Obesity Treatment Flashcards
Currently available tx options
- Accept weight where it is
- Diet/Exercise (3-10%)
- Drugs (5-12%)
- Medically supervised/Combo of diet + drug (10-15%)
- Surgery (15-30%)
Increasing effectiveness from 1-5
Risks/Time/Money increasing from 1-5
If you have a patient with a BMI of 36, is surgery indicated for Tx?
Yes if you have a co-morbidity
Obesity treatment pyramid
1 .Surgery
- Pharmacotherapy
- Lifestyle modification (diet + exercise)
Meds that may promote weight gain
- Anti-diabetic meds (sulfonylureas, insulin, TZDs)
- Mood stabilizers, antipsychotics
- Birth control pills
- Glucocorticoids
Pharmacologic Tx of Obesity
- Current meds 5-12% wt loss
- Benefits last as long as patient takes the med. Chronic tx is needed
- Drugs probably not paid for by insurance so cost is a big issue
- FDA approval, long term safety, and efficacy
- Choice of mechanisms, OTC vs prescriptions or combos?
Phentermine
- increases NE content in the brain
- chemically related to amphetamine but is not addictive
- Dose: 15-37.5 mg/d
- Cost: $ 15-25/mo (CHEAP)
- FDA approved only for 3 month use
- 5-8% wt loss
- Side effects: HTN, headache, nervousness
Orlistat (Xenical; ally)
- Pancreatic lipase inhibitor
- Inhibits fat absorption by 30%
- 120 mg TID
- Cost $100/mo
- GI side effects: oily stools, urgency
- multivitamin needed
- May be used in those with poorly controlled HTN or psych problems
Benefits of each med
Phentermine: CHEAP (but not long term)
Orlistat: SAFEST (but limited wt loss and coverage)
Lorcasarin: LEAST SIDE EFFECTS (but only modestly effective)
Phentermine/Topiramate: MOST EFFECTIVE (but costs a lot)
Naltrexone/bupropion: intermediate
Lorcasarin (Belviq)
- Serotonin 2C receptor agonist
- Previous serotonin agonists caused cardiac valve disease
- 2C receptor only in the brain, not the heart
- Least side effects
- Cost $220
- no better wt loss than phentermine or orlistat
Phentermine/Topiramate compound
- Risk of birth defects: women need pregnancy test
- Reduces BP, glucose, insulin, TG, and raises HDL
- Unclear if will be prescribed off label
- Most effective med available 10-12% weight loss
Naltrexone SR/Bupropion SR
- Combo is hard to dose
- Stimulates hypothalamic propiomelanocortin (POMC) neurons to reduce food intake
- Naltrexone blocks opioid receptor-mediated POMC auto-inhibition, augmenting POMC firing in a synergistic manner. Alters reward pathways
- Intermediate in effectiveness and side effects
- Black box: for suicidal ideation
- Category X in pregnancy
- Stop if clinically significant increase in BP or pulse
- Stop if
3 surgeries
- Lap band
- Sleeve gastrectomy
- Gastric bypass
Not super effective –> very effective from 1 ->3
Low to high risk from 1->3
Comparison of operations
- Lap band - 20% wt loss, very low mortality and low complication
- Sleeve gastrectomy - 25% wt loss, low mortality, slightly higher complication
- Gastric bypass - 30% wt loss, slightly higher (barely any) mortality, and more complication rate
What can bariatric surgery help prevent the most? Why?
- Cancer!
- Reduce the activation of that mitogenic pathway from insulin signaling
Benefits of weight loss surgery
- Sleep apnea improved
- HTN improved in half
- Gastroesophageal reflux: improved in most
- Urinary incontinence: improved in most
