Obesity Treatment: Pharmacological and Surgical Treatments

Question 1

BMI to start pharm

Answer 1

30-34.9

27-29.9 with comorbid

Question 2

BMI for surgery

Answer 2

40

35-39 with comorbid

Question 3

Pharmacological Treatment of Obesity

Answer 3

Current medications 5-12% wt loss

Benefits only last as long as patient takes the medication. Chronic treatment likely needed.

Drugs probably not paid for by insurance so cost is a big issue for patients.
Issues of FDA approval, long term safety, and efficacy.

Choice of mechanisms, OTC versus prescription, combinations?

Question 4

Phentermine

Answer 4

Increases NE content in the brain

Chemically related to amphetamine, ‘not addictive’

Dose: 15-37.5 mg/d,
Cost: $15-25.00/month Cheapest

FDA approved for only 3 months use

5-8% weight loss

Side effects: hypertension, headache, nervousness

Question 5

Increases NE content in the brain

Chemically related to amphetamine, ‘not addictive’

Dose: 15-37.5 mg/d,
Cost: $15-25.00/month Cheapest

FDA approved for only 3 months use

5-8% weight loss

Side effects: hypertension, headache, nervousness

Answer 5

Phentermine

Question 6

Pancreatic Lipase inhibitor
Inhibits fat absorption by 30%
120 mg three times per day
Cost: $100.00/mo
GI side effects: oily stools, urgency
MVI to prevent fat soluble vitamin deficiency

Answer 6

Orlistat (Xenical)

Safest weight loss medication, approved for long term use, OTC form

Question 7

Much greater weight loss (10-12%)

s/e: Dry mouth, paresthesias, insomnia, dizziness, anxiety, irritability, attention problems

Answer 7

Phentermine/topiramate

Question 8

• Recently approved
• 4-5% weight loss (may be combined with phentermine in future to get greater combined loss)
• $220-$250/month

Answer 8

Lorcasarin

Question 9

• Not systemically absorbed=no systemic side effects
• Oily stools, sense of urgency, diarrhea, oily leakage
• Fat soluble deficiency is not common, but still take multivitamin
• DDI: Increased INR with warfarin, decreased levels cyclosporine

Answer 9

Orlistat (Xenical) side effects

Question 10

Orlistat

Answer 10

safest

May be useful in those with poorly controlled hypertension or psych problems

Question 11

Phentermine

Answer 11

cheapest

Question 12

Lorcasarin

Answer 12

Least side effects

minimal headache, dizziness and nausea
Cost: $220/mo

Question 13

The most effective treatment we have for obesity.

The best treatment we have for type 2 diabetes

Answer 13

Bariatric Surgery

Question 14

Benefits of Weight Loss Surgery

Answer 14

Sleep apnea: Improved in almost all
Hypertension: improved in half
Gastroesophageal reflux: improved in most
Urinary incontinence: improved in most

Question 15

Comparison of Operations

Answer 15

Lap band: 20% weight loss, very low mortality, 1% serious or 2.4% any complication

Sleeve gastrectomy: 25% weight loss, 0.1% mortality, 2.4% serious or 6.3% any complication

Gastric bypass: 30% weight loss, 0.2% mortality, 2.5% serious or 10% any complication

Question 16

Naltrexone SR/Bupropion

Answer 16

Combination of Naltrexone SR and Bupropion

Bupropion stimulates hypothalamic pro-opiomelanocortin (POMC) neurons reduces 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

Question 17

_____ is the safest option but limited weight loss, cost and lack of insurance coverage.

Answer 17

Xenical

Question 18

_______ is less expensive so most prescribed but is not FDA approved for long term use.

Answer 18

Phentermine

Question 19

_________ is the most effective but costs a lot

Answer 19

Phentermine/topiramate

Question 20

______ is only modestly effective but least side effects

Answer 20

Lorcasarin

Question 21

_______intermediate effectiveness.

Answer 21

Naltrexone/bupropion

SI warning
sz risk