Obesity Pharmacology

Goal of _-_ lb weight loss per week is a good dietary recommendation

1-2 lb per week

Sustained weight loss of _-_% in overweight or obese patients can reduce blood pressure, improve cholesterol, decrease risk of developing diabetes, and improve diabetes control.

3 - 5%

Eventual goals of Aerobic exercise for weight loss

30 minutes daily Moderae intensity aerobic exercise At least 150 minutes per week Resistance training 2-3 times per week is also recommended Remember that maintenance of weight loss is hard

1 pound of fat =

3500 calories 1500-1800 kcal/day males 1200-1500 kcal/day females

If patient has not lost ___% of body weight at 3 months, discontinue medications

5%

Diet Characteristics for Ornish, Atkins, Mediterranean, and Weight Watchers

Onrish: Low fat Atkins: High protein and High fat Mediterranean: High Protein Weight Watchers: Calorie consumption < Calorie Expenditure

Seperate levothyroxine from this drug by at least four hours

Orlistat

This drug may reduce absorption of cyclosporine and anti-epileptic drugs.

Orlistat

This drug will need to be taken with a MVI with A,D,E,K and Beta carotene 2 hours before or after due to interferences with absorption of fat soluble vitamins

Orlistat

This drug may decrease amiodarone efficacy, vitamin K absorption, and oral contraceptives absorption.

Orlistat Watch INR in warfarin ptns

What are the adverse effects associated with Sympathomimetic drugs? Ex: Diethylpropion and Phentermine

Think sympathetic stimulation so increased HR and BP Dry mouth Insomnia Constipation Asthenia Palpitations Anxiety Headache

Drug interactions with Locaserin (Belviq)

Triptans Bupropion Dextromethorphan (OTC) St. John's Wort SSRI SNRI Inhibits CYP 2D6 Low abuse potential listed as C4

Don't use high ___________ diet in patient with renal disease

protein

MOA of contrave

reduces appetite, decreases cravings

What is metabolic syndrome?

A group of risk factors that increase the risk of heart disease, stroke, and diabetes. Diabetes + Hyperlipidemia + Hypertension = Metabolic syndrome

In obese patients with Type 2 diabetes and HTN, what HTN medications should you use?

ACE inhibitors ARBs Ca Channel Blockers NOT beta blockers

MOA of Lorcaserin (Belviq)

Activates 5-HT2C receptors with promotes satiety

Phentermine Brand Name

Adipex-P

Has the highest risk of weight gain of all the TCAs

Amitriptyline

Assess efficacy and safety of pharmacotherapy ______________ for the first __________ months, then at least every _____ months in patients prescribed weight loss medications

Assess efficacy and safety of treatment monthly for the first three months, then at least every 3 months in patients prescribed weight loss medications

Pharmacologic therapy can be used as adjunct therapy if...

BMI > 30 OR BMI > 27 with comorbidity Only use if weight related complications are present Treatment with medications may amplify adherence to behavior changes allowing improved physical function

Bariatric surgery can be used as adjunct therapy if...

BMI >40 OR BMI >35 with comorbidity

Lorcaserin Brand name

Belviq

Drug interactions for Contrave

Bupropion is a substrate and inhibitor of 2D6. Cut dose of Contrave if used with clopidogrel or ticlopidine. Induces opioid withdrawal Minimize seizure risk by adhering to titration schedule

Obesity is associated with an increased risk of death from...

CV disease Diabetes Kidney Disease

Adverse effects of Liraglutide (Saxenda)

Constipation, N/V, Thyroid Tumors

Don't give a patient that is on an opioid this drug

Contrave

Naltrexone + Bupropion Brand name

Contrave

Adverse effects of Lorcaserin (Belviq)

Decreased white or red blood cell count (Monitor CBCs) Headache, dizziness, fatigue, dry mouth

Weight loss may necessitate changes in what therapy?

Diabetes therapy

Sympathomimetic drug examples

Diethylpropion Phentermine

Additional contraindications for Phentermine (Adipex-P)

Do not use with SSRIs Do not use in patients with cardiac diseases Caution with hazardous activities such as driving

These anti epileptics are associated with weight GAIN

Gabapentin Pregabalin Valproic Acid Vigabatrin Carbamazepine

Contraindications for Orlistat

Gallbladder disease Pregnancy Chronic malabsorption syndrome

Helpful dietary recommendations for weight loss

Eat breakfast Add dietary fiber Eat at regular intervals Limit sugary beverages Eat fruits and vegetables Limit fast food meals Fiber and protein cause satiety Food diary

Lifestyle changes are recommended for...

Everyone

Use a low _____ diet for a patient with hyperlipidemia

Fat

These anti epileptics are associated with weight LOSS

Felbamate Topiramate Zonisamide

These antidepressants are associated with weight LOSS

Fluoxetine Sertraline Bupropion

Adverse effects of Orlistat

GI effects such as oily spotting, fecal urgency, fecal incontinence, bloating, cramping, and increased risk of renal stones

Antidiabetic drug doses should be decreased when patients start a...

GLP-1 agonist Such as Liraglutide

It is recommended to use antidiabetic agents in obese patients that promote weight loss such as these diabetic medications

GLP-1 agonists SGLT-2 Inhibitors These promote weight loss

MOA of Liraglutide (Saxenda)

Glucagon like peptide (GLP) - 1 agonist. Increases satiety

What diseases are associated with Obesity?

HTN Diabetes Dyslipidemia Obstructive Sleep Apnea

Adverse effects of Qsymia

Insomnia Dysgeusia (abnormal taste) Tachycardia Depression Metabolic Acidosis Elevation of serum creatinine

Surgical options for weight loss

Laparoscopic Adjustable Gastric Band (LABG) Laparoscopic Sleeve Gastrectomy (LSG) Roux-en-Y Gastric Bypass (RYGB) Biliopancreatic Diversion with Duodenal Switch

When dosing this drug, must slowly escalate dose to lessen GI effects

Liraglutide (Saxenda)

Contraindications for Lorcaserin (Belviq)

MAOI use within 14 days CV disease Stroke Glaucoma Pregnancy

What are the contraindications for Sympathomimetic drugs? Ex: Diethylpropion and Phentermine

MAOI use within 14 days Pulmonary HTN Hyperthyroidism CV disease Valvular Heart Disease HTN (think of the side effects) Glaucoma History of substance abuse

Technique for waist circumference

Measure after expiration Tape measure placed at the iliac crest and wrapped around the umbilicus

Waist circumference cut points

Men: >102 cm Women: >88 cm

Which weight loss drugs can be used during pregnancy?

NONE (contraindicated)

Classification for BMI

Normal: 18.5-25 kg/m2 Overweight: 25-30 Obesity Class 1: 30-35 Obesity Class 2: 35-40 Extreme Obesity (Class 3) >40 2016 AACE guidelines also: stage obesity based on whether or not complications are present AND indicate a BMI of >23 in Asian population indicates excess adiposity.

When would measuring a waist circumference be necessary?

Only recommended if BMI is <35 High risk for men if >40 inches High risk for women if >35 inches Waist to hip ratio also useful

Has the highest risk of weight gain of all the SSRIs

Paroxetine

Contraindications for Liraglutide (Saxenda)

Personal or family hx of thyroid cancer

Most commonly prescribed anti-obesity agent

Phentermine (Adipex-P)

This drug is a REMS drug due to pregnancy category X associated with risk of congential malformations. Prescribers must be trained and dispensed by specialty pharmacies.

Phentermine/Topiramate (Qsymia)

This drug will need to be tapered by taking every other day for at least one week to reduce seizure risk

Phentermine/Topiramate ER (Qsymia)

Contraindications for Qsymia

Pregnancy Depression Caution if history of kidney stones and CNS depressants

MOA for Orlistat

Prevents absorption of fat by inhibiting intestinal lipase

Phentermine/Topiramate ER Brand Name

Qsymia

With this drug, need to counsel patients on adequate fluid intake due to the risk of renal stones

Qsymia

Liraglutide brand name

Saxenda (weight loss) Victoza (diabetes)

In obese patients, use the least _______________ antihistamines

Sedating

When taking Lorcaserin (Belviq) monitor for __________________ syndrome, especially if also taking other serotonergic drugs.

Serotonin Syndrome Ex: agitation, palpitations, hyperthermia, and hallucinations

Things to look at on the nutritional facts label

Serving Size Amount of Calories Limit Fats, Cholesterol, and Na Get enough vitamins and fiber Daily Values

__________ term treatment (3-6 months) using weight loss drugs has NOT been shown to improve health long-term.

Short term

Sympathomimetics are only approved for _________ term use

Short term use (few weeks)

In obese patients with Type 2 diabetes that is using insulin consider these...

Start with basal insulin only Add metformin, pramlintide, or GLP-1 agonist to mitigate weight gain.

Adverse effects of Contrave

Suicidal Ideation Mood changes Increased HR and BP

What needs to be monitored with Qsymia?

Suicidality Pregnancy monthly Electrolytes, serum creatinine, bicarb, and glucose before treatment and periodically thereafter Remember plain topiramate tables are not ER

Medications summary

Sympathomimetic Amines: Diethylpropion Phendimetrazine Phentermine Qsymia Serotonin receptor agonist Lorcaserin (Belviq) Pancreatic lipase inhibitor Orlistat Dopa and NE reuptake inhibitor, opioid antagonist Contrave SGLT2 inhibitors Dapagliflozin (Farxiga) Canagliflozin (Invokona) Empagliflozin (Jardiance) GLP-1 agonist Liraglutide (Saxenda)

Are only approved for short-term (few weeks) use regardless of amount of weight loss achieved

Sympathomimetics

Cause a reduction in appetite

Sympathomimetics

Diethylproprion Brand name

Tenuate

Contraindications for Contrave

Think seizure risk, mood changes, and HTN Pregnancy MAOI

What needs to be monitored with Liraglutide (Saxenda)?

Watch for signs of pancreatitis such as severe abdominal pain, fever, n/v

Monitoring with Contrave

Watch for worseing of depression/mood changes

All atypical antipsychotics cause...

Weight GAIN

Mirtazapine is associated with...

Weight Gain

Orlistat brand names

Xenical (Rx) Alli (OTC)

This atypical antipsychotic causes the least weight gain

Ziprasidone (Geodon)

Insulin causes weight __________

weight GAIN