Orlistat FDA approved for ≥12years of age Inhibits gastric & pancreatic lipases, resulting in reduced absorption of fats Fatty/oily stool, abdominal cramps, fecal incontinence, reduced absorption of fat soluble vitamins Metformin not FDA approved for treatment of obesity Reduces hepatic glucose production, decreases intestinal absorption of glucose & increases peripheral insulin sensitivity GI complaints, nausea/vomiting, vitamin B12 deficiency, lactic acidosis (rare) Approved for ≥10 years of age for treatment of T2DM, metformin could also be used to regulate menses in obese girls with PCOS Other drugs used only in certain special situations are: • Growth hormone: Prader Willi syndrome • Octreotide: Hypothalamic obesity • Leptin: Leptin deficiency The FDA approved a number of weight-loss medications for adults and these medications are appropriate for those ≥16 years of age with BMI ≥30kg/m2 or who have BMI ≥27 kg/m2 and at least one weight related comorbidity (e.g., hypertension or T2DM). Medication should be discontinued and the child should be re-evaluated if he/she does not have a 0.4% BMI/BMI z-score reduction after taking full dose of anti-obesity medication for 12 weeks. BARIATRIC SURGERY Pre-requisites (Endocrine Society recommendations): 1) Adolescent Tanner 4-5, and final/near final adult height. 2) BMI 40kg/m2 or BMI >35kg/m2 and significant extreme comorbidities. 3) Extreme obesity and co-morbidities persist despite lifestyle modification, with or without trial of pharmacotherapy. 4) Psychological evaluation confirms stability & competence of the family 5) Patient demonstrates ability to adhere to the principles of healthy dietary and activity habits. 6) Access to experienced surgeon in medical center. Contraindications of bariatric surgery: preadolescents, pregnant/ breastfeeding, unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome.>