Obesity Treatment: Drugs and Surgery Flashcards
4 options for overweight/ obese people
- accept
- modify diet/ activity
- medication
- surgery
physician resistance to weight loss medications
- unsafe medications: metabolife/ sibutramine–> ischemic heart disease
- behavioral problems: corrected with good diet and exercise
guidelines on weight loss medication
-prescribing weight loss medication is appropriate option for properly selected patients
3 considerations for weight loss medications
- only work as long as taking
- able and willing to pay for expensive med not covered by insurance
- amount of weight loss is modest ~5% baseline weight
phentermine MOA
- chemically related to amphetamine and increases brain NE wo abuse potential
- centrally to reduce satiety and reduce food intake
- experience fullness at end of meals to reduce portion sizes
phentermine cost
-inexpensive $20-40 per month
phentermine side effects
nervousness, increased blood pressure (1-2% patients), difficulty sleeping, headache, dry mouth
phentermine contraindications
-uncontrolled HTN
phentermine dosing
- low dose with blood pressure rechecked 7-10 days
2. low dose for at least 1 month before increasing dose
phentermine FDA
-approved for 3 mths
> 3mths: off label
- commonly done
- no long term safety and efficacy data on drug because it is old and generic
phentermine effectiveness
- 5% baseline weight
- range of responses
orlistat MOA
- pancreatic lipase inhibitor and blocks dietary fat absorption from GI tract
- scrip dose blocks 1/3 dietary fat from being absorbed
orlistat dose
OTC: Alli 60mg
Script: Xenical 120mg
orlistat cost
$90-200 per month
orlistat effectiveness
- 5% baseline weight
- range of responses
orlistat actual side effect
- Oily stools, urgency, diarrhea, oily leakage
- controlled by reducing dietary fat or not taking med with high fat meal
orlistat theoretical side effect
fat soluble vitamin deficiency
Orlistat FDA approval
-long term
Orlistat can treat what conditions
- efficacy in adolescents
- prevent DM in high risk
- improves blood lipids
- lowers HbA1c with DM
orlistat drug interactions
- coumadin: increased INF
- cyclosporine: reduced drug levels
lorcasarin (Belviq) cost
$220-250
lorcasarin (Belviq) MOA
- selective serotonin 2C receptor agonist
- 2C only in brain but not the heart
fenfluramide & dexfenfluramide
- older nonspecific serotonin receptor agonists with moderate efficacy as weight loss drugs
- taken off market: cardiac valve problems
loracsarin FDA
- FDA approval for post marketing surveillance for evidence of cardiac dysfunction
- approved for long term use
Phen/fen: phentermine/fenfluramine
efficacy
- Phen/fen in late 90’s
- weight loss 12-15%
- fenfluramine off the market
Does lorcasarin+ phentermine have a large efficacy?
we don’t know if it is the new phen/fen
locasarin cost
$220-250/month
Phetermine/ topiramate (qsymia) Contraindication
Pregnancy:
topiramate: teratogenic potential
- requires negative pregnancy test once monthly
phetermine/ topiramate (qsymia) side effects
-dry mouth, paresthesias, insomnias, dizziness, irritability, attention disturbance
phetermine/ topiramate (qsymia) weight loss
10-12%
phetermine/ topiramate (qsymia) cost
$150
naltrexone SR/ bupropion SR (Contrave) MOA
-combination opioid receptor antagonist & dopamine/ NE reuptake inhibitor
naltrexone SR/ bupropion SR (Contrave) weight loss
5%
naltrexone SR/ bupropion SR (Contrave) FDA
- concerned about modest increase in pulse rate: passed CV safety trial
- Black Box Warning: increased risk of suicidal ideation
naltrexone SR/ bupropion SR (Contrave) dosing
-gradually increase dose from 1pill/day to two pills twice a day over a month
naltrexone SR/ bupropion SR (Contrave) uncommon risks
-suicidal ideation, lowering seizure threshold, increased pulse and BP, rarely increase LFTs, closed angle glaucoma
Liraglutide 3mg (saxenda)
- recently approved by FDA as weight loss drug
- not available in pharmacies
- GLP-1 agonist
- treatment of diabetes
weight loss drugs:
least expensive to most expensive
- phentermine: $20-40
- Orlistat: $90-200
- Phetermine/topiramate (qsymia): $150
- lorcasarin (belviq): $220-250
*no price provided for naltrexone/bupropion or liraglutide
weight loss drugs:
least effective to most effective
Modest:
- Phentermine: 5%
- otlistat: 5%
- Lorcasarin: 4-5%
- Naltrexone/Bupropion: 5%
Moderate:
- phetermine/topiramate (Qsymia): 10-12%
- phentermine/fenfluramine: 12-15% (taken off the market)
psychiatric drugs and weight change
Weight Gain:
- atypical antipsychotics
- mood stabilizers
- antidepressants
Least likely Weight Gain:
- ziprasidone (geodon)
- aripiprazole (abilify)
- bupropion (wellbutrin)
glucose lowering drugs and weight change
Weight gain:
- insulin
- sulfonylureas
- TZDs
Least likely Weight Gain:
-GLP-1 agonists (weight loss)
-DPP4 antagonists
SGLT2 antagonists
other drugs that cause weight gain
- birth control with progesterone
- steroids
patients with migraines, seizures, or mood stabilizer
topiramate
-15% weight loss in higher dose
Side effects: dose related
- paresthesias
- neurocognitive
3 bariatric surgery subtypes & weight loss
- lap band: 20-24%
- sleeve: 24-27%
- RYGB: 28-30%
long term weight loss following surgery
- RYGB: maintain 25-28% weight loss for 15 years
- Lap band: less impressive
- Sleeve: no data
lap band advantages and disadvantages
advantages:
- reversible
- easier operations
- fewer complications
disadvantages:
- close follow up
- band is mechanical device with risk of failure including erosion of band through stomach
- slippage of band from proper position
- rupture of tube that connects band to subcutaneous port
reasons to choose sleeve
- intermediate between RYGB and lap
- does not need adjustments
- not associated with vitamin and nutritional deficiencies
RYGB Risks
-1% risk dying within first 30 days
Perioperative risks:
- thromboembolic disease
- leak from staple line
- pneumonia or wound infection
-greater risk than lap or sleeve
Nutritional deficiency:
-niacin, B12, Vitamin D
–>
bone disease and iron deficiency
Diabetic Benefits Weight loss surgery
- RYGB: >40% resolution of diabetes
- effect sleeve is close to RYGB
- lowest in lap band but still superior to standard medical therapy in controlling glucose in T2DM
6 other health conditions that benefit from weight loss surgery
- sleep apnea
- gastroesophageal reflux
- degenerative arthritis
- weight related infertility
- HTN
- Cancer reduction
psychiatric effects of weight loss surgery
- QOL improves
- depression and suicide increases post operatively
- depression, substance abuse, behavioral issue that develop post-operatively
- group support sessions help
BMI qualifications for Medications
- BMI >30
2. BMI >27 + weight related co-morbid health conditions
BMI qualifications for Bariatric surgery
- BMI >40
- BMI >35 + weight related co-morbid health conditions
- BMI >30 + 1 co-morbid condition for lap banding
bariatric surgery and risk of death
within 30 days:
-0.7% (0-2%) with bypass and less with sleeve and banding
Late death: within 2 years
-2-3% after bypass surgery
patients who fail to lose weight following surgery
10-15% of all patients
gastric bypass deficiencies
-thiamine
Vitamin D
Iron
B12
wernicke korsakoff syndrome in gastric bypass
- 3-10 weeks following surgery
- associated with vomiting
- double vision, ataxia, altered mental status
what to avoid for 1 year after gastric bypass surgery?
- use birth control
- avoid pregnancy because restriction in energy intake may not allow for optimal growth and development of baby