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Obesity Medicine > Obesity Medications > Flashcards

Obesity Medications Flashcards

1
Q

What medication was discontinued in 1997? Why?

A

Fen-Phen combination pills which was discontinued due to rare but serious valvular heart disease and pulmonary HTN. However, these effects were isolated to the other component of the medication (Fenfluramine which had non selective 5-HT activity) and has not been reported with Phentermine alone. However, there remains significant unfounded stigma surrounding Phentermine due to its association with this medication

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2
Q

Use of Metformin for weight loss in non-diabetics

A

Off label indication as not FDA approved

Study gave non-diabetic patients 2200-2500 mg per day total and average weight loss was ~6kg

Getting to that dose is a bit awkward. Could do 875 TID or add an extra half dose of 1000

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3
Q

The difference between Alli and Xenical

A

Alli is OTC and 1/2 the dose of prescription strength Xenical

Xenical costs about 10 times as much

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4
Q

Side effects with Topiramate

A 
Change in taste (primarily soda)
Dizziness
Drowsiness
Forgetfulness 
Paresthesias (transient and seen in ~30%of patients)
Nausea
Abdominal pain
Diarrhea
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5
Q

1/2 life for Phentermine

A

Longer-acting medication. Half-life 20 hours, with peak effect at 4 hours. This is why it is typically dosed in the morning

Diethylpropion works similarly, but only lasts ~5 hours and has to be dosed multiple times a day

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6
Q

This med can cause false positive amphetamine testing

A

Contrave

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7
Q

Phentermine addiction potential? What level DEA schedule is it?

A

DEA schedule IV controlled substance (Need to review EFORSCE first), even though studies show no evidence of addictive potential, cravings, or withdrawal with this medication (unlike other medications in the class)

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8
Q

This medication can cause emergent priapism

A

Lorcaserin

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9
Q

Mechanism of action for Orlistat

A

Pancreatic lipase inhibitor, prevents absorption of about 30% of ingested fat

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10
Q

What obesity med was recently pulled from the market by FDA due to concerns about cancer

A

Lorcaserin/Belviq

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11
Q

If patient is possible candidate for future bariatric surgery, what should you keep in mind when considering weight loss medications

A

People who are on the border of qualifying for weight loss surgery might lose enough weight with meds to no longer meet criteria for more effective bariatric surgery

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12
Q

The cheapest and most widely available form of phentermine is? How much does it cost?

A

37.5mg tablets with a score down the middle.

About $10 for 30 at Publix

Capsules r more expensive, hard to find, and can’t be cut in half

Lomaira costs about $30 for 90 8mg tabs

There is an ODT version that costs ~$300

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13
Q

Weight loss meds that require titrating the dose

A

Qysmia
Contrave
Liraglutide

In some cases Phentermine and Metformin

Don’t need to titrations Belviq or Orlistat

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14
Q

This medication can increase risk of seizures with abrupt withdrawal

A

Topiramate

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15
Q

BMI criteria for starting weight loss medications?

A

BMI ≥ 30 or BMI ≥ 27 with co-morbidities

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16
Q

Cost of Bupropion with Good Rx coupon

A

~$20

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17
Q

Weight loss med(s) which effect serotonin levels

A

Lorcaserin
Zonisamide
Fenfluramine (Taken off the market)

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18
Q

The best weight loss med for patients who also have Migraines

A

Topamax

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19
Q

Weight loss medication to avoid in patients with history of bulimia or anorexia

A

Bupropion

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20
Q

The best weight loss med for patients who also have Pre-diabetes/diabetes

A

Metformin

Liraglutide

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21
Q

Weight loss medications that are off label

A
  • Phentermine (and other sympathimemetics) for long term use
  • Topiramate by itself
  • Generic combination of Phen and Top rather than approved (more expensive) Qysmia
  • Metformin
  • Bupropion by itself
  • Generic combination of Naltrexone and Bupropion rather than approved (more expensive) Contrave
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22
Q

These medications are taken TID with meals

A

Orlistat
Lomaira
Diethylpropion

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23
Q

This weight loss medication is free at Publix

A

Metformin

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24
Q

Preferred weight loss medication for patients with significant cravings

A

Contrave

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25
Q

This oral weight loss medication does not have any dose titration

A

Lorcaserin

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26
Q

Preferred weight loss med in obese patients who smoke

A

Bupropion

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27
Q

Contraindications to Phentermine use

A

Relative contraindications = uncontrolled HTN, CAD, hyperthyroidism, substance abuse, glaucoma, pregnancy, renal disease, and seizure disorder

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28
Q

This medication has been shown to have ASCVD benefit (at least in diabetes)

A

Liraglutide

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29
Q

This medication is probably the least effective as far as average weight loss

A

Orlistat

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30
Q

Mechanism of Setmelanotide

A

MC4R agonist for treatment of POMC Def

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31
Q

This medication has the same mechanism as Phentermine

A

Diethylpropion. Rarely used now

Way shorter half life than Phentermine so taken TID

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32
Q

Systemic absorption of this medication is minimal

A

Orlistat

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33
Q

This condition in female patients is a contraindication to all the weight loss medications

A

Pregnancy

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34
Q

Effect of Bupropion on anxiety

A

Can worsen anxiety and cause agitation, but not a clear contraindication

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35
Q

How do you treat POMC deficiency

A

Setmelanotide is an MC4R agonist for the treatment of POMC deficiency

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36
Q

Weight loss medications which are controlled substances

A

Phentermine/Qysmia
Lorcaserin/Belviq
Diethlpropion

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37
Q

If you start lower dose Phentermine and have some effect but don’t reach goal, what steps can you take to titrate up effect?

A

Can increase to a max dose of 37.5mg tab once per day

Many like to start with generic Phentermine and then later add generic Topiramate if needed to mimic Qysmia. Effect is synergistic, not just additive

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38
Q

Dosage of Topiramate

A

In Qysmia is 23mg ER —> titrations up to 46 or 94

Topiramate ER QD is $400-700 per month

Topiramate BID is available for about $10. Starting dose for other conditions is 25-50mg BID

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39
Q

Preferred med for sleep related eating disorder

A

Clonazepam

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40
Q

The only FDA approved weight loss medication that is available over the counter

A

Alli (Orlistat)

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41
Q

Titration and dosages of Qysmia

A

Phentermine-Topiramate 3.75-24

  1. 5-46 (suggested dose)
  2. 25-69

15-92 (high dose)

All QD

Spend at least 14 days at each dose before increasing

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42
Q

These weight loss medications may be best for patients with chronic constipation

A

Orlistat

Metformin

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43
Q

This weight loss medication can not be combined with antidepressants

A

Lorcaserin

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44
Q

Contraindications to Metformin

A

Severe heart failure and severe CKD

Caution in liver disease and alcohol abuse

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45
Q

The medication that has the biggest average weight loss

A

Qysmia

Liraglutide is prob second best

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46
Q

This weight loss medication causes nasopharingitis

A

Lorcaserin

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47
Q

Are Topamax neurological side effects self limited?

A

Tingling tends to be self limited and may not necessarily be an indication to stop the medication. Cognitive side effects are not self limited and therefore the Med should be stopped

48
Q

Women with PCOS should be warned about this possible adverse effect of weight loss medications?

A

Pregnancy as become more regular

49
Q

The bioavailability of this Med can be dangerously increased if taken with a high fat meal

A

Contrave

50
Q

Injectable obesity medication

A

Liraglutide

51
Q

The trade names for Orlistat

A

Alli and Xenical

52
Q

Contraindications for Lorcaserin

A

Already on antidepressant, eGFR <30, on viagra, sickle cell (predisposed to priapism), or valvular heart disease

53
Q

You should take this with Orlistat

A

Multivitamin (due to risk of fat soluble vitamin deficiency)

Fiber/Psylium supplement (to decrease side effects)

54
Q

These weight loss meds can cause seizures

A

Bupropion/Contrave

Stopping Topamax suddenly can also cause seizures

Book said Phentermine, but Epocrates doesn’t

55
Q

Trade name for low dose Phentermine taken with each meal

A

Lomaira

56
Q

Difference between Saxenda and Victoza

A

Saxenda is about double the dose, but same med

57
Q

These weight loss medications are sympathomimetics that stimulate the sympathetic nervous system directly

A

Phentermine
Diethylpropion

Indirectly other meds activate the sympathetic nervous system through intermediates like POMC

58
Q

Patients taking this weight loss medication should also take a multivitamin

A

Orlistat

59
Q

At this point in time, patients weight loss tends to plateau on a given medications

A

6-9 months

60
Q

These meds should not be taken alongside Phentermine

A

Linezolid
MAOIs
Other stimulants (such as ADHD meds)

61
Q

Generic name for Saxenda

A

Liraglutide

62
Q

The most teratogenic weight loss medication

A

Topamax/Qysmia

63
Q

Saxenda dosing

A

Titrated over 5 weeks = 0.6mg SC x 7 days –> 1.2mg SC x 7 days –> 1.8mg SC x 7 days –> 2.4mg SC x 7 days –> 3.0mg SC maintenance dose

64
Q

Preferred weight loss Med for patients with chronic migraines

A

Topamax

65
Q

Naltrexone use for weight loss on its own

A

Not really done on its own. Thought to augment effects of other medications

66
Q

The trade name for Lorcaserin

A

Belviq

67
Q

Stimulant similar to Phentermine which is much less commonly used now

A

Diethylpropion

68
Q

Dual Efficacy weight loss medications

A
  • Bupropion for depression and smoking cessation
  • Metformin for pre-diabetes/diabetes and PCOS
  • Liraglutide for DM
  • Topiramate for seizures and migraines
69
Q

Mechanism of Action for Liraglutide/Saxenda

A

GLP-1 agonist delays gastric emptying

Activates POMC and inhibits NPY

70
Q

These medications activate POMC

A

Liraglutide/Saxenda
Lorcaserin/Belviq
Bupropion (And combo Contrave)
Phentermine (and combo Qysmia)

Basically everything other than orlistat

71
Q

Contrave side effects

A

Gastrointestinal symptoms are common with naltrexone/bupropion. Up to one in three patients will report nausea and 19% will experience constipation, especially early in treatment. Headache, dizziness, and sleep disorders are also common. In premarketing studies, about 20% of patients discontinued treatment because of adverse effects.

72
Q

Long term use of this weight loss specific medication is off label?

A

Prescribing for more than three months of Phentermine is considered “off label.” Generic so nobody is gonna study it. There is abundant experience and observational literature demonstrating the safety and efficacy of these drugs well beyond twelve weeks and Qysmia is a combination medication with phentermine in it which. If that is safe long term, phentermine alone must be too

73
Q

The best weight loss med for patients who also have PCOS

A

Metformin

74
Q

Obesity medications to avoid in patients with Glaucoma

A

Phentermine

Bupropion

75
Q

Effect of Naltrexone on POMC

A

Prevention of autoinhibition of POMC

76
Q

Use of Bupropion for weight loss without mental health indication

A

Off label cuz not FDA approved.

Have been studies that show about 10% weight loss

77
Q

Mechanism of Phentermine

A

Reduced reuptake of catecholamines (mainly norepinepherine from hypothalamus)

Activates POMC

78
Q

Most common side effects with Loracaserin? Rare but severe adverse reactions?

A

Headache and dizziness

Suicidal ideation/worsening depression, priapism, hypoglycemia when combined with insulin, and possibly increased risk of valvular regurg (debatable)

79
Q

Mechanism of action for Topiramate

A

GABA receptor modulator

80
Q

Weight loss med(s) which effect norepinepherine levels

A

Phentermine

Bupropion

81
Q

Contrave dosing

A

Naltrexone-Bupropion 8 mg-90 mg ER in each tab.

Titrate number of tabs, not the dose.

1 AM x 7 days –> 1 AM 1 PM x7 days –> 2 AM 1 PM x 7 days –> 2 AM 2 PM x 7 days

82
Q

Med that should not be used in a patient at risk for abrupt opioid or alcohol withdrawal

A

Contrave/Bupropion due to lower seizure threshold

But substance abuse is really a relative contraindication for all the weight loss meds

83
Q

Trade name of Pranlintide

A

Symlin

84
Q

Mechanism of Pranlintide (Symlin)

A

Amylin which Antagonize glucagons action in the liver

Diabetic medication with some weight loss

85
Q

Generally speaking, you can expect this % of weight loss with a weight loss medication

A

8-15% (this number doesn’t have placebo effect removed)

86
Q

Weight loss med(s) which effect dopamine levels

A

Bupropion

Zonisamide

87
Q

What is the most commonly used weight loss medication?

A

Phentermine

88
Q

Contraindications for Saxenda/Liraglutide

A

Medullary Thyroid Cancer, personal or family history of MEN, history of pancreatitis

89
Q

This medication used off label for weight lose is also sometimes used off label for tremor

A

Topiramate

90
Q

Contraindications to Orlistat

A

Pregnancy, Malabsorptive syndromes, severe liver disease, history of oxalate kidney stones, and cholestasis

91
Q

This medication should be taken in the morning

A

Phentermine

92
Q

Expected weight loss for Phentermine?

A

Don’t have specific numbers for expected weight loss as it was only studied for short term, but appears to be in the ball park of other medications

93
Q

Mechanism of Zonisamide

A

Activation of serotenergic and dopaminergic pathways

94
Q

Risk Evaluation and Mitigation Strategy’s (REMS) is required for which meds

A

Saxenda (Pancreatitis and MEN1)

Qysmia (teratogenic)

Really optional not required

95
Q

Saxenda adverse effects

A

Nausea and vomiting common (about 40%)

Can have other GI side effects too such as abdominal pain, diarrhea/constipation …

Headache and dizziness less common

Rare but severe side effects include medullary thyroid cancer and pancreatitis

96
Q

Dosages and formulations of Belviq

A

Don’t titrate. Either get 10mg of Belviq (immediate release) BID or 20mg ER QD of Belviq XR

97
Q

Preferred weight loss med for obese patient with depression

A

Bupropion

Can’t use Lorcaserin/Belviq if already on another depression Med

98
Q

Which FDA approved weight loss medication is probably the safest overall

A

Orlistat. Longer studies, less significant side effects, and fewer contraindications

99
Q

Mechanism of action for Loracaserin

A

Selective serotonin 5-HT2C receptor agonist in the hypothalamus promoting satiety —> activates POMC

Fenfluramine was non-selective

100
Q

What medication is FDA approved for treating bulimia

A

Fluoxetine is FDA approved, while all SSRIs are effective

Topamax and Trazadone are used off label to treat

101
Q

Phentermine adverse reactions

A

Dry mouth (weak anticholinergic), Insomnia, palpitations, hypertension, tachycardia, and headaches (can worsen underlying migraines)

102
Q

This medication is probably the least well tolerated

A

Orlistat

103
Q

Only medication FDA approved for use in Binge Eating Disorder with obesity? Other options?

A

Lisdexamfetamine (FDA approved)

Topamax or Zonisamide (antiepileptic)

104
Q

This currently available medication is most similar to Fenfluramines mechanism of action

A

Lorcaserin/Belviq (is more selective than fenlfuramine)

Phentermine was in combo with fenfluramine, but works differently

105
Q

This is the only weight loss medication that is safe to use during pregnancy

A

Metformin

106
Q

Timing of taking weight loss meds with and without food

A

Orlistat is with food

Others doesn’t matter

107
Q

Outcome changes with weight loss medications

A

Opponents of the use of weight loss meds argue that the studies on these meds have flaws including short duration, lack of head to head comparison, high attrition rates, and inadequate reporting of clinical outcomes such as cardiovascular outcomes. However, there is data to show clinically significant changes in BP, Lipids, HbA1c etc with many of the obesity medications.

108
Q

Bupropion mechanism

A

Norepi and dopamine uptake inhibitor

Activates POMC

109
Q

The best weight loss med for patients who also have Seizures

A

Topamax

110
Q

Treatment of night eating syndrome

A

Progressive Muscle Relaxation

Sertraline. Topamax is also an option

111
Q

Obesity Medicines which can worsen BP

A

Bupropion/Contrave

Phentermine/Qysmia

112
Q

Per FDA, you should stop obesity medications after this amount time if weight loss is < than this %?

A

If 5% weight loss is not achieved at 12 weeks while at max dose the drug should be discontinued for lack of effectiveness.

113
Q

Weight loss medications approved for pediatric patients

A

Orlistat is approved for ages 12 and up

Phentermine is approved for ages 16 and up

Metformin is approved for ages 10 and up, but not for obesity alone. Need insulin resistance or PCOS for it to not be “off label”

114
Q

This weight loss medication is contraindicated for patients on chronic opioids

A

Contrave

115
Q

These medications should be used with caution in patients with a history of nephrolithiasis

A

Topamax

Orlistat

116
Q

This medication can lessen the Euphoric effects of alcohol

A

Contrave/Naltrexone

Obesity Medicine (5 decks)

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