Obesity Pharmacotherapy Exam 3

Question 1

What are the medications associated with weight gain?

Answer 1

• Anticonvulsants (e.g. carbamazepine, gabapentin, pregabalin, valproic acid)
• Antidepressants (e.g. mirtazapine, tricyclics)
• Atypical antipsychotics (e.g. clozapine, olanzapine, quetiapine, risperidone)
• Conventional antipsychotics (e.g. haloperidol)
• Hormones (e.g. corticosteroids, insulin, medroxyprogesterone)

Question 2

What should be done with the patient before initiation pharmacotherapy of obesity?

Answer 2

• Assess readiness to engage in weight loss efforts and identify potential barriers
• Educate on potential health consequences of excessive body weight
• Discuss risks of therapies

Question 3

What are the different type of treatment options?

Answer 3

– Comprehensive lifestyle intervention
– Pharmacotherapy
– Implantable medical devices
– Bariatric surgery

Question 4

When should pharmacotherapy of obesity be initiated?

Answer 4

• have failed to achieve/sustain weight loss with lifestyle alone
• BMI >= 30 kg/m2
• BMI >= 27 kg/m2 with > 1 comorbidity

Question 5

Phentermine brand name

Answer 5

Adipex-P

Question 6

When should phentermine be discontinued?

Answer 6

if tolerance develops

Question 7

What can happen if you d/c phentermine abruptly?

Answer 7

• can cause caused extreme fatigue and depression

- will want to taper it off

Question 8

CI to phentermine

Answer 8

– Cardiovascular disease
– Hyperthyroidism
– Substance abuse
– Glaucoma

Question 9

Precautions in phentermine

Answer 9

– Renal impairment

– CNS depressants

Question 10

phentermine drug interactions

Answer 10

• do not use with SSRI’s

- interaction with MAOI

Question 11

patient education for phentermine

Answer 11

administer before breakfast or 1-2 hours after breakfast

Question 12

orlistat brand name

Answer 12

• Xenical (Rx)

- Alli (OTC)

Question 13

orlistat monitoring

Answer 13

s/s of liver toxicity and obtain LFTs if symptoms occur

Question 14

orlistat patient education

Answer 14

– Take during or up to 1 hour after meal.
– Skip dose if meal skipped or contains no fat
– Supplement with MVI 2 or more hours before or after orlistat to prevent vitamin deficiency

Question 15

lorcaserin brand name

Answer 15

Belviq (XR)

Question 16

orlistat drug interaction

Answer 16

• warfarin

- decrease absorption of oral drugs

Question 17

lorcaserin precautions

Answer 17

– Moderate renal impairment and severe hepatic impairment
– Increased risk of serotonin syndrome if used with other serotonergic or dopaminergic medications
– Valvular heart disease

Question 18

lorcaserin monitoring

Answer 18

– CBC
– depression or suicidal thoughts
– s/s serotonin syndrome
– s/s vavlular disorder (based on history with fenfluramine)

Question 19

lorcaserin drug interactions

Answer 19

may increase levels of drugs metabolized by 2D6 (dextromethorphan, paroxetine, sertraline, risperidone, metoprolol)

Question 20

phentermine and topiramate brand name

Answer 20

Qsymia

Question 21

phentermine and topiramate dosing

Answer 21

– 3.75/23 mg PO daily x 14 days, then increase to 7.5/46 mg daily
– If 3% weight loss not achieve by week 12, increase to max dose of 15/92 mg PO daily
– If discontinue, gradually taper to prevent possible seizure

Question 22

phentermine and topiramate contraindications

Answer 22

– pregnancy (REMS program requires negative pregnancy test before initiation and monthly during therapy)
– glaucoma
– Hyperthyroidism
– Cardiovascular disease

Question 23

phentermine and topiramate precautions

Answer 23

Use reduced dose in moderate-severe renal and moderate hepatic impairment

Question 24

phentermine and topiramate drug interaction

Answer 24

– MAOI inhibitors
– CNS depressants
– Carbonic anhydrase inhibitors

Question 25

phentermine and topiramate monitoring

Answer 25

– Pregnancy – check at baseline and monthly thereafter – s/s of depression or suicidal thoughts, sleep disorders – Heart rate – Electrolytes and creatinine at baseline and during therapy

Question 26

phentermine and topiramate patient education

Answer 26

– Take in morning to avoid insomnia | – Ensure adequate fluid intake reduce risk of kidney stones

Question 27

bupropion and naltrexone brand name

Answer 27

Contrave®

Question 28

bupropion and naltrexone contraindications

Answer 28

– Chronic opioid or opiate agonist therapies – Seizures – MAO inhibitors

Question 29

bupropion and naltrexone precautions

Answer 29

– Use reduced dose in moderate-severe renal impairment and hepatic impairment – Lowers seizure threshold – Rare reports of hepatotoxicity

Question 30

bupropion and naltrexone titration

Answer 30

- exists - 8/90 mg PO daily x 1 week, 8/90 mg PO BID x 1 week, 16/180 mg PO in AM and 8/90 in PM x 1 week, then 16/180 mg (2 tabs) PO BID

Question 31

bupropion and naltrexone drug interactions

Answer 31

– May increase levels of drugs metabolized by 2D6 (e.g. paroxetine, sertraline, risperidone, metoprolol) – Inhibitors or inducers of 2B6 might increase or decrease levels of bupropion (e.g. rifampin, carbamazepine)

Question 32

bupropion and naltrexone monitoring

Answer 32

– Heart rate and blood pressure at baseline and periodically throughout – s/s of seizures mania, suicidal thoughts

Question 33

bupropion and naltrexone patient education

Answer 33

do not take with a high-fat meal

Question 34

liraglutide titration

Answer 34

– exists – 5-week titration schedule to reduce GI adverse effects – 0.6 mg SC daily x 1 week, 1.2 mg x 1 week, 1.8 mg x 1 week, 2.4 mg x 1 week, then 3 mg daily thereafter

Question 35

liraglutide contraindication

Answer 35

personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2

Question 36

liraglutide precaution

Answer 36

Moderate and severe renal and hepatic impairment

Question 37

liraglutide brand name

Answer 37

Saxenda®

Question 38

liraglutide monitoring

Answer 38

– Monitor glucose and adjust diabetes medications as necessary – s/s of thyroid tumors – s/s of pancreatitis. – Heart rate

Question 39

liraglutide patient education

Answer 39

Proper technique for injection into subcutaneous of abdomen, thigh, or upper arm

Question 40

What are usual things to monitor for for an obese patients especially on these medications?

Answer 40

- BMI - Weight - WC - BP - Medication tolerability - Medication and lifestyle adherence - Glucose and A1c if have diabetes - Lipids

Question 41

What happens after bariatric surgery?

Answer 41

- Monitor medications and medical conditions after surgery - For up to 2 months post-op, all meds should be given in a liquid dose form, a crushed tablet, an opened capsule, or non-oral dose form - Consider reducing or stopping meds for diabetes, hypertension, GERD - Avoid enteric coated or extended-release meds for all acutely and long-term after Roux-en-Y gastric bypass - Avoid sorbitol and other nonabsorbable sugar due to increased risk of dumping syndrome - Recommend contraception for 1-2 years after surgery - Avoid GI irritants such as oral NSAIDs and bisphosphonates - Increase monitor especially of narrow therapeutic index drugs and adjust dose as indicated - Watch for transition to other addictive behaviors - Empiric supplementation with MVI plus minerals, calcium, vitamin D, folic acid, thiamine, iron, B12 - Emphasize lifelong adherence to vitamin and mineral supplements

Question 42

PPCP: Collect

Answer 42

* Patient characteristics (e.g., age, race, sex) * Patient history (past medical, family, social—dietary habits, tobacco use) * Obesity-related conditions * Current medications including prescription, nonprescription, and herbal product use * Weight loss history and prior attempts to lose weight * Objective data

Question 43

PPCP: Assess

Answer 43

* Presence of secondary obesity (e.g., hypothyroidism, Cushing syndrome) * Current medications that may contribute to weight gain * Presence of obesity-related comorbidities (e.g., hypertension, dyslipidemia, coronary artery disease, type 2 diabetes mellitus, sleep apnea, increased waist circumference) * Class of overweight and obesity determined by BMI, waist circumference, and obesity-related comorbidities) * Readiness to engage in weight loss efforts and potential barriers to success * Candidacy for treatment with implantable medical devices, bariatric surgery, or pharmacotherapy

Question 44

PPCP: Plan

Answer 44

* Nonpharmacologic lifestyle intervention including low-calorie diet, physical activity, and behavioral modifications * Pharmacotherapy (if appropriate) including specific medication, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies * Initial weight loss goal of 5% to 10% over a 6-month time period * Monitoring parameters including efficacy (weight loss) and tolerability (medicationspecific adverse effects) * Patient education (e.g., purpose of dietary and lifestyle modification, drug therapy) * Self-monitoring of weight—when and how to record results * Referrals to other providers when appropriate (e.g., physician, dietician, psychologist)

Question 45

PPCP: Implement

Answer 45

* Educate patient regarding health risks associated with overweight and obesity * Provide patient education regarding all elements of treatment plan * Use motivational interviewing and coaching strategies to maximize adherence * Schedule follow-up (e.g., monthly for first 3 months and every 3 months thereafter) * Collaborate with patient, caregiver, and health care providers

Question 46

PPCP: Follow-up: Monitor & Evaluate

Answer 46

* Determine weight loss goal attainment * Presence of adverse effects * Patient adherence to treatment plan using multiple sources of information