Obesity Flashcards
overweight BMI
25 - 29.9
Obesity BMI
> 30
normal BMI
18.5 - 24.9
Prevalence of obesity 2015-2016
39.8% 93.3 million
Obesity is linked with increased risk of
diabetes HTN hyperlipidemia arthritis breast and GI cancer non alcoholic steatohepatitis
Medical costs related with obesity in 2008
$147 billion
What is the second leading cause of preventable death in US?
obesity
Metabolic syndrome
- abdominal obesity
- hyperinsulinemia
- high fasting plasma glucose
- impaired glucose tolerance
- hypertriglyceridemia
- low HDL cholesterol
- HTN
CVD and metabolic syndrome
CVD mortality increased in metabolic syndrome
____% weight reduction in combo with ___ exercise daily = ____% reduction in development of diabetes vs control of diabetes prevention
5%
30 min
58%
T/F weight loss consistently demonstrates a + impact on triglycerides and HDL
true
each ___kg in weight loss reduces systolic BP _____ mmHg. roughly equal to effect _____
10kg
5-20mmHg
1 antihypertensive
T/F there is a positive correlation between weight and blood glucose
true
mainstay treatment such as ____ and ____ cause weight gain in diabetes
insulin
sulfonylureas
____ and ____ agonists are associated with weight loss
metformin
GLP-1
Secondary causes of weight gain
- disease states
- drugs
- decreased food intake
- increased food intake
What is the cornerstone of obesity management?
lifestyle modifications
T/F lifestyle modifications do not always need to be instituted when medication management becomes part of treatment plan
false!
Should always!!
Noradrenergic agents for obesity
amphetamines
phentermine
phentermine agent MOA
promote catecholamine release at pre-synaptic terminals: NE, DA or both
T/F phentermine can be used more than 6 months
False
approved for short term use up to 6 months
Max weight loss of ____% at ___ months with phentermine then usually plateau
5-10% at 6 months
T/F rapid tolerance can develop within a few weeks in phentermine
True
ADE of phentermine
HA insomnia nervousness tachycardia HTN dry mouth diarrhea constipation
phentermine long term use ADE
primary pulmonary hypertension (PPH)
what should you monitor when on phentermine?
weight
BP
symptoms of PPH
phentermine CI
moderate to severe HTN
CVD
glaucoma
concomitant MOA
phentermine and SSRIs or other antidepressants
safety and efficacy unclear
SSRIs and obesity
sertraline fluoxetine paroxetine citalopram escitalopram
SSRI MOA
inhibit CNS neuronal reuptake of serotonin
Sertaline and fluoxetine and obesity
demonstrate initial, but non-sustainable weight loss
not FDA approved for weight loss
Lorcaserin (Belviq)
serotonergic agent
Lorcaserin MOA
selective 5HT 2c receptor agonist
- effects nearly exclusive in CNS/ hypothalamus
- decreased caloric intake and increased satiety
Lorcaserin approved for
BMI >30
BMI >27, 1 weight related comorbidity
What are weight related co-morbidities?
T2D
HTN
hyperlipidemia
Lorcaserin dosing
10mg BID up to 1 year
Lorcaserin weight loss
5% in 40% of patients
When should you stop Lorcaserin?
when weight loss not achieved in 12 weeks
Lorcaserin ADE CNS
HA, dizziness, blurred vision, somnolence, paresthesia
Lorcaserin GI ADE
nausea
dry mouth
Lorcaserin ADE CV
no increase risk of CV events
Lorcaserin should not be used with what?
other serotonergic medications (antidepressants, triptans)
Lorcaserin other ADE
hypoglycemia in diabetics
priapism
Orlistat (Xenical) MOA
blocks intestinal absorption of dietary fat
lipase inhibitor
How long can you use orlistat?
up to 2 years
How should you take orlitstat?
only if eating fat containing meal
take during or up to 1 hour after meal
Orlistat 360mg/day blocks ____% of dietary fat absorption
30%
Orlistat weight loss
6-10g weight loss at 1 year
sustained in 65% of patients between 1-2 years
Orlistat ADE
abdominal pain
flatulence
fecal urgency
incontinence (up to 80%)
What increases the likelihood of ADE in orlistat?
high fat meal
Orlistat decreases absorption of what?
fat soluble vitamins
- should take vitamin 2 hours separate
Topiramate/phentermine (Qsymia) MOA
increased satiety
decreased appetite
taste aversion
Qsymia approved for
BMI >30
BMI >27, obesity comorbidity
Why is topiramate and phentermine a good combo?
both induce weight loss individually
combined can use smaller doses to improve side effects/tolerability
How to dose Qsymia
low, mid, high dose: start low 14 days, titrate to mid dose
When should you increase dose or discontinue Qsymia?
if weight loss 3% not achieved at 12 weeks
Discontinue if weight loss 5% not achieved after 12 weeks at highest dose
Dose related weight loss on Qsymia
7-9% at 56 weeks
Qsymia CNS ADE
insomnia dizziness depression (suicide) anxiety **risk for seizure if sudden withdrawal from highest dose
Qsymia GI/GU ADE
dry mouth dysguesia constipation kidney stones elevated serum creatinine
Qsymia CV ADE
palpitations
BP increase
Who should you avoid Qsymia in?
patients with CVD
Special note with qsymia
increased risk of fetal malformations
- requires initial pregnancy test, monthly testing, contraception
- *REMS
Bupropion/Naltrexone (Contrave) MOA
synergistic
appetite regulation in hypothalamus
resolimbic dopamine circuit (reward system)
Contrave approved for
BMI >30
BMI >27, comorbidity
Contrave weight loss
Mean weight decrease 8.2%
- peak weight loss at 36 weeks, sustained through week 56
Contrave dosing
dose titrate by 1 tablet weekly up to 2 tabs BID over 4 weeks to improve tolerance
When should you discontinue contrave?
after 12 weeks if not at least 5% weight loss
Contrave ADE
N/C/dry mouth Increased BP, HR dizzy tremor risk for seizure
CI contrave
- seizure disorder
- uncontrolled HTN
- chronic opioid use
- pregnancy
- during or within 14 days of MAOI
Liraglutide (Saxenda) MOA
increased satiety due to slowed gastric emptying
Saxenda weight loss
5-10% body weight at 56 weeks
Saxenda dosing
once daily
injectable
start at 0.6mg/day and increase in weekly intervals to target dose of 3mg/day
Saxenda side effects
mostly GI, nausea, bloating
Saxenda REMS
monitor for medullary thyroid carcinoma and pancreatitis
What is Saxenda also approved for?
diabetes (Victoza)
Stimulants for obesity
Ma Huang Ephedrine Guarana yerba mate bitter orange
Alternatives to obesity
- stimulate release of NE, DA, direct stimulation of B receptors
Appetite suppressants claim to increase _____
thermogenesis
Stimulants ADE
tremor nervousness insomnia palpitations GI mania HTN
Reports of what in stimulants
hemorrhagic stroke MI seizure psychosis deaths
Do not use stimulants for weight loss if history of _____ or _____
HTN
CVD
HCG for weight loss
no benefit
- usually concomitant very restrictive diet
HCG risk for
thromboembolism, edema, behavior change
St. John’s Wort for weight loss
synaptic reuptake inhibition of NE, DA, serotonin
- no studies showing efficacy
Bulk fibers for weight loss
expand within GI to induce sensation of fullness
Leptin for weight loss
believed to be involved in feedback system relating to body weight regulation
- human studies lacking
Chromium picolinate for weight loss
proposed mechanism is increased insulin sensitivity resulting in more efficient metabolism
- studies not shown effecitveness
White willow bark for weight loss
active component is salicylate
proposed to potentiate other ingredients
Non-pharmacologic management for weight loss
- behavior modification
- bariatric surgery
- diet
- exercise
Drugs that can cause weight gain
Anticholinergic/H1 blockade Progesterone Neuroleptics Corticosteroids Insulin Sulfonylureas Lithium TCAs Anticonvulsants THC
Disease states cause of weight gain
Hypothyroidism
Cushing’s
Depression
What leads to decreased food intake?
Stimulation of DA, NE
Increased 5HT concentration and stimulation
What leads to increased food intake?
Block DA, NE, serotonin receptors or decreased concentration
Histamine receptor blockade
