Overweight and Obesity Flashcards
What are some medical conditions that can contribute to overweight and obesity?
depression
growth hormone deficiency
Cushing syndrome
polycystic ovary syndrome
What are some medications categories that can contribute overweight and obesity?
anticonvulsants antidepressants atypical antipsychotics conventional antipsychotics hormones
What are some examples of antipsychotics that cause wt gain?
carbamazepine
gabapentin
pregabalin
valproic acid
What are ome examples of antidepressants taht cause wt gain?
mirtazapine
tricyclic antidepressants
What are som examples of atypical antipsychotics that cause wt gain?
clozapine
olanzapine
quetiapine
risperidone
What are some examples of conventional antipsychotics that cause wt gain?
haloperidol
What are some examples of hormones that cause wt gain?
corticosteroids
insulin
medroxyprogesterone
What are the waist circumference thresholds for abdominal fat content?
> 88 cm for females
>102 cm for males
What does an increased waist circumference indicate?
elevated risk of: HTN, dyslipidemia type 2 DM CVD all-cause mortality
What are indications for weight loss?
obese BMI>30kg/m^2
overweight BMI>25kg/m^2 w/ at least one risk factor
What is the goal reduction in body wt for wt loss therapy?
initial goal is 5-10% over 6 mos
What are some appropriate prescribed calorie intake for wt loss?
1200-1500 kcal/d for women
1500-1800 kcal/d for men
What are the critera for bariatric surgery?
BMI >= 40 or >= 35 w coexisiting conditions AND motivated to lose wt AND have not responded to behavioral treatment w/ or w/o pharmacotherapy
What is the avg wt loss w bariatric surgery?
50% of BW
What are potential complications of bariatric surgery?
wound infection GI leaks DVT depression cholecystitis Fx vitamin def
What are Rx therapy options for wt loss?
CNS stimulants lipase inhibitors serotonin 5-HT2C REceptor agonists sympathomimetic and anticonvulsants opiod antagonist and dopamine norepinephrine reuptake inhibitor GLP-1 agonist
What are CNS stimulants that can be used for short-term wt loss?
Phentermine: Adipex-P, Lomaira Methamphetamine: Desoxyn Phendimetrazine: generic Benzphetamine: Regimex Diethylpropion; generic only
What are lipase inhibitors that can be used for wt loss?
orlistat: Xenical or Alli
What are serotonin 5-HT2C receptor agonists that can be used for wt loss?
lorcaserin: Belviq
What are sympathomimetics and anticonvulsants used for wt loss?
phentermine and topiramate: Qsymia
What are opiod antagonist and dopamine/norepinephrine reuptake inhibitors used for wt loss?
naltrexone & buproppion ER: Contrave
What are GLP-1 agonists used in wt loss?
liraglutide: Saxenda
What are indications for Rx wt loss therapy?
BMI >=30 kg/m^2 OR BMI >=27 kg/m^2 w other risk factors
risk factors: HTN, DM, dyslip, etc.
did NOT lose wt or maintin wt loss w behavior intervention
What are the indications for CNS stimulants in wt loss?
adjunct to exercise, behav mod, caloric restriction in SHORT-TERM management (wk) of exogenous obesity
What is the mechanism of action of CNS stimulants in wt loss?
incr conc of NE to stimulate receptors in hypothalamus–>appetite suppression
What are SEs of CNS stimulants in wt loss?
palpitation tachycardia incr BP overstimx restlessness insomnia tremor dizziness HA euphoria dysphoria xerostomia
What wt loss medications are aproved by the FDA for chronic management of obesity?
orlistat lorcaserin phentermine & topiramate naltrexone & bupropion ER liraglutide
What are the brand names of orlisat?
Xenical
Alli
Which wt loss med is available OTC?
Alli
What is the moa of orlisat?
reversibly inhibits gastric and pancreatic lipases, which allow abs of long-chain TGs
decr dietary fat abs by 30%
What is the dosing of Xenical?
120 mg po tid, take w/in 1 h of eating fat-containing meal
approved for pts >=12 yoa
What is the dosing for Alli?
60 mg orally tid, taken w/in 1 hr of eating fat-containing meal
approved for pts >=18 yoa
What is an important counseling point for lipase inhibitors for wt loss?
dose should be omitted if a meal is missed or does not contain any fat
What is the avg wt loss w orlistat above diet and exercise?
2.9-3.4 kg after 1 yr
What are special considerations for using orlistat?
sugg’d for pts w CVD
rec’d standard MVI
what are common adverse rxns to orlistat?
GI: oily spotting, abdominal pain/discomfort, flat w discharge, fecal urgency, fatty/oily stool, increased defectation
decreased abs of fat-soluble vits
What are contraindications for orlistat?
pregnancy
chronic malabs syndrme
cholestasis
What are some precautions or warnings for orlistat?
rare hepatotoxicity (dark urine, lack of appetite, dark stools)
Orlistat interacts w which drugs?
cyclosporine levothyroxine MVI warfarin OC
How should cyclosporine be admin’d w orlistat?
3 hr p orlistate, monitor pt
How should levothyroxine be admin’s w orlistat?
admin >4 hr apart, monitor
How should MVI be admin’d w orlistat?
> 2 hr apart
rec MVI at bedtime
How should warfarin be admin’d w orlistat?
monitor INR
How should OC be admin’d w orlistat?
recommend use of back up contraceptive if pt experiences severe diarrhea.
What is the brand name for lorcaserin?
Belviq
What is the moa of lorcaserin?
selective activation of serotonin 5-HT2c reeptors in the hypothalamus–>satiety and decr food intake
What is the dosing of lorcaserin?
Belviq: 10 mg po bid
Belviq XR: 20 mg po d
can be taken w or w/o food
How should lorcaserin be used in renal impairment?
mod: caution
sev, ESRD: not rec’d
What is the avg wt loss w lorcaserin above diet and exercise?
3.6 kg after 1 y
What schedule is lorcaserin?
C-IV
pot for abuse and psychodependence
What are common ADR for lorcaserin?
depression, memory lapses
dizziness, fatigue
HA
nausea, dry mouth, constipation
What are contraindications for lorcaserin?
pregnancy
What are precautions and warnings for lorcaserin?
psychiatric disorder
cardiac valvular disease–> reported w agonist activity at receptors in interstitial cardiac cells
CVD
priapism
pulmonary HTN
elevated serum prolactin level
serotonin syndrome/neuroleptid malignant syndrome-like rxns
What durg classes does lorcaserin interact w?
serotonergic agents
CYP2D6 substrates
What are examples of serotonergic agents?
MAOIs linezolid SSRIs, SNRIs, TCAs bupropion lithium tramadol triptans SJW
What are the recommendation for serotonergic agent use with lorcaserin?
concomitant use should be avoided
What is the brand name for penthermine/topiramate ER?
Qsymia
What is the moa of phentermine/topiramate ER?
phenterine–sympathomimetic amine: reducing appetite through CNS effects (hypothalamus stim–>NE)
topiramate–anticonvulsants: mech unknown, thought to cause appetite suppression and enhance satiety
What is the dosing for phentermine/topiramate ER?
start: 3.75/23 mg po d after 14 d: 7.5/46 mg po d *if <3% wt lost, d/c or incr dose after 12 wks: 11.25/69 mg po d after 14 days: 15/92 mg po q **if 5% of bseline not lost after 12 wks, gradulaly d/c
When shold phentermine/topiramate ER be taken?
in morning to avoid insomnia
How should phentermine/topiramate ER be dose in renal imp?
CrCl <50 mL/min: do not exceed p/t ER 7.5/46 mg po d
dialysis: not rec
How should phentermine/topiramate ER be dosed in hepatic impairemtn?
mod: do not exceed 7.5/46 mg po daily
sev: not rec’d
How should phentermine/topiramate ER be d/c’d?
gradually decr by taking qod for >1 wk prior to d/cing
Sz risk
What is the avg wt loss for phentermine/topiramate ER above diet and exercise?
6.6-8.6 kg after 1 yr
What are special consideration for dispensing phentermine/topiramate ER?
C-IV
must be distriuted by REMS-certified pharmacies
What are common ADRs of phentermine/topiramate ER?
constipation dry mouth paraesthesia dysgeusia dizziness, lightheadedness blurry vision insomnia
What are contraindications to phentermine/topiratmate ER?
pregnancy hyperthyroidism glaucoma use during or w/in 14 d following MAOI known hypersensitivity or idiosyncrasy to the sympathomimetic amines
what are precautions/warnings for phentermine/topiramate ER?
incr HR suicidal behavior/ideation mood and sleep disorders cog impairment kidney stones acute myopia and secondary angle closure glaucoma incr sCr metabolic acidosis decr NaHCO3 and K
What drug classes does phentermine/topiramate ER interact with?
combination OC CNS depressants alcohol non-potassium sparing diuretics antiepileptic drugs carbonic anhydrase ihbitions
How should combination OCs be admin’d w phentermine/topiramate ER?
counsel on potential for breathrough bleeding
rec back-up method
How should CNS depressants be admin’d w phentermine/topiramate ER?
avoid combination, when possible
How should alcohol be admin’d w phentermin/topiramate ER?
avoid alcohol intake
How should non-potassium sparing diuretics be admin’d w phentermine/topiramate ER?
monitor for risk of hypokalemia
How should carbonic anhydrase inhibitors be admin’s w phentermine/topiramate ER?
avoid concurrent use
What is the brand of naltrexone/bupropion ER?
Contrave
What is the moa of naltrexone/bupropion ER?
naltrexone: opiod antag: decr food ccravings
buproprion: weakly inhib neuronal reuptake of dopamine and NE; may suppress appetite
exact wt loss effects not understood
How should naltrexone/bupropion ER be dosed?
8 mg/ ER 90mg wk 1: 1 tab qam Wk2: 1 tab qam+qpm wk3: 2 tab qam + 1 tab qpm wk4: 2 tab qam+qpm
if 5% wt loss not achieved by 12 wk pt titrated to appropriate dose then therapy should be d/c
How should naltrexone/bupropion ER be taken?
not w high fat meal
not crushed, cut, or chewed
How should naltrexone/bupropion ER be dosed in renal imp?
mild: caution
mod/sev: do not exceed 1 tab bid
dialysis: not rec
How should naltrexone/bupropion ER be dosed in hepatic imp?
do not exceed 1 tab d
What are special considerations for naltrexone/buproprion ER?
boxed warningf or suicidal behaivor and ideation.
potential to cause false positive urine tests for amphetamines
What are common ADRs of naltrexone/bupropion ER?
GI effects HA dizziness dry mouth insomnia
What are contraindications for naltrexone/bupropion ER?
pregnancy
use of other bupropion procuts or chronic opiod use
acute opiods withdrawl
uncontrolled HTN
Hx of Sz
bulimia or anorexia nervosa
abrupt d/c of alcohol, benzodiazepines, barbiturates or antiepileptic drugs
use during or w/in 14 d of MAOI therapy
initiation of Contrave concurrently pt taking linezolid or IV methylene blue
What are precautions/warning for naltrexone/bupropion ER?
incr BP, HR Sz risk narrow-angle glaucoma hepatotoxicity suicidal behavior or idea (boxed warning)
What are drug classes that interact w naltrexone/bupropion ER?
opiods CYP2B6 inducers/inhibitors CYP2D6 substrates MAOIs drugs that lower Sz threshold
How should opiods be admin’d w naltrexone/bupropion ER?
avoid
How should CYP2B6 inhibitors be admin’d w naltrexone/bupropion ER?
do not exceed max dose of Contrave 1 tab bid
How should MAOIs be admin’d w naltrexone/bupropion ER?
avoid concomitant use or use w/in 14 d
What is the brand name for liraglutide?
Saxenda
What is the moa of liraglutide?
glucagon-like peptide-1 (GLP-1) receptor agonist–>
reduction of food intake and slowed gastric emptying
(suppresses glucagon and stimulation insulin secretion)
What is the dosing of liraglutide?
SQ inj
wk1: 0.6 mg
incr by 0.6 mg each wk for up to 3 mg
if cannot toleate dose incr, delay for 1 wk
d/c if 4% wt loss not achieved after 16 wks
What are special considerations for liraglutide?
Boxed warning: thyroid C-cell tumors
REMS program
What are common ADRs of liraglutide?
GI effects
redness, bruising, discomfort at inj site
hypoglycemia
What are contraindications for liraglutide?
pregnancy
hx of medullary thyroid carcinoma
hx o multiple endocrine neoplasia syndrome type 2
What are precautions/warnings for liraglutide?
acute pancreatitis acute gall bladder disease suicidal behavior and ideation incr HR renal imp thyroid C-cell tumors (boxed warning)
What are notable drug-drug interactions with liraglutide?
abs or other concomitantly admin’d po meds may be delayed (delayed gastric emptying)
What are common herbal/natural remedies used for wt loss?
hoodia green tea citrus aurantium fenugreek caffeine ephredrine capsaicin yohimbine chitosan guar gum hydroxycitric acid garcina cambogia
How should secondary obesity be treated?
treat primary disease!
hypothyroidism
Cushing syndrome
ypothalmic causes
What is appropriate wt therapy management for 25<=BMI <27?
<= 1 risk factor weight maintenance (lifestyle)
>=2 risk factors lifestyle therapy
What is appropriate wt therapy management for 27<=BMI <30?
w/o risk factors: maintenance
w risk factor: lifestyle + drug
What is appropriate wt therapy management for 30<=BMI <35?
lifestyle + drug
What is appropriate wt therapy management for 35<=BMI <40?
<=1 risk factor drug + lifestyle
> =2 risk factors weight loss surgery
What is appropriate wt therapy management for BMI>=40?
weight loss surgery
How should wt loss patients in general be monitored?
closely during first 6 mos
follow-up q4wks
Which chornic wt loss drugs can be used in T2DM?
all of them!
but monitor for hypoglycemia
Which chronic wt loss drugs cannot be used in TN?
naltrexone/bupropion ER:
- caution, monitor BP and HR
- if HTN uncontrolled, avoid
Which chronic wt loss drugs can be used with CAD/arrhythmias?
orlistat, lorcaserin
otherwise caution: monitor HR, rhythm, (BP for Contrave)
Which chronic wt loss drugs can be used with CHF?
none of the them–not enough data
Which chornic wt loss meds can be used with mild-mod CKD?
mild=50-79 mL/min
mod=30-49 mL/min
all of them!
for mod:
- Qsymia can’t exceed 7.5mg/46 mg d
- Contrave can’t exceed 8mg/90 mg BID
Which chornic wt loss meds can be used with severe CKD? (<30 mL/min)
orlistat–> caution, watch for oxalate nephropathy
liraglutide–>caution, watch for volume depletion and vomiting
avoid others: cleared renally
Which chornic wt loss meds can be used with mild-mod hepatic imp?
CAUTION ALL.
orlistat & liraglutide: monitor for gallstone
lorcaserin: hep metab
Qsymia: max 7.5mg/46 mg d
Contrave: max 8mg/90 mg qam
Which chornic wt loss meds can be used with severe hepatic imp?
AVOID ALL
Which chornic wt loss meds can be used with depression?
orlistat, liraglutide
Qsymia: avoid max dose (15mg/92mg)
Caution: lorcaserin (avoid concomitant serotonergic drug), Contrave (avoid in young people)
Which chornic wt loss meds can be used with anxiety?
all of them :)
Qsymia: avoid max dose (15mg/92mg)
Which chornic wt loss meds can be used with glaucoma?
orlistat, locaserin, liraglutide
Which chornic wt loss meds can be used with Szs?
all except Contrave
remember to taper Qsymia
Which chornic wt loss meds can be used with pancreatitis?
all
AVOID: liraglutide if Hx of pancreatitis
montiro: orlistat, liraglutide
Which chornic wt loss meds can be used with opiods?
all except Contrave
Which chornic wt loss meds can be used with pregnancy?
NONE
use contraception and stop if become pregnant
Which wt loss med should do monthly preg tests?
Qsymia
What wt loss meds can be used in peds?
lifestyle bigger focus
Xenical >=12 yoa
Which chornic wt loss meds can be used with breasting?
none
Which chornic wt loss meds can be used with alcoholism/additction
orlistat, liraglutide OK
CAUTION: lorcaserin (abuse), Qsymia
AVOID: Contrave
When should wt loss pharmacotherapy be d/c’s?
lorcaserin, Qsymia, Contrave: <5% wt loss after 12 wks max dose therapy
liraglutide <4% wt loss not achieved after 16 wk therapy
