Fundamentals Of Obesity Pharmacotherapy

Question 1

Documentation best practices for obesity meds

Answer 1

Initial drug Rx rationale

Vs, appearance, mood every visit

Beneficial and adverse effects every visit

Rationale for Rx change

Question 2

What is qsymia

Answer 2

Phertermine and topiramate

Question 3

What is saxenda

Answer 3

Liraglutide

Question 4

What is contrave

Answer 4

Naltrexone/bupropion

Question 5

Orlistat dosage

Answer 5

60 mg po tid with meals

Question 6

Orlistat mechanism of action

Answer 6

Pancreatic lipase inhibitor, prevents absorption of 30 percent ingested fat

Question 7

Orlistat contraindications

Answer 7

Pregnancy
Chronic malabsorption syndrome
Cholestasis
Hypersensitivity

Question 8

Orlistat adverse effects

Answer 8

Diarrhea
Oily stools
Fecal incontinence
Fat soluble vitamin def
Increase urinary oxalate
Rare hepatotoxicity

Question 9

Orlistat weight loss 2 yr

Answer 9

2.3 percent

Question 10

Qsymia dose

Answer 10

Start AM dosing 3.75/23 x 14 days

Increase to 7.5/46

After 12 weeks:
If wt loss < 3% increase to 11.25/69 x 14 days then increase to 15/92

Stop medication if weight loss < 5% after 12 weeks at 15/92

If downtitrating from max dose, need to downtitrate QOD for at least 7 days to reduce sz risk

Question 11

Phentermine MOA

Answer 11

Release of NE in hypothalamus => decreased appetite and food intake

Question 12

Topiramate MOA

Answer 12

Unknown

Possibly augmenting GABA or inhibiting carbonic anhydrase to help with increased satiety

Question 13

Qsymia response rate

Answer 13

5% WL: 67% at full dose vs 17% placebo

10% WL: 47% at full dose vs 7% placebo

Question 14

Qsymia contraindications

Answer 14

Pregnancy
Glaucoma
Hyperthyroidism
MAOI use 14 days

Question 15

Qsymia adverse reactions

Answer 15

Paresthesias
Dizziness
Dysguesia
Insomnia
Constipation
Dry mouth
Makes carbonated beverages taste bad

Fetal toxicity (oral cleft lip/palate)

Question 16

Qsymia monitoring

Answer 16

Check urine pregnancy monthly (can be done by patient at home)

Or

Document 2 forms contraception

Question 17

Contrave dosing

Answer 17

Titration of 8 mg naltrexone and 90 mg bupropion over 4 weeks

Week 1: 1 tab AM
Week 2: 1 tab AM and 1 tab PM
Week 3: 2 tabs AM and 1 tab PM
Week 4: 2 tabs AM and 2 tabs PM

Question 18

Naltrexone MOA

Answer 18

Opioid antagonist

Works in hypothalamus and mesolimbic/DA circuit to decrease appetite and reward

Question 19

Bupropion MOA

Answer 19

Weak inhibitor of reuptake of DA and NE

Works in hypothalamus and mesolimbic/DA circuit to decrease appetite and reward

Question 20

Contrave wight loss percentages

Answer 20

42-56 percent had 5 percent weight loss

21-35 percent has 10 percent weight loss

Question 21

Contrave contraindications

Answer 21

Black box: inc SI in young people

Uncontrolled HTN
Seizure
Anorexia
Bulimia
Undergoing abrupt discontinuation etoh, benzo, barb, anti-sz meds
Chronic opiate use 
MAOI usage in last 14 days

Question 22

Contrave adverse reactions

Answer 22

N/V/D/C

HA
Dizziness
Insomnia

Dry mouth

Avoid contaminant opioid usage with high fat foods

Question 23

Saxenda dosage

Answer 23

Titrate over 5 weeks once daily with SC injection

Week 1: 0.6 mg SC x 7 days
Week 2: 1.2 mg SC x 7 days
Week 3: 1.8 mg SC x 7 days
Week 4: 2.4 mg SC x 7 days
Week 5: 3.0 mg SC ongoing

Can change injection site and timing without dose adjustment

If less than 4 percent weight loss after 16 weeks, consider stopping

Question 24

Saxenda MOA

Answer 24

GLP-1 agonist

Results in activation of areas in hypothalamus to reduce food intake, increased satiety, and decreased caloric intake

Also improves glucose metabolism

Question 25

Saxenda weight loss percentages

Answer 25

62 percent had 5 percent weight loss 34 percent had 10 percent weight loss

Question 26

Saxenda contraindications

Answer 26

Pregnancy Personal or fam hx medullary thyroid CA or MEN 2 Hypersensitivity Black box: causes c cell tumors in mice, unk in humans

Question 27

Saxenda adverse reactions

Answer 27

``` Nausea/vomiting Hypoglycemia esp when used with insulin Diarrhea Constipation HA Dec appetite Fatigue Dizziness AP Inc lipase ``` ``` Acute pancreatitis GB disease Tachycardia Renal impairment SI ```

Question 28

Which obesity med can increase systolic bp

Answer 28

Contrave (naltrexone/bupropion)

Question 29

Daily recommended phentermine doses

Answer 29

15-37.5 mg

Question 30

Phentermine adverse effects

Answer 30

Most common: Dry mouth Insomnia, usually fades, helped with melatonin Constipation ``` Less common: Bruxism Palpitations Urinary retention in setting of BPH HA ``` Uncommon: Impotence Dysphoria Irritability

Question 31

How to use diethylpropion and phentermine

Answer 31

Am phentermine with 25 diethylpropion as late afternoon or evening dose because no of shorter half life

Question 32

Weight loss metformin

Answer 32

2% in DM2/insulin resistance

Question 33

Obesity dose of topiramate

Answer 33

start at 25 mg Qhs, inc dose every 2 weeks by 25 mg (usually BID) based on clinical response, up to 100 BID, tolerate, ASE

Question 34

Topiramate adverse effects

Answer 34

``` Attention/memory difficulty Fatigue Acute myopia and glaucoma (rare) Kidney stones (rare) paresthesias, dysguesia Depression, anxiety, SI Increase risk oral clefts if taken during pregnancy in first trimester (use caution in child bearing age) ```

Question 35

First choice for obesity pt with MDD

Answer 35

bupropion/contrave

Question 36

First choice for obesity pt with binge eating disorder

Answer 36

Lisdexamfetamine (Vyvanse) | Topiramate (not FDA approved for BED)

Question 37

Dosing of lisdexamfetamine (Vyvanse)

Answer 37

start 30 mg po q daily in AM titrate in increments of 20 mg weekly usual maintenance dose is 50-70 mg q AM

Question 38

First choice obesity pt with night eating syndrome

Answer 38

sertraline citalopram escitalopram

Question 39

First choice obesity pt with diabetes

Answer 39

metformin GLP1 agonists SGLT2 inhibitors flubosidase inhibitors Dpp4 inhibitors weight neutral

Question 40

First choice obesity pt with premenstrual carb cravings

Answer 40

spironolactone in later half of cycle to 2nd day of menses Caution with pts who may be pregnant, scant medical literature