Obesity, even in childhood, is a recalcitrant disease with strong biological underpinnings. Treatments aimed at counteracting the body's attempts to defend its energy stores offer patients with obesity a better chance to lose and maintain weight over the long term. Pharmacotherapy is one example of a treatment that can be used in conjunction with lifestyle modification therapy to target the underlying biology of obesity and potentially improve long-term weight loss and comorbidity outcomes. Although only one obesity medication is approved for pediatric use in the United States, others have been evaluated for safety and efficacy in the pediatric population. Importantly, four new medications have been recently approved for the treatment of adult obesity, which has set the stage for pediatric trials to be conducted with the goal of providing additional therapeutic options to pediatric patients that desperately need them. This chapter reviews the evidence from pediatric obesity clinical trials of approved and off-label medications, discusses the pediatric pipeline by briefly introducing the medications recently approved for adult use and plans for pediatric development, and offers a glimpse into the future directions for the field of pediatric obesity medicine.