Chapter 57 - Weight Loss Flashcards
Overweight BMI
25 - 29.9 kg/m2
Obese BMI
> = 30 Kg/ m2
BMI formula
Weight (KG) / Height 2 (m2)
- Anti psychotics (clozapine, olanzapine, risperidone, quetiapine)
- Diabetes drugs (insulin, meglitinides, sulfonylureas, thiazolidinediones)
- Divalproex/valproic acid
- Gabapentin, pregabalin Lithium
- Mirtazapine
- Steroids
- TCAs (amitriptyline, nortriptyline)
- Conditions: Hypothyroidism
Others:
- Beta-blockers Dronabinol
- Hormones (e.g., estrogen, megestrol)
- MAO inhibitors
- SSRls (paroxetine, others may be weight neutral)
- Vasodilators (e.g., minoxidil)
Treatment principles - Lifestyle modifications
- Reduced calorie (daily deficit ~500 - 750 kcal)
- Mediterranean, DASH, low-carb, low-fat, volumetric, high protein and vegetarian diets.
- Physical activity should increase to >= 150 minutes per week, performed on three to five separate days
- Behavioral Interventions
OTC SUPPLEMENTS
- Stimulants: bitter orange
- Excessive amounts of caffeine
– yerba mate
– guarana
– concentrated green tea powder - Generally ineffective and are not recommended, as they can be harmful, especially in patients with cardiovascular disease
PRESCRIPTION WEIGHT LOSS MEDICATIONS:
- Indication
- What drugs are used short term and for long term (maintenance)
- What drugs are removed from the US market and why?
- When should weight loss drugs be discontinued?
- They are indicated with a BMI >= 30 kg/m2, or BMI >= 27kg/m2 + at least one weight- related condition, such as dyslipidemia, hypertension or diabetes
- Older stimulant drugs (phentermine, diethylpropion) are only used short-term to “jump-start” a diet.
- The newer drugs Qsymia, Contrave, Saxenda and the orlistat formulations can be continued long-term for weight maintenance.
- Lorcaserin (Belviq,BelviqXR), a serotonin 5-HT2C receptor agonist, has been withdrawn from the U.S. market due to an increased risk of cancer.
- Weight loss drugs should be discontinued if they do not produce at least a 5% weight loss at 12weeks_
SELECT DRUGS/CONDITIONS THAT CAN CAUSE WEIGHT LOSS
- ADHD drugs (amphetamine, methylphenidate)
- Bupropion
- GLP-1 agonists (exenatide, liraglutide(Victoza))
- Pramlintide
- Roflumilast
- SGLT2 inhibitors (canagliflozin, empagliflozin)
- Topiramate
Conditions:
- Hyperthyroidism
- Celiac disease
- Inflammatory bowel disease
Others:
- Acetylcholinesterase inhibitors (e.g.,donepezil, rivastigmine, galantamine)
- Antiepileptic ethosuximide)
- Interferons
- Thyroid drugs (e.g., levothyroxine)
Conditions:
- Cystic fibrosis
- GERD or peptic ulcer disease
- Lupus
- Tuberculosis (active disease)
Rx drugs and Pregnancy:
Avoid all weight loss drugs
Rx drugs and HTN:
Avoid:
- Contrave (Naltrexone/ Bupropion): contraindicated with uncontrolled BP (contains bupropion)
Caution
- Qsymia (Phentermine/ Topiramate): monitor HR (contains phentermine)
Rx Drugs and Depression
Caution in young adults and adolescents
- Contrave - suicide risk
(contains bupropion)
Rx drugs and SEIZURES
Avoid
Contrave- lowers seizure threshold (contains bupropion)
Caution
Qsymia- must taper off slowly if used (contains topiramate)
Rx drugs and taking opioids
Avoid
Contrave- blocks opioid receptors (contains naltrexone)
Phentermine and Topiramate MOA
- Phentermine: sympathomimetic (stimulant); release of norepinephrine stimulates the satiety center which dec appetite
- Topiramate: inc satiety and dec appetite, possibly by inc GABA, blocking glutamate receptors and/or inhibition of carbonic anhydrase
Phentermine/Topiramate ER:
- Brand?
- Control?
- REMS Why?
(Qsymia)
C-IV
REMS drug due to teratogenic risk; pregnancy test needed before treatment and monthly thereafter; use effective contraception during treatment
CI Phentermine/Topiramate ER:
Pregnancy, glaucoma, hyperthyroidism, MAO inhibitor use within past 14 days
SE of Phentermine/Topiramate ER:
- Tachycardia
- Insomnia (take in the morning)
- Vision Problems
- Taper off due to seizure risk
Naltrexone/Bupropion
- Brand
- How does each work
(Contrave)
- Naltrexone: Dec food cravings
- Bupropion: Dec appetite
CI of Naltrexone/Bupropion
- Pregnancy
- Chronic opioid use or acute opiate withdrawal
- Uncontrolled hypertension
- Seizure disorder
- Use of other bupropion-containing products
- Bulimia/anorexia
- Abrupt discontinuation of alcohol
- Benzodiazepines
- Barbiturates
- Antiepileptic drugs
- Use of MAO inhibitors within 14 days
Warning of Naltrexone/Bupropion
Use caution with psychiatric disorders, discontinue with s/sx of hepatotoxicity, can inc HR and BP, glaucoma
Naltrexone and opioids
Can you give them together?
- Naltrexone blocks opioids and buprenorphine, which blocks analgesia and can induce withdrawal;
- Discontinue opioids or buprenorphine 7-14 days prior to use of Contrave
GLP-1 receptor agonist:
- How does it work
- Brand names
- For what is it approved?
- Administration?
- Inc satiety
- Liraglutide (Saxenda)
- Victoza- for diabetes
- Approved for use in children age >= 12 years with weight > 60 kg and BMI corresponding to >= 30 kg/m 2 for adults
- SC daily
Liraglutide
- CI
- Warnings
- CI: pregnancy
- Warning: Pancreatitis, hypoglycemia
- SE: Nausea
- Notes: May need to dec insulin or sulfonylurea/ meglitinide doses to dec risk of hypoglycemia
Lipase inhibitor:
Orlistat
Rx-Xenical
OTC-Alli
- Dec absorption of dietary fats by 30%
- Must be used with a low-fat diet plan
- SE: GI (flatus with discharge, fatty stool, fecal urgency)
- Take multivitamin with A, D, E, Kand beta carotene at bedtime or separated by > 2 hours
- Diet: max 30% of kcals from fat
Appetite suppressants:
Phentermine
- Sympathomimetics (stimulants), release of norepinephrine stimulates the satiety center which dec appetite
- Phentermine (Adipex-P)
CI of phentermine
- Cardiovascular disease (uncontrolled hypertension, arrhythmias, heart failure, CAD),
- Hyperthyroidism (since it could inc thyroid activity)
- Glaucoma
- Pregnancy, breast feeding
- History of drug abuse
- MAO inhibitors within the past 14 days
SE and monitoring of phentermine
when do you take it?
Tachycardia, agitation, inc BP, insomnia, dizziness, tremor, psychosis
Monitor: HR, BP
Used short-term, up to 12 weeks, to “jump-start” a diet
Stimulants taken later in the day can cause insomnia
Potential for misuse/dependence
When do we recommend bariatric surgery?
BMI >= 40 kg/m2 or when BMI >= 35kg/m2 with an obesity-related condition
COMMON NUTRIENT DEFICIENCIES
■ Calcium is mostly absorbed in the duodenum, which may be bypassed. Calcium citrate supplementation is preferred as it has non-acid-dependent absorption.
■ Anemia can result from vitamin Bl2 and iron deficiency; both may require supplementation.
■ Iron and calcium supplements should be taken two hours prior or four hours after antacids.
■ Patients may require life-long supplementation of the fat- soluble vitamins A, D,E and K due to fat malabsorption.
MEDICATION CONCERNS
■ Medications may require dose reduction and may need to be crushed and put in liquid or used in transdermal form for up to two months post-surgery. Pharmacists need to assess which drugs can be safely crushed and provide alternatives to drugs that cannot be crushed (i.e., extended- release formulations).
■ Rapid weight loss can cause gallstones. Ursodiol (Actigall, Urso 250, Urso Forte) dissolves gallstones and may be needed, unless the gallbladder has been removed.
counseling ALL WEIGHT LOSS MEDICATIONS
- Weight loss can improve diabetes and hypertension.
- Monitor these conditions closely; dose reductions may be needed for medications.
Phentermine/Topiramate (Qsymia) counseling
■ Take this medication in the morning. Avoid taking this medication in the evening, to prevent insomnia.
■ Phentermine can cause increased heart rate.
Naltrexone/Bupropion (Contrave) counseling
■ Do not take with opioids or with a history of seizures.
■ Can cause increased blood pressure.
Liraglutide (Saxenda}
■ Subcutaneous injection.
■ Can cause:
o Hypoglycemia.
o Pancreatitis.
o Nausea.
■ Do not take with Victoza.
These medications contain the same ingredient.
Orlistat (Xenical and Alli)
■ Take one capsule at each main meal, or up to one hour after a meal that contains fat.
■ You should be eating a healthy diet that is low in fat in order to reduce GI side effects.
■ Can cause stomach issues (fatty/oily stool, oily spotting, intestinal gas with discharge, need to have a bowel movement right away, increased number of bowel movements or poor bowel control).
Appetite Suppressants
■ Can cause:
o Increased blood pressure.
o Increased heart rate.
