Obesity Pharmacotherapy Exam 3 Flashcards
What are the medications associated with weight gain?
- 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)
What should be done with the patient before initiation pharmacotherapy of obesity?
- 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
What are the different type of treatment options?
– Comprehensive lifestyle intervention
– Pharmacotherapy
– Implantable medical devices
– Bariatric surgery
When should pharmacotherapy of obesity be initiated?
- have failed to achieve/sustain weight loss with lifestyle alone
- BMI >= 30 kg/m2
- BMI >= 27 kg/m2 with > 1 comorbidity
Phentermine brand name
Adipex-P
When should phentermine be discontinued?
if tolerance develops
What can happen if you d/c phentermine abruptly?
- can cause caused extreme fatigue and depression
- will want to taper it off
CI to phentermine
– Cardiovascular disease
– Hyperthyroidism
– Substance abuse
– Glaucoma
Precautions in phentermine
– Renal impairment
– CNS depressants
phentermine drug interactions
- do not use with SSRI’s
- interaction with MAOI
patient education for phentermine
administer before breakfast or 1-2 hours after breakfast
orlistat brand name
- Xenical (Rx)
- Alli (OTC)
orlistat monitoring
s/s of liver toxicity and obtain LFTs if symptoms occur
orlistat patient education
– 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
lorcaserin brand name
Belviq (XR)
orlistat drug interaction
- warfarin
- decrease absorption of oral drugs
lorcaserin precautions
– Moderate renal impairment and severe hepatic impairment
– Increased risk of serotonin syndrome if used with other serotonergic or dopaminergic medications
– Valvular heart disease
lorcaserin monitoring
– CBC
– depression or suicidal thoughts
– s/s serotonin syndrome
– s/s vavlular disorder (based on history with fenfluramine)
lorcaserin drug interactions
may increase levels of drugs metabolized by 2D6 (dextromethorphan, paroxetine, sertraline, risperidone, metoprolol)
phentermine and topiramate brand name
Qsymia
phentermine and topiramate dosing
– 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
phentermine and topiramate contraindications
– pregnancy (REMS program requires negative pregnancy test before initiation and monthly during therapy)
– glaucoma
– Hyperthyroidism
– Cardiovascular disease
phentermine and topiramate precautions
Use reduced dose in moderate-severe renal and moderate hepatic impairment
phentermine and topiramate drug interaction
– MAOI inhibitors
– CNS depressants
– Carbonic anhydrase inhibitors
phentermine and topiramate monitoring
– 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
phentermine and topiramate patient education
– Take in morning to avoid insomnia
– Ensure adequate fluid intake reduce risk of kidney stones
bupropion and naltrexone brand name
Contrave®
bupropion and naltrexone contraindications
– Chronic opioid or opiate agonist therapies
– Seizures
– MAO inhibitors
bupropion and naltrexone precautions
– Use reduced dose in moderate-severe renal impairment and hepatic impairment
– Lowers seizure threshold
– Rare reports of hepatotoxicity
bupropion and naltrexone titration
- 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
bupropion and naltrexone drug interactions
– 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)
bupropion and naltrexone monitoring
– Heart rate and blood pressure at baseline and periodically throughout
– s/s of seizures mania, suicidal thoughts
bupropion and naltrexone patient education
do not take with a high-fat meal
liraglutide titration
– 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
liraglutide contraindication
personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2
liraglutide precaution
Moderate and severe renal and hepatic impairment
liraglutide brand name
Saxenda®
liraglutide monitoring
– Monitor glucose and adjust diabetes medications as necessary
– s/s of thyroid tumors
– s/s of pancreatitis.
– Heart rate
liraglutide patient education
Proper technique for injection into subcutaneous of abdomen, thigh, or upper arm
What are usual things to monitor for for an obese patients especially on these medications?
- BMI
- Weight
- WC
- BP
- Medication tolerability
- Medication and lifestyle adherence
- Glucose and A1c if have diabetes
- Lipids
What happens after bariatric surgery?
- 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
PPCP: Collect
- 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
PPCP: Assess
- 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
PPCP: Plan
- 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)
PPCP: Implement
- 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
PPCP: Follow-up: Monitor & Evaluate
- Determine weight loss goal attainment
- Presence of adverse effects
- Patient adherence to treatment plan using multiple sources of information
