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Overweight and obesity are recognized as a public health crisis and considered a global pandemic. In adults with congenital heart disease (ACHD) it is also considered a growing menace affecting up to half of this population. In ACHD, the negative impact of obesity on cardiovascular outcomes is likely amplified by already present underlying structural and physiological cardiac abnormalities, further increasing the risk of heart failure, arrhythmias, and other cardiovascular complications. As a potentially reversible risk factor, obesity represents a clear target for improving outcomes in this already vulnerable population. While lifestyle interventions remain foundational, the use of anti-obesity medications has expanded rapidly, though evidence in ACHD remains scarce. In this state-of-the-art review, informed by a comprehensive 30-year literature overview and the expertise of an international, multidisciplinary authorship, we provide clinically practical recommendations for the judicious use of anti-obesity therapies in ACHD. This document aims to guide clinicians in real-world decision-making and serve as a foundation for future research at the intersection of obesity and congenital heart disease.