Obesity Tx

Question 1

Medications and % weight loss

Answer 1

5-12%

• likely would have to be chronic tx
• high cost
• issues of FDA approval, long term safety, and efficacy
• Choice of mechanisms, OTC versus Rx vs combos?

Question 2

Phentermine

Answer 2

-increases NE content in brain
-related to amphetamine, “not addictive”
-Dose: 15-37.5 mg/d
cost $15-25
CHEAPEST
-FDA approved for only 3 mo use
-5-8% weight loss
-SE: htn, headache, nervousness
-most widely prescribed drug
-no long term side effects as single drug
-Is it ethical to prescribe long term?

Question 3

Orlistat

Answer 3

Pancreatic lipase inhibitor
-inhibits fat absorption by 30%
-Cost: $100/mo at least
GI SE: oily stools, urgency
MVI: to prevent fat soluble vitamin deficiency
SAFEST
OTC available
5-8% weight loss
may be useful in poorly controlled htn or psych problems

Question 4

Lorcasrin

Answer 4

Serotonin 2C receptor agonist
-2C receptor only in brain not in heart (so avoid heart valve problems)
LEAST SIDE EFFECTS: miminal headache, dizziness, nausea
Cost: $220/mo
-weight loss: 4-5%, no better than phentermine or orlistat

Question 5

Phentermine/Topiramate

Answer 5

-combo gives greater efficacy, fewer side effects
-$150/mo
SE: dry mouth, paresthesias, insomnia, dizziness, anxiety, irritability and disturbance in attention
-**Risk of birth defects: women need pregnancy test on starting and monthly while using
-Reduces BP, glucose, insulin, TGs, and raises GDL
**MOST EFFECTIVE: 12%

Question 6

Naltrexon SR/Bupropion SR

Answer 6

-bupropion stimulates hypothalamic POMC neurons reduces food intake
Naltrexone block opioid receptor-mediated POMC autoinhibition, augmenting POMC firing in a synergistic manner. Alters reward pathways

Intermediate in effectiveness and SE

SE: increased blood pressure and pulse, lowers seizure threshold, suicidal ideation (black box).
Common side effects: Nausea, constipation, diarrhea, headache, dry mouth
Category X in pregnancy

$200

Question 7

Surgical procedures

Answer 7

Lap Band: 20% loss
Sleeve gastrectomy: 25% loss
Gastric bypass (small pouch of stomach, cut out duodenum) (most effective): 30% loss

Question 8

Ghrelin after gastric bypass

Answer 8

• very low

- people don’t feel hungry after surgery, feel full fast

Question 9

After surgery, decreased

Answer 9

• diabetes
• CV issues
• cancer

Question 10

Other benefits of surgery

Answer 10

sleep apnea improves in almost all
HTN: improved in half
GERD: improved in most
Urinary incontinence: improved in most

Question 11

Who is a good candidate?

Answer 11

-BMI>35 kg/m2 with co-morbidities or >40 without
Age 20-60 (can be done in adolescents)
Co-morbidities: Diabetes, sleep apnea, reflux > Hypertension, DJD
Failed other forms of therapy
No serious, active cardiac, pulmonary, or psychiatric disease

Question 12

Risk of Bariatric Surgery

Answer 12

Death
failure of surgery to produce weight loss
PE
Anastamotic leaks/sepsis
Thiamin deficiency: early vomiting, Wernike Korsakoff

Late risks:
B12 deficiency: 30% 1-9 yrs post op
Fe deficiency: particularly menstruating women, may need parenteral Fe
-Calcium/Vitamin D deficiency, osteoporosis: monitor levels and DXA

• Anastamotic ulcers or stricutres with GBPS: may cause bleeding or Fe def anemia, nausea, vomiting
• Band erosion/slippage with lap band
• Depression: 20% may last 3-6 months
• avoid pregnancy for at least 1 yr
• Folate deficiency: one prenatal vitamin per day

Question 13

Bariatric surgery summary

Answer 13

The most effective treatment we have for obesity.
The best treatment we have for type 2 diabetes
Doesn’t just restrict food intake, it is a neurohumoral treatment
Risk is not trivial but is falling with imrpoved methods
Needs lifelong followup.