Weight Loss Flashcards
What BMI is considered overweight vs. obese
BMI 25-29.9 kg/m^2 = overweight
BMI >/= 30 kg/m^2 = obese
Being overweight puts you at higher risk for
Coronary heart disease*
T2DM*
Stroke*
HTN*
Certain cancers and premature death
Define energy deficit and what are some diet recommendations for weight loss by AACE/ACE
This is how weight loss is achieved. Decreasing calories or increasing energy expenditure
AACE/ACE (Clinical/College of Endocrinology) recommend diets that reduce calories by 500 - 750 cal (ex: mediterranean, DASH - dietary approaches to stop HTN, low carb, low fat, volumetric, high protein and vegetarian diets, or very low calorie diets)
Many weight loss drugs work by…
Increasing satiety or reducing appetite
Questions to ask when a patient experiences weight gain
Do any of their medications cause weight gain
Do any of their conditions cause weight gain
Did they discontinue a weight loss medication
Are they just edemic
Drugs that cause weight gain
Key Drugs
Antipsychotics (clozapine, olanzapine, risperidone, quietapine)
Diabetes meds (insulin, sulfonylureas, meglitinides, thiazolidinediones)
Divalproex/valproic acid
Gabapentin, Pregabalin
Lithium
Mirtazapine
Steroids
TCA’s (e.g. amitriptyline, nortriptyline)
Others:
Beta Blockers
Dronabinol
Hormones (e.g. estrogen, megesterol)
MAO Inhibitors
SSRIs (paroxetine, others may be weight neutral)
Vasodilators
Condition that causes weight gain
Hypothyroidism
Ideal amount of physical activity
at least 150 minutes of activity performed 3-5 days of the week + resistance exercises 2-3 times weekly
When is it okay to add weight loss medications
When patient has failed to achieve adequate weight loss, maintain it, or prevent continued weight gain with the lifestyle measures
If patients have complications related to their weight (diabetes, dyslipidemia, hypertension, sleep apnea) then they can start medications at the same time as their lifestyle factors.
OTC supplements for weight loss (generally not recommended because ?)
Bitter orange
Excessive caffeine (ex: guarana, yerba mate, concentrated green tea powder)
Generally not recommended because they can be harmful esp. in patients with cardiovascular disease.
Criteria for weight loss drugs
BMI >/= 30 kg/m^2 or
BMI >/= 27 kg/m^2 with at least one weight related condition (HLD, HTN, T2DM)
What must always be coupled with weight loss medications
Dietary plan and increased physical activity
Older stimulant drugs that were used short term to jump start a diet
Phentermine, diethylpropion
Newer, long term weight loss drugs
Qsymia, wegovy, contrave, saxenda, and the orlistat formulations
If weight loss meds don’t produce ____% weight loss within ____ weeks, they need to be discontinued
5% weight loss in 12 weeks
Drugs that cause weight loss
Key drugs:
ADHD Drugs (amphetamine, methylphenidate)
Bupropion
GLP1 agonists (exenatide, liraglutide)
Pramlintide
Roflumilast
SGLT2 inhibitors (canagliflozin, empagliflozin)
Topiramate
Others:
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine)
Antiepileptic drugs (zonisamide, ethosuximide)
Interferons
Thyroid drugs (ex: levothyroxine)
Conditions that cause weight loss
Hyperthyroidism
Celiac disease
Inflammatory bowel disease
Conditions:
Cystic fibrosis
GERD or peptic ulcer disease
Lupus
Tuberculosis (active disease)
True or false: weight loss drugs can never be used in pregnancy
True
Which weight loss drugs should be avoided and which should be used with caution in pts with HTN
Contrave - contraindicated with uncontrolled HTN because it contains bupropion which can increase blood pressure.
Qsymia - use with caution and monitor HR because it contains phentermine which can elevate BP and HR
Which weight loss drug should be used with caution in young adults and adolescents and those with depression
Contrave because it contains bupropion, it comes with a suicide risk
Which weight loss drug should be avoided and which should be used with caution in people with seizure disorders
Contrave - avoid bc it contains bupropion which lowers the seizure threshold
Qsymia- use with caution and you must taper off slowly if used because it contains topiramate.
MOA of phentermine
A sympathomimetic stimulant that releases NE to stimulate the satiety center and decrease appetite
MOA of topiramate
Its complicated:
Increases satiety, decreases appetite, possibly increases GABA, blocks glutamate receptors and/or inhibits carbonic anhydrase
Qsymia generic name + control class
Phentermine/topiramate
Schedule 4 ! CIV
Qsymia (phentermine/topiramate) starting, max, and renal dosing
Start: 3.75mg /23 mg PO QAM x 14 days; then titrate up based on weight loss (taken in the morning due to insomnia SE)
Max dose: 15 mg /92 mg PO QAM
CrCl < 50 ml/min, then max dose is 7.5 mg/46 mg daily (half the normal max)
CI’s for Qsymia
- Avoid if pregnant (REMS - pregnancy test needed before tx and for every month of treatment + use effective contraception)
- Avoid in glaucoma
- Hypothyroidism
- MAO inhibitor use within the past 14 days
Side effects of Qsymia
tachycardia
CNS effects (e.g. insomnia so take in AM, depression
anxiety, suicidal thoughts, headache, paresthesias)
vision problems
constipation
dry mouth
decrease HCO3-
URTI’s
Risk of seizures, so we NEED to TAPER off
Contrave generic name and the MOA of each part
Naltrexone: decreases food craving
Bupropion: decreases appetite
Contrave (naltrexone/bupriopion) dosing regimen and counseling when taking
ER tablet: 8 mg / 90 mg
Week 1: 1 tab PO QAM
Week 2: 1 tab PO BID
Week 3: 2 tabs PO QAM & 1 tab PO QPM
Week 4+: 2 tabs PO BID
NEVER crush or chew swallow whole (ER)
Don’t take with fatty meal because it increases drug levels
Contrave boxed warning
Not approved for treatment of major depressive disorder, or psych disorders. Buproprion can increase the risk of suicidal thinking and behavior in children, adolescents, and young adults, not approved for pediatrics
Contraindications and warnings for contrave
CI: pregnancy, chronic opioid use or acute opioid withdrawal, uncontrolled HTN, seizure disorder, use of other bupropion containing products, bulimia/anorexia, abrupt discontinuation of alcohol, benzos, barbiturates, antiepileptic drugs, and use of MAOi’s within 14 days
Warnings: Use caution with psychiatric disorders, discontinue with s/sx of hepatotoxicity, can increase HR, BP, and glaucoma
SE of contrave
N/V, constipation, HA, dizziness, dry mouth, insomnia, increased SCr
Jenna is on buprenorphine and she wants to start taking contrave. What do we need to counsel her on?
The naltrexone component of Contrave blocks buprenorphine and opioids from working and producing analgesia and this can lead to withdrawal. We should make sure she stops buprenorphine 7-14 days before starting contrave
GLP1s that can be used for weight loss and what is their boxed warning and contraindication.
Liraglutide (Saxenda or Victoza)
Semaglutide (Wegovy or Ozempic)
Ozempic and Victoza are specifically for DM pts
Boxed warning for Thyroid C cell carcinomas in animal studies, the risk to humans is unknown.
Contraindicated in patients with personal or family history of medullary thyroid carcinoma (MTC) or patients with multiple endocrine neoplasia syndrome type 2 (MEN2). Saxenda is contraindicated in pregnancy (i think all weight loss drugs are)
MOA of GLP1s for weight loss
Increase satiety
Dosing for Liraglutide (saxenda and Victoza) and how young can it be used
They are approved for children at least 12 years old who are >60 kg and BMI is corresponding to a BMI of at least 30kg/m^2 in adults
0.6 mg SC daily x 1 week, then titrate up by 0.6 mg SC daily at weekly intervals until you reach target dose of 3 mg SC daily (4 weeks about)
How is Semaglutide (Wegovy and ozempic) dosed
0.25 mg SC weekly for 4 weeks, then titrate up every 4 weeks to target dose of 2.4 mg SC weekly
What are some warning s for GLP1s and side effects
Pancreatitis, hypoglycemia, acute gallbladder disease, gastroparesis
Nausea**, vomiting, diarrhea, constipation, injection site reactions
Orlistat Rx vs OTC name
Orlistat (Xenical) - Rx only
Orlistat (Alli) - OTC
MOA of orlistat
decreases absorption of dietary fats by 30%
Dosing of (Orlistat) Xenical and age
120 mg PO with each meal containing fat; can take with the meal or up to 1 hour after ; for ages 12 an above
Dosing of (Orlistat) Alli
60 mg PO with each meal containing fat; MUST BE USED WITH a low fat diet plan
Contraindications for Orlistat
Pregnancy, chronic malabsoprtion syndrome, cholestasis
Warnings for orlistat
Liver damage (rare), cholelisthiasis, increased urinate oxalate/kidney stones,
Side effects of Orlistat
GI (farting with discharge, fatty stool), fecal urgency
Counseling points for patients on Orlistat
Take fat absorbed vitamins (KADE) and beta carotine at bed time or separate by at least. 2 hrs
Never use with cyclosporine or separate by at least 3 hours; separate levothyroxine by at least 4 hours
Patients MUST stick to the dietary plan for both weight improvement and to help reduce side effects (max of 30% of their kcals should be from fat)
MOA of appetite suppressants like
Phentermine (Adipex-P, Lomaira) (CIV)
Diethylpropion (CIV)
Phendimetrazine (CIII)
Benzphetamine (CIII)
They are sympathomimetics (stimulants) releasing NE stimulates satiety center to decrease appetite
Contraindications of appetite suppressants like
Phentermine (Adipex-P, Lomaira) (CIV)
Diethylpropion (CIV)
Phendimetrazine (CIII)
Benzphetamine (CIII)
Cardiovascular disease (uncontrolled HTN, arrythmias, heart failure, CAD,) hyperthyroidism, glaucoma, pregnancy, breastfeeding, history of drug abuse, MAO inhibitors in last 14 days
Side effects of appetite suppressants like
Phentermine (Adipex-P, Lomaira) (CIV)
Diethylpropion (CIV)
Phendimetrazine (CIII)
Benzphetamine (CIII)
what should we monitor
Tachycardia, agitation, Increased BP, insomnia, dizziness, tremor, psychosis
MONITOR HR AND BP
Counseling points for appetite suppressants
For short term use to help jump start a diet
stimulants should be taken early in the day to avoid insomnia
Potential for misuse/dependence
Dosing for
Phentermine (Adipex-P, Lomaira) (CIV)
15-37.5 mg PO daily before or after breakfast or in divided doses
Dosing for Diethylpropion (CIV)
IR: 25 mg PO TID , 1 hour before meals and mid evening
SR: 75 mg PO once in mid morning
Dosing for Phendimetrazine (CIII)
IR 35 mg PO BID-TID 1 hr before meals
ER: 105 mg PO daily 30-60 min before the morning meal
Dosing for Benzphetamine (CIII)
25-50 mg PO daily TID (avoid late afternoon administartion)
When is bariatric weight loss recommended
for adults whos BMI is > 40 kg/m^2 OR WHEN BMI>35 kg/m^2 with an obesity related
What does bariatric surgery do
Restricts the amount of food people eat because stomach is smaller and this leads to weight loss . This is a life time commitment to healthy eating and regular exercise to sustain the weight loss.
Nutrient deficiencies related to bariatric surgery
Calcium - bc normally absorbed in duodenum and may be bypassed – > give calcium citrate because its a non acid dependent absorption supplement
Vitamin B12 and Iron - deficiency can result in anemia
Iron and calcium supplements must be taken 2 hours before or 4 hours after antacids
Life long supplementation of fat soluble vitamins (KADE) because of fat malabsoption
Medication concerns related to bariatric surgery
Meds may need to be dose adjusted and crushed and put into liquid or used in transdermal form for up to TWO months post surgery. - BE SURE TO ASSESS WHICH DRUGS CAN BE CRUSHED/DOSAGE FORM CHANGED
Weight loss helps to improve what comorbid conditions
HTN and DM
We should monitor these conditions well and also consider dose reductions for medications
Which weight loss medication contains a stimulant that can increase HR and should also be taken in the morning to avoid insomnia
Phentermine/Topiramate (Qsymia)
Which weight loss medication can increase BP and also should be avoided with opioids and with a history of seizures and cautioned in those with depression
Burpropion/Naltrexone (Contrave)
What are the side effects of using GLP1’s and counseling points for patients using it for weight loss
Nausea, pancreatitis, hypoglycemia
Avoid taking with other GLP1’s for DM
Counseling points for patients on Orlistat
Take one capsule at each meal or up to one hour after each meal that contains fat
Eating a healthy, low fat diet is an important way to reduce the GI SE
SE: stomach issues: oily stools, oily spotting, intestinal gas with discharge, urgency to booboo/poor control, increased frequency of booboo)
What should we monitor while patients are on appetite suppressants
Monitor HR and BP
Avoid using if they have CVD like uncontrolled HTN, arrhythmias, etc. or hyperthyroidism, pregnancy, galucoma, breast feeding, or history of drug abuse or MAO in past 14 days
