (n = 673) in the
20 mg of rimonabant group. More than
98% of patients receiving rimonabant
took more than 80% of the prescribed
study medication. There were no dif-
ferences in compliance between com-
pleters and noncompleters. The
completion rates for rerandomized pa-
tients in year 2 were 72% for patients
who received placebo both years, 70%
for patients who received 5 mg of ri-
monabant in year 1 and placebo in year
2, 69% for patients who received 20 mg
of rimonabant in year 1 and placebo in
year 2, 71% for patients who received
5 mg of rimonabant in both years, and
77% for patients who received 20 mg
of rimonabant in both years.
Weight Loss During Year 1
During the 4-week placebo plus diet
run-in period, body weight decreased
by a mean (SEM) of 1.9 (0.04) kg and
waist circumference by 2.1 (0.08) cm.
Also during this period, level of HDL
cholesterol decreased by a mean (SEM)
of 5.8% (0.2%) and level of triglycer-
ides decreased by 1.2% (0.7%). After
randomization, weight loss from base-
line in the 1-year modified ITT popu-
lation (Figure 2 and Figure 3) was sig-
Figure 4. Change From Baseline Over Year 1 for Levels of High-Density Lipoprotein (HDL) Cholesterol, Triglycerides, and Fasting Insulin
0
Change From Baseline, mg/dL
Last
Observation
Carried Forward
532
1057
1087
Baseline
Imputed
606
1214
1218
Repeated
Measures
532
1057
1087
HDL Cholesterol
End Point Analysis
10
–15
–20
–25
–10
0
–5
5
–30
Change From Baseline, mg/dL
Last
Observation
Carried Forward
532
1058
1088
Baseline
Imputed
606
1212
1214
Repeated
Measures
532
1058
1088
Triglycerides
Placebo
20 mg of Rimonabant
5 mg of Rimonabant
No. of Patients
Placebo
5 mg of Rimonabant
20 mg of Rimonabant
2
0
4
6
–2
8
12
10
10
–15
–20
–25
–10
–5
5
0
–30
Weeks
Change From Baseline, mg/dL
Tre nd
Triglycerides
0
532
1058
1088
52
316
645
697
36
363
734
773
24
436
884
912
12
530
1052
1079
Last
Observation
Carried Forward
532
Baseline
Imputed
606
Repeated
Measures
532
1063 1213 1063
1090 1215 1090
Fasting Insulin
Change From Baseline, µIu/mL
No. of Patients
Placebo
5 mg of Rimonabant
20 mg of Rimonabant
2
0
4
6
8
–2
12
10
Weeks
Change From Baseline, mg/dL
HDL Cholesterol
0
532
1057
1087
52
316
642
698
36
364
732
773
24
436
882
911
12
530
1051
1078
–4.0
–3.0
–2.0
–1.0
4.0
3.0
2.0
1.0
0
–4.0
–3.0
–2.0
–1.0
4.0
3.0
2.0
1.0
Weeks
Change From Baseline, µIu/mL
Fasting Insulin
0
532
1063
1090
52
317
651
701
36
364
742
773
24
438
889
913
12
530
1061
1084
Error bars indicate SEM. To convert HDL cholesterol to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply by 0.0113.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
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nificantly greater in patients receiving
20 mg or 5 mg of rimonabant than in
patients receiving placebo. Similar re-
sults were seen when the data were ex-
pressed as a placebo-subtracted change
from baseline (Table 2). The percent-
age of patients achieving a 5% or greater
weight loss at 1 year was 26.1% for pa-
tients receiving 5 mg of rimonabant
(odds ratio [OR], 1.4; 95% confidence
interval [CI], 1.1-1.8; P =.004), 48.6%
for patients receiving 20 mg of rimona-
bant (OR, 4.1; 95% CI, 3.2-5.2;
P⬍.001), and 20.0% for patients re-
ceiving placebo. The percentage of pa-
tients achieving a 10% or greater weight
loss was 25.2% for patients receiving 20
mg of rimonabant and 8.5% for pa-
tients receiving placebo (OR, 4.0; 95%
CI, 2.9-5.5; P⬍.001). However, only
10.6% of patients receiving 5 mg of ri-
monabant achieved a 10% or greater
weight loss (OR, 1.3; 95% CI, 0.9-
1.8). Compared with the patients re-
ceiving placebo, waist circumference
decreased more in the patients receiv-
ing 20 mg of rimonabant (Figure 2 and
Figure 3).
Weight Loss During Year 2
The 2-year modified ITT population that
was previously treated with 20 mg of ri-
monabant continued treatment with 20
mg of rimonabant and maintained a
mean (SEM) weight loss from baseline
of 7.4 (0.4) kg whereas the participants
who were rerandomized to placebo re-
gained most of their previous weight loss
(Figure 2 and Figure 3). A similar pat-
tern was seen for waist circumference.
Weight Loss in Patients Receiving
the Same Treatment for 2 Years
Compared with patients receiving pla-
cebo, cumulative weight loss was sig-
nificantly greater in patients receiving
20 mg of rimonabant in both years (but
not in those receiving 5 mg of rimona-
bant in both years) (Table 3). A greater
percentage of patients receiving 20 mg
of rimonabant achieved a weight loss
of 5% or greater (40% vs 19% of pa-
tients receiving placebo; OR, 2.9 [95%
CI, 2.3-3.7]; P⬍.001) and 10% or
greater (17% vs 8% of patients receiv-
ing placebo; OR, 2.3 [95% CI, 2.1-
3.3]; P⬍.001). The 2-year mean (SEM)
change from baseline in waist circum-
ference was also significantly greater in
patients receiving 20 mg of rimona-
bant (−5.0 [0.2] cm) compared with pa-
tients receiving placebo (−2.2 [0.3] cm;
P⬍.001).
Cardiometabolic Risk Factors
During Year 1
Levels of HDL cholesterol increased
and fasting insulin levels decreased in
patients receiving either 5 mg or 20
mg of rimonabant. Levels of triglycer-
ides decreased in patients receiving 20
mg of rimonabant but not in patients
receiving 5 mg of rimonabant (Table 2
and F
IGURE 4). The prevalence of the
metabolic syndrome according to
Adult Treatment Panel III criteria
significantly declined in patients
receiving 20 mg of rimonabant (from
34.8% to 21.2%) compared with
patients receiving placebo (31.7% to
29.2%; P⬍.001). Levels of total cho-
lesterol and low-density lipoprotein
cholesterol were not significantly dif-
ferent among the 3 groups (data
available on request). Insulin resis-
tance estimated by the HOMA-IR
increased in patients receiving pla-
cebo but not in patients receiving 20
mg of rimonabant. Systolic and dia-
stolic blood pressures tended to
decrease slightly but not significantly
in patients receiving either 5 mg or
20 mg of rimonabant (Table 2).
In patients receiving 20 mg of ri-
monabant, the observed effects at 1 year
in levels of HDL cholesterol, triglycer-
ides, fasting insulin, and in HOMA-IR
were approximately twice that attrib-
utable to the concurrent weight loss
alone using analysis of covariance. For
example, of the observed 7.2% in-
crease in level of HDL cholesterol in pa-
tients receiving 20 mg of rimonabant,
there was only a 4.2% increase in level
of HDL cholesterol after adjustment for
weight loss (P⬍.001). The residual ef-
fects after weight-loss adjustment in pa-
tients receiving 20 mg of rimonabant
were 47% of observed effects for tri-
glycerides (P =.008); 50% of observed
effects for fasting insulin (P =.04); and
Figure 5. Change in the Completers Population From Baseline Over Years 1 and 2 for Levels of High-Density Lipoprotein (HDL) Cholesterol
and Triglycerides
4
2
6
8
10
12
0
–2
No. of Patients
Placebo
20 mg of Rimonabant
Weeks
Change From Baseline, mg/dL
Placebo
20 mg of Rimonabant
208
253
206
251
207
253
208
251
206
251
206
249
206
249
204
250
208
253
0 12 24 36 52 64 76 88 104
–20
–25
–15
–5
–10
0
5
10
–30
Weeks
Change From Baseline, mg/dL
207
253
205
252
206
253
206
251
205
251
205
249
205
249
203
250
207
253
0 12 24 36 52 64 76 88 104
HDL Cholesterol Triglycerides
Error bars indicate SEM. To convert HDL cholesterol to mmol/L, multiply by 0.0259; triglycerides to mmol/L, multiply by 0.0113.
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51% of observed effects for HOMA-IR
(P = .07).
Cardiometabolic Risk Factors
in Year 2
Compared with patients who contin-
ued to receive 5 mg or 20 mg of ri-
monabant, patients who were reran-
domized to placebo in year 2 had
increased levels of triglycerides and de-
creased levels of HDL cholesterol (data
available on request). In the patients
who completed the study and who were
treated with either placebo or 20 mg of
rimonabant for 2 years, levels of HDL
cholesterol continued to increase from
baseline during year 2 but signifi-
cantly so in patients who were treated
with 20 mg of rimonabant (P⬍.001;
F
IGURE 5). Compared with patients re-
ceiving placebo, both levels of triglyc-
erides and the prevalence of the meta-
bolic syndrome declined more from
baseline in patients receiving 20 mg of
rimonabant (P⬍.001).
Safety and Tolerability
The percentage of patients reporting at
least 1 adverse event was similar
across treatment groups (85.5% for
patients receiving 20 mg of rimona-
bant, 83.4% for patients receiving 5
mg of rimonabant, and 82.0% for
patients receiving placebo; T
ABLE 4).
Compared with patients receiving pla-
cebo, the overall incidence of adverse
events leading to study withdrawal in
year 1 was slightly higher in patients
receiving 5 mg of rimonabant and
even greater in patients receiving 20
mg of rimonabant, mainly due to psy-
chiatric, nervous system, and gastroin-
testinal tract adverse events. Com-
pared with patients receiving placebo,
adverse events (upper respiratory tract
infection, nasopharyngitis, nausea,
influenza, diarrhea, arthralgia, anxiety,
insomnia, viral gastroenteritis, dizzi-
ness, depressed mood, and fatigue)
were reported in 5% or greater of
patients receiving 20 mg of rimona-
bant. There were no differences
among the treatment groups in
changes over time in corrected QT
interval and either the anxiety or
Table 4. Safety Data, Adverse Events, and Hospital Anxiety and Depression Scores*
Placebo
(n = 607)
Rimonabant
5mg
(n = 1214)
20 mg
(n = 1219)
Safety Data for Year 1†‡
Overall drop-out rate 298 (49.1) 595 (49.0) 547 (44.9)
Adverse event
Any 498 (82.0) 1013 (83.4) 1042 (85.5)
Serious§ 21 (3.5) 46 (3.8) 55 (4.5)
Discontinued study due to adverse event 44 (7.2) 114 (9.4) 156 (12.8)
Psychiatric disorder 14 (2.3) 44 (3.6) 76 (6.2)
Depressed mood 㛳 8 (1.3) 25 (2.1) 27 (2.2)
Anxiety 2 (0.3) 7 (0.6) 12 (1.0)
Irritability 0 2 (0.2) 6 (0.5)
Insomnia 1 (0.2) 1 (⬍0.1) 6 (0.5)
Nervous system 6 (1.0) 14 (1.2) 27 (2.2)
Headache 2 (0.3) 4 (0.3) 6 (0.5)
Dizziness 1 (0.2) 0 9 (0.7)
Gastrointestinal tract 4 (0.7) 8 (0.7) 20 (1.6)
Nausea 1 (0.2) 2 (0.2) 11 (0.9)
Adverse Events‡
(n = 498) (n = 1013) (n = 1042)
Upper respiratory tract infection 76 (15.2) 163 (16.1) 193 (18.5)
Nasopharyngitis 70 (14.0) 163 (16.1) 177 (17.0)
Nausea 29 (5.8) 69 (6.8) 117 (11.2)
Arthralgia 41 (8.2) 88 (8.7) 92 (8.8)
Sinusitis 58 (11.7) 88 (8.7) 91 (8.7)
Headache 51 (10.2) 92 (9.1) 81 (7.8)
Back pain 30 (6.1) 71 (7.0) 61 (5.9)
Influenza 38 (7.7) 76 (7.5) 92 (8.8)
Diarrhea 25 (5.1) 73 (7.2) 55 (5.3)
Gastroenteritis viral 24 (4.8) 49 (4.8) 59 (5.7)
Dizziness 20 (4.0) 46 (4.5) 58 (5.6)
Anxiety 10 (2.1) 33 (3.3) 64 (6.1)
Bronchitis 25 (5.1) 48 (4.7) 45 (4.3)
Depressed mood 15 (3.1) 42 (4.1) 54 (5.2)
Fatigue 18 (3.6) 38 (3.8) 54 (5.2)
Insomnia 22 (4.4) 30 (3.0) 60 (5.8)
Hospital Anxiety and Depression Scores
(n = 490) (n = 991) (n = 1026)
Depression subscore, mean (SD)
Baseline 3.0 (2.7) 3.0 (2.8) 2.9 (2.8)
Last value during year 1 3.1 (3.2) 3.0 (3.2) 3.0 (3.2)
Change 0.1 (2.8) 0 (2.8) 0.1 (3.0)
Anxiety score, mean (SD)
Baseline 5.0 (3.2) 5.0 (3.3) 4.8 (3.1)
Last value during year 1 5.2 (3.6) 5.3 (3.7) 5.6 (3.9)
Change 0.2 (3.0) 0.3 (2.9) 0.9 (3.3)
*Values are expressed as number (percentage) unless otherwise indicated. Additional data available on request.
†One patient may report several events. Onset date during treatment exposure and up to 75 days following the last
study drug intake.
‡Coded using MedDRA (version 7.0) to a preferred term and associated primary system organ class and made con-
sistent between patients by the use of a standard preferred term that belongs to a single primary system organ class.
§Two deaths were reported in the 5-mg rimonabant group: 1 male patient was found dead by gunshot and 1 female
patient with a history of long QT syndrome died from cardiac arrest. In the RIO program (n = 6625), the deaths were
equally distributed across groups (4 in the placebo group, 3 in the 5-mg rimonabant group, and 4 in the 20-mg
rimonabant group).
㛳Consisted of depression, major depression, depressed mood, and depressive symptoms.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
772 JAMA, February 15, 2006—Vol 295, No. 7 (Reprinted) ©2006 American Medical Association. All rights reserved.
by PKAPADIA, on March 6, 2007 www.jama.comDownloaded from
depression subscales of the hospital
anxiety and depression scale.
In year 2, the overall rates of ad-
verse events, study withdrawals, and ad-
verse event–related study withdraw-
als were lower than in year 1; there were
no differences in overall rates among
the treatment groups (T
ABLE 5). Up-
per respiratory tract infection, naso-
pharyngitis, or influenza occurred in 5%
or greater of patients receiving either
5 mg or 20 mg of rimonabant at year 2
and overall were more frequent in ri-
monabant-treated patients for both
years.
COMMENT
Rimonabant, the first selective canna-
binoid-1 receptor blocker to enter clini-
cal trials, was tested in a randomized,
double-blind, placebo-controlled 2-year
multicenter study. The results suggest
that 20 mg/d of rimonabant is effective
in reducing body weight and waist
circumference, while also favorably
affecting several cardiometabolic risk
factors. Most of these effects were dose-
dependent. Furthermore, the differ-
ences in the patients receiving 20 mg
of rimonabant compared with patients
receiving placebo in levels of HDL cho-
lesterol, triglycerides, fasting insulin,
and HOMA-IR appeared to exceed that
expected from the weight loss achieved.
These findings support and extend
results from other randomized con-
trolled trials of rimonabant therapy.
22,23
RIO-North America addressed the ef-
ficacy and safety profile of rimona-
bant over 1 year; the long-term effec-
tiveness of rimonabant in preventing
weight regain; and the efficacy and tol-
erability of continuous long-term ri-
monabant treatment over 2 years. Clini-
cally significant weight loss achieved
during year 1 was well maintained dur-
ing year 2 in patients receiving 20 mg
of rimonabant during both years. When
patients treated with 5 mg or 20 mg of
rimonabant at year 1 were rerandom-
ized to placebo in year 2, they re-
gained a substantial amount of the
weight they had lost. However, body
weight still remained slightly lower in
these patients than in the patients
treated with placebo for 2 years. These
findings highlight the concept that sus-
tained weight loss and associated fa-
vorable changes in cardiometabolic risk
factors require continuous long-term
treatment as seen in other chronic dis-
orders, such as diabetes and hyperten-
sion in which treatment is effective only
for as long as patients are receiving
therapy.
Compared with patients who re-
ceived placebo, patients who received
20 mg of rimonabant had favorable
changes in levels of HDL cholesterol,
triglycerides, and fasting insulin and in
HOMA-IR that appeared to be approxi-
mately twice that expected from the
achieved weight loss alone, suggest-
ing a direct pharmacological effect of
rimonabant on glucose and lipid me-
tabolism beyond the weight loss
achieved. In patients who received 20
mg of rimonabant, levels of HDL cho-
lesterol increased continuously
throughout the 2-year study whereas
body weight stabilized, further sup-
porting a direct pharmacological effect
not attributable to weight loss alone.
Preclinical studies indicate that rimona-
bant increases adiponectin gene ex-
pression and production in adipose
tissue,
11
increases insulin-mediated glu-
cose uptake in isolated soleus muscle,
12
and that cannabinoid-1 receptor an-
tagonism or deletion decreases de novo
hepatic fatty acid synthesis and lipid ac-
cumulation in response to the con-
sumption of high-fat foods.
9
Patients
with the metabolic syndrome who have
insulin resistance have multiple de-
fects in glucose and lipid metabolism
associated with excess intraabdomi-
nal fat, hypoadiponectinemia, and high
levels of cytokines and adhesion mol-
ecules.
24
While further study is needed
to elucidate the specific mechanisms
underlying the apparent direct action
of rimonabant on lipid and glucose me-
tabolism, these effects may be medi-
ated by adiponectin and reduction of
abdominal obesity.
23,25
Rimonabant significantly reduced
waist circumference, a measure of
abdominal adiposity, and the preva-
lence of the metabolic syndrome. A
recent study
26
showed that measured
intraabdominal fat was independently
associated with all 5 of the metabolic
syndrome criteria, suggesting that it may
have a central pathophysiological role.
Table 5. Adverse Events in Patients Who Received the Same Treatment in Both Years
No. (%) of Patients
Placebo
(n = 298)
Rimonabant
5mg
(n = 300)
20 mg
(n = 333)
Adverse event*
Any 246 (82.6) 243 (81.0) 276 (82.9)
Serious 14 (4.7) 18 (6.0) 13 (3.9)
Discontinued study due to adverse event 12 (4.0) 19 (6.3) 14 (4.2)
Psychiatric disorder 4 (1.3) 6 (2.0) 7 (2.1)
Depressed mood† 3 (1.0) 4 (1.3) 4 (1.2)
Anxiety 0 1 (0.3) 2 (0.6)
Upper respiratory tract infection 44 (14.8) 53 (17.7) 55 (16.5)
Nasopharyngitis 47 (15.8) 41 (13.7) 64 (19.2)
Sinusitis 27 (9.1) 23 (7.7) 25 (7.5)
Arthralgia 29 (9.7) 25 (8.3) 20 (6.0)
Back pain 20 (6.7) 21 (7.0) 17 (5.1)
Influenza 22 (7.4) 12 (4.0) 25 (7.5)
Bronchitis 11 (3.7) 25 (8.3) 11 (3.3)
Extremity pain 9 (3.0) 15 (5.0) 12 (3.6)
*One patient may report several events. Onset date during treatment exposure and up to 75 days following the last
study drug intake. Coded using MedDRA (version 7.0) to a preferred term and associated primary system organ
class and made consistent between patients by the use of a standard preferred term that belongs to a single primary
system organ class.
†Consisted of depression, major depression, depressed mood, and depressive symptoms.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, February 15, 2006—Vol 295, No. 7 773
by PKAPADIA, on March 6, 2007 www.jama.comDownloaded from
Moreover, multivariable analyses indi-
cated that waist circumference and level
of triglycerides together might be a use-
ful surrogate marker for measured insu-
lin resistance and intraabdominal adi-
posity in individuals without diabetes.
Furthermore, fasting insulin and waist
circumference predicted insulin sensi-
tivity measured directly by the hyper-
insulinemic euglycemic clamp and
intraabdominal fat measured by com-
puted tomography. These results sug-
gest that fasting insulin level and waist
circumference are reliable indicators of
high-risk patients in clinical practice.
In the context of the current obesity epi-
demic and the associated burden on
health care resources, clinical tools such
as waist circumference may enable phy-
sicians to identify those patients at high
risk for type 2 diabetes and cardiovas-
cular disease, who may benefit from
early intervention to improve their car-
diometabolic risk status.
Rimonabant was generally well tol-
erated with adverse effects that were
mostly mild and moderate. In patients
receiving the same treatment for 2 years,
the study withdrawal rate due to ad-
verse events became comparable among
all patients during year 2, suggesting
that the adverse effects occur early and
that 5 mg/d and 20 mg/d of rimona-
bant have a comparable safety and tol-
erability profile with placebo.
There are several limitations to our
study. The low retention rates of only
about 50% in all treatment groups, while
consistent with previous studies in over-
weight or obese patients,
27
present a ma-
jor challenge in data analysis and inter-
pretation. The use of the LOCF approach
to impute missing values assumes that
individual data at the time of dropout
are representative of data at the end of
the study if the participant had com-
pleted the study.
28
The results of the
study also may be affected by partici-
pants who derived less benefit and
dropped out more frequently. More-
over, data from patients who com-
pleted the study may not be represen-
tative of the overall study population
when the drop-out rate is high. How-
ever, sensitivity analyses, including a re-
peated-measures approach and an im-
putation of final values adjusted for
duration of participation, supported the
conclusions of the LOCF analysis. Other
factors that may diminish the general-
izability of the study results include the
limited racial diversity and the overall
predominance of white women in the
study. Lastly, larger studies are neces-
sary to assess less frequent adverse events
and longer duration studies will be
needed to confirm the long-term safety
of rimonabant beyond 2 years.
In conclusion, in the RIO-North
America trial, 20 mg of rimonabant plus
a standard dietary intervention pro-
duced sustained, clinically meaning-
ful weight loss and favorable changes
in cardiometabolic risk factors over 1
year and prevented weight regain in
year 2 with favorable effects compared
with placebo on fasting serum levels of
HDL cholesterol and triglycerides and
HOMA-IR. Compared with patients
who had received 20 mg of rimona-
bant in year 1 and were then reas-
signed to receive placebo in year 2, those
treated with 20 mg of rimonabant for
2 years maintained weight loss and dif-
ferences from patients receiving pla-
cebo in multiple cardiometabolic risk
factors, reflecting the potential effec-
tiveness of long-term rimonabant
therapy. It must be acknowledged that
the trial was limited by a high drop-
out rate and that long-term effects of
the drug require further study. Still, our
observations collectively suggest that
rimonabant may well represent an inno-
vative approach to the management of
multiple cardiometabolic risk factors,
facilitating and maintaining improve-
ments through weight loss–depen-
dent and –independent pathways.
Author Affiliations: Obesity Research Center, St Luke’s-
Roosevelt Hospital Center, Columbia University Col-
lege of Physicians and Surgeons, New York, NY (Dr
Pi-Sunyer); Department of Medicine, Cornell Weil
Medical College, New York, NY (Dr Aronne); Sanofi-
Aventis, Malvern, Pa (Dr Heshmati and Ms Devin);
and Dallas Diabetes and Endocrine Center, Dallas, Tex
(Dr Rosenstock).
Author Contributions: Dr Pi-Sunyer had full access to
all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data
analysis.
Study concept and design: Pi-Sunyer, Aronne, Heshmati.
Acquisition of data: Pi-Sunyer, Aronne, Heshmati,
Rosenstock.
Analysis and interpretation of data: Pi-Sunyer, Aronne,
Heshmati, Devin, Rosenstock.
Drafting of the manuscript: Pi-Sunyer, Aronne.
Critical revision of the manuscript for important in-
tellectual content: Aronne, Devin, Rosenstock.
Statistical analysis: Devin.
Obtained funding: Pi-Sunyer.
Administrative, technical, or material support:
Pi-Sunyer, Heshmati, Rosenstock.
Study supervision: Aronne, Heshmati, Rosenstock.
Financial Disclosures: Drs Pi-Sunyer and Aronne have
received honoraria from Sanofi-Aventis for speaker’s
presentations. No other authors reported financial dis-
closures.
Funding/Support: RIO-North America was sup-
ported by a research grant from Sanofi Synthelabo Re-
search, a division of Sanofi Synthelabo Inc, a mem-
ber of the Sanofi-Aventis group.
Role of the Sponsor: Sanofi-Aventis participated in dis-
cussions regarding study design and protocol devel-
opment and the sponsor provided logistical support
for the trial, data collection, and data analysis, and
helped in preparing the manuscript. The sponsor was
permitted to review the manuscript, but the final de-
cision on content was with the corresponding author
in conjunction with the other authors.
Independent Statistical Review: All study data were
transferred from Sanofi-Aventis to the Department of
Medicine at St Luke’s-Roosevelt Hospital Center for
independent reanalysis by Stanley Heshka, PhD. Sta-
tistical reanalyses of the raw data were performed by
Dr Heshka. There were no discrepancies between the
reanalysis and the original interpretation of the re-
sults and conclusions. In lieu of financial compensa-
tion for Dr Heshka’s time and effort in performing the
statistical analyses, an unrestricted educational grant
from Sanofi-Aventis was given to the Obesity Re-
search Center at St Luke’s-Roosevelt Hospital Center
in New York, NY.
Data and Safety Monitoring Board: Alain Leizo-
rovicz, MD (chairman), Universite´ Claude Bernard,
Lyon, France; Michael Weintraub, MD, University
of Rochester School of Medicine and Dentistry, Roch-
ester, NY; Jean-Louis Imbs, MD, Hoˆ pital Civil,
Strasbourg, France; Elliot Danforth, MD, University
of Vermont, Burlington; David P. L. Sachs, MD,
Palo Alto Center for Pulmonary Disease, Palo
Alto, Calif.
RIO North America Investigators: Canada (On-
tario): Denis Callaghan, Hamilton; Jeff Daiter, Rich-
mond Hill; John Nuttall, Kingston; William O’Mahony,
Corunna; Duncan Sinclair, Aylmer; Donald Spink, Pe-
terborough; Paul Willoughby, Woodstock; Paul Ziter,
Windsor. United States: Andrew Ahmann, Portland,
Ore; James Anderson, Lexington, Ky; Louis Aronne,
New York, NY; Richard Atkinson, Madison, Wis; Mi-
chael Basista, Bloomfield, NJ; Kathleen Baskett, Mis-
soula, Mont; Harold Bays, Louisville, Ky; Gregory
Bishop, San Diego, Calif; Scott Bleser, Bellbrook, Ohio;
Marshall Block, Phoenix, Ariz; Stephen Brady, Naples,
Fla; Ronald Brazg, Renton, Wash; Robert Call, Rich-
mond, Va; Antonio Caos, Ocoee, Fla; Harry Collins,
South Plainfield, NJ; Gordon Connor, Birmingham, Ala;
Martin Conway, Albuquerque, NM; Lydia Corn, Sara-
sota, Fla; Walter Dunbar, Atlanta, Ga; Ronald Emkey,
Wyomissing, Pa; James Ferguson, Salt Lake City, Utah;
Harold Fleming, Spartanburg, SC; Nicholas Fleming,
Spartanburg, SC; Arthur Frank, Washington, DC; Ken
Fujioka, San Diego, Calif; Sidney Funk, Atlanta, Ga;
Elizabeth Gallup, Overland Park, Kan; W. Thomas
Garland, Lawrenceville, NJ; Jeffrey Geohas, Chicago,
Ill; Eric Goldberg, West Palm Beach, Fla; Frank Green-
way, Baton Rouge, La; Paula Hall, Indianapolis, Ind;
Wayne Harper, Raleigh, NC; Scott Horn, San Anto-
nio, Tex; Roy Kaplan, Concord, Calif; Richard Krause,
Chattanooga, Tenn; Diane Krieger, Miami, Fla; Rob-
erta Loeffler, Wichita, Kan; Barry Lubin, Norfolk, Va;
Thomas Marbury, Orlando, Fla; Clark McKeever, Hous-
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
774 JAMA, February 15, 2006—Vol 295, No. 7 (Reprinted) ©2006 American Medical Association. All rights reserved.
by PKAPADIA, on March 6, 2007 www.jama.comDownloaded from
ton, Tex; James McKenney, Richmond, Va; Curtis
Mello, Swansea, Mass; Neerja Misra, Lawrenceville,
NJ; Patrick O’Neil, Charleston, SC; F. Xavier Pi-
Sunyer, New York, NY; David Podlecki, Longmont,
Colo; Gary Post, Highlands Ranch, Colo; R. Walter
Powell, Newark, Del; Stephen Rafelson, Langhorne,
Pa; Kenneth Rictor, Scotland, Pa; Julio Rosenstock, Dal-
las, Tex; Daniel Rowe, West Palm Beach, Fla; John Ru-
bino, Raleigh, NC; Donald Schumacher, Charlotte, NC;
Douglas Schumacher, Columbus, Ohio; Howard
Schwartz, Miami, Fla; Simona Scumpia, Austin, Tex;
Stephan Sharp, Nashville, Tenn; Earl Shrago, Madi-
son, Wis; Diane Smith, Augusta, Ga; Norman Soler,
Springfield, Ill; Paul Tung, Dover, NH; Greggory Volk,
Beavercreek, Ohio; Ralph Wade, Salt Lake City, Utah;
Richard Weinstein, Walnut Creek, Calif; Todd Wine,
Oceanside, Calif; Lisa Wright, Birmingham, Ala; John
Zerbe, Cincinnati, Ohio; Douglas Zmolek, Manlius, NY.
Previous Presentation: Presented in part at the Ameri-
can Heart Association’s Scientific Sessions, New Or-
leans, La, November 7-10, 2004.
Acknowledgment: We appreciate the expert assis-
tance of Stanley Heshka, PhD (St Luke’s-Roosevelt
Hospital Center, Columbia University, New York, NY)
in conducting an independent statistical analysis of the
study data and in providing guidance on appropriate
statistical methods.
REFERENCES
1. Hedley AA, Ogden CL, Johnson CL, Carroll MD,
Curtin LR, Flegal KM. Prevalence of overweight and
obesity among US children, adolescents, and adults,
1999-2002. JAMA. 2004;291:2847-2850.
2. Klein S, Burke LE, Bray GA, et al. Clinical implica-
tions of obesity with specific focus on cardiovascular
disease: a statement for professionals from the Ameri-
can Heart Association Council on Nutrition, Physical
Activity, and Metabolism: endorsed by the American
College of Cardiology Foundation. Circulation. 2004;
110:2952-2967.
3. Solomon CG, Manson JE. Obesity and mortality:
a review of the epidemiologic data. Am J Clin Nutr.
1997;66:1044S-1050S.
4. National Institutes of Health Expert Panel on the
Identification Evaluation and Treatment of Over-
weight in Adults. Clinical guidelines on the identifi-
cation, evaluation, and treatment of overweight and
obesity in adults: the evidence report. Obes Res. 1998;
6(suppl 2):51S-209S.
5. Matsuda LA, Lolait SJ, Brownstein MJ, Young AC,
Bonner TI. Structure of a cannabinoid receptor and
functional expression of the cloned cDNA. Nature.
1990;346:561-564.
6. Munro S, Thomas KL, Abu-Shaar M. Molecular
characterization of a peripheral receptor for
cannabinoids. Nature. 1993;365:61-65.
7. Howlett AC. The cannabinoid receptors. Prosta-
glandins Other Lipid Mediat. 2002;68:619-631.
8. Cota D, Marsicano G, Tschop M, et al. The en-
dogenous cannabinoid system affects energy bal-
ance via central orexigenic drive and peripheral
lipogenesis. J Clin Invest. 2003;112:423-431.
9. Osei-Hyiaman D, DePetrillo M, Pacher P, et al. En-
docannabinoid activation at hepatic CB1 receptors
stimulates fatty acid synthesis and contributes to
diet-induced obesity. J Clin Invest. 2005;115:1298-
1305.
10. Di Marzo V, Goparaju SK, Wang L, et al. Leptin-
regulated endocannabinoids are involved in maintain-
ing food intake. Nature. 2001;410:822-825.
11. Bensaid M, Gary-Bobo M, Esclangon A, et al. The
cannabinoid CB1 receptor antagonist SR141716 in-
creases Acrp30 mRNA expression in adipose tissue of
obese fa/fa rats and in cultured adipocyte cells. Mol
Pharmacol. 2003;63:908-914.
12. Liu YL, Connoley IP, Wilson CA, Stock MJ. Ef-
fects of the cannabinoid CB1 receptor antagonist
SR141716 on oxygen consumption and soleus muscle
glucose uptake in Lep(ob)/Lep(ob) mice. Int J Obes
(Lond). 2005;29:183-187.
13. Ravinet Trillou C, Arnone M, Delgorge C, et al.
Anti-obesity effect of SR141716, a CB1 receptor
antagonist, in diet-induced obese mice. Am J Physiol
Regul Integr Comp Physiol. 2003;284:R345-
R353.
14. Harris JA, Benedict FG. A Biometric Study of Basal
Metabolism in Man. Washington, DC: Carnegie In-
stitute of Washington; 1919. Publication 279.
15. Jacobs D, DeMott W, Grady H, Horvat R, Hues-
tis D, Kasten B, eds. Laboratory Test Handbook. 4th
ed. Cleveland, Ohio: Lexi-Comp Inc; 1996.
16. Rifai N, Warnick G, eds. Laboratory Measure-
ment of Lipids, Lipoproteins, and Apolipoproteins.
Washington, DC: AACC Press; 1994.
17. National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treat-
ment of High Blood Cholesterol in Adults (Adult Treat-
ment Panel III). Executive summary of the third re-
port of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). JAMA. 2001;285:2486-
2497.
18. Zigmond AS, Snaith RP. The hospital anxiety and
depression scale. Acta Psychiatr Scand. 1983;67:361-
370.
19. Matthews DR, Hosker JP, Rudenski AS, Naylor BA,
Treacher DF, Turner RC. Homeostasis model assess-
ment: insulin resistance and beta-cell function from
fasting plasma glucose and insulin concentrations in
man. Diabetologia. 1985;28:412-419.
20. Hochberg Y. A sharper Bonferonni procedure for
multiple tests of significance. Biometrika. 1988;75:800-
802.
21. Buyse M, Molenberghs G. Criteria for the vali-
dation of surrogate endpoints in randomized
experiments. Biometrics. 1998;54:1014-1029.
22. Van Gaal LF, Rissanen AM, Scheen AJ, Ziegler O,
Rossner S. Effects of the cannabinoid-1 receptor blocker
rimonabant on weight reduction and cardiovascular
risk factors in overweight patients: 1-year experience
from the RIO-Europe study. Lancet. 2005;365:1389-
1397.
23. Despres JP, Golay A, Sjostrom L; Rimonabant in
Obesity-Lipids Study Group. Effects of rimonabant on
metabolic risk factors in overweight patients with
dyslipidemia. N Engl J Med. 2005;353:2121-2134.
24. Salmenniemi U, Ruotsalainen E, Pihlajamaki J, et al.
Multiple abnormalities in glucose and energy metabo-
lism and coordinated changes in levels of adiponec-
tin, cytokines, and adhesion molecules in subjects
with metabolic syndrome. Circulation. 2004;110:
3842-3848.
25. Berg AH, Combs TP, Scherer PE. ACRP30/
adiponectin: an adipokine regulating glucose and lipid
metabolism. Trends Endocrinol Metab. 2002;13:84-89.
26. Carr DB, Utzschneider KM, Hull RL, et al. Intra-
abdominal fat is a major determinant of the National
Cholesterol Education Program Adult Treatment Panel
III criteria for the metabolic syndrome. Diabetes. 2004;
53:2087-2094.
27. Padwal R, Li S, Lau D. Long-term pharmaco-
therapy for overweight and obesity: a systematic re-
view and meta-analysis of randomized controlled trials.
Int J Obes Relat Metab Disord. 2003;27:1437-1446.
28. Gadbury GL, Coffey CS, Allison DB. Modern sta-
tistical methods for handling missing repeated mea-
surements in obesity trial data: beyond LOCF. Obes Rev.
2003;4:175-184.
RIMONABANT AND MANAGEMENT OF CARDIOMETABOLIC RISK FACTORS
©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, February 15, 2006—Vol 295, No. 7 775
by PKAPADIA, on March 6, 2007 www.jama.comDownloaded from
through its postpayment audit process, will try to recoup
from physicians who make frequent home visits.
Bernard Leo Remakus, MD
remakus@epix.net
Family and Community Medicine
Temple University School of Medicine
Hallstead, Pa
Financial Disclosures: None reported.
1. Landers SH, Gunn PW, Flocke SA, et al. Trends in house calls to Medicare
beneficiaries. JAMA. 2005;294:2435-2436.
2. Administrators HGS. Comparative Billing Reports. Available at: http://www
.hgsa.com/professionals/cbr.shtml. Accessed January 21, 2006.
3. Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule
Look-up. Available at: http://www.cms.hhs.gov/apps/pfslookup. Accessed Janu-
ary 21, 2006.
In Reply: Dr Remakus suggests that the increase in house
calls to Medicare beneficiaries from 1998 to 2004 is un-
likely to be related to Medicare’s increase in reimburse-
ment for home visits in 1998. Although our analysis was
unable to determine the exact reasons that this increase oc-
curred, he is incorrect when he states that we referenced
the allowed charge for the highest-level home visit to an es-
tablished patient (99350) in our report. The charge of $110
is the 2004 charge allowed by Ohio’s Medicare carrier for a
99349 code, which he correctly cites as one of the most com-
monly used.
1
Our nonstandard use of “comprehensive” in
this context may have been confusing, because a 99350 code
requires a “comprehensive” examination. It would have been
more precise for us to have simply referred to the specific
code (99349).
Nevertheless, I agree that the rates do not fully reflect the
effort, resources, and administrative hurdles associated with
house calls. In spite of recent growth, house calls remain
relatively infrequent, and without further changes in Medi-
care policy they may remain so. Expanding physician home
care could be a cost-effective and compassionate way to ad-
dress the needs of an aging population, but more policy
changes are needed for this to become a reality.
Stephen H. Landers, MD, MPH
steven.landers@uhhs.com
Department of Family Medicine
Case Western Reserve University School of Medicine
Cleveland, Ohio
Financial Disclosures: None reported.
1. Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule
Look-Up. Available at: http://www.cms.hhs.gov/apps/pfslookup. Accessed Janu-
ary 27, 2006.
CORRECTION
Failure to Disclose Financial Interest: In the Original Contribution entitled “Effect
of Rimonabant, a Cannabinoid-1 Receptor Blocker, on Weight and Cardiometa-
bolic Risk Factors in Overweight or Obese Patients: RIO-North America: A Ran-
domized Controlled Trial” published in the February 15, 2006, issue of JAMA (2006;
295:761-775), the following financial disclosure should be added for Julio Rosenstock,
MD. On page 774, under “Financial Disclosures,” “Dr Rosenstock has received
honoraria from Sanofi-Aventis for lectures and for consultant services” should be
added right before “No other authors reported financial disclosures.”
LETTERS
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