Weight, smoking, alcohol, opioids

Question 1

How do you calculate BMI?

Answer 1

BMI = weight (kg)/ Height^2 (m)

Question 2

What are the classifications according to BMI?

Answer 2

<18.5 underweight, 18.5-24.9 normal, >25 overweight
pre-obese 25-29.9
obese 1 30-34.9
obese 2 35-39.9
obese 3 >40

Question 3

What waist circumference places you at risk?

Answer 3

> 88cm in women, >102cm in men

Question 4

What medications can cause weight gain?

Answer 4

Benzodiazepines, anti-epileptics, antipsychotics, TCAs, corticosteroids, sulphonylureas (diabetes drug), insulin

Question 5

What are the 3 categories of shakes used for weight loss?

Answer 5

Formulated supplementary foods, formulated meal replacements, VLCD

Question 6

How does a VLCD help lose weight?

Answer 6

Induces mild ketosis.

Question 7

What medications may need to be adjusted in a VLCD?

Answer 7

Diabetes drugs, antihypertensives and lipid disorder drugs; monitor lithium and warfarin.

Question 8

How does phentermine work?

Answer 8

It is a sympathomimetic amine that works in the appetite control centre in the hypothalamus. It supresses appetite.

Question 9

What precautions and drug interactions does phentermine have?

Answer 9

Only use for max 12 w
It may cause increase BP
May interact with SSRI, MAOI, urinary acidifiers and alkalisers (excretion increased with acidification, reduced with alkaline urine)
Can cause withdrawal symptoms - drowsiness, fatigue, nausea, trembling, insomnia

Question 10

What are the clinical indications for orlistat?

Answer 10

BMI>30 or >27 with comorbidities

Question 11

What are counterindications and precautions for orlistat?

Answer 11

Cholestasis
Major GI surgery
Chronic malabsorption syndrome
Pancreatic enzyme deficiency
Chronic pancreatitis
Pregnancy and lastation

Bulimia, laxative abuse, fat-soluble vitamin deficiency (ADEK), peptic ulcer disease

Question 12

What S4 drug combination may work for weight loss?

Answer 12

Bupropion+naltrexone

Question 13

How do liraglutide and semaglutide work?

Answer 13

Slow gastric emptying and supress hunger

Question 14

What are some AEs of GLP-1 agonists?

Answer 14

Constipation, nausea, diarrhoea

Question 15

What is smoking’s effect on metabolic enzymes?

Answer 15

Smoking induces CYP1A2 and CYP2B6 (not via nicotine , therefore nicotine replacement does not induce these enzymes)

Question 16

What medicines should be monitored when a patient quits smoking? Give some examples?

Answer 16

Antipsychotics, benzos and zolpidem, some antidepressants, heparin and warfarin, insulin, theophylline

Question 17

What are the most effective 1st line treatments for smoking cessation?

Answer 17

NRT combination and varenicline (S4)

Question 18

How does varenicline work?

Answer 18

Nicotine receptor patial agonist - in the absence of nicotine it reduces withdrawals and cravings, in the presence of nicotine it blocks its ability to bind the receptor and produce pleasurable effects

Question 19

Whare are important notes for varenicline?

Answer 19

Can exacerbate mental health conditions, needs to be started at least 1 week before the quit date, must be swallowed whole, can cause nausea (take with food), follow up with dr 2-3 weeks after starting

Question 20

How does bupoprion work?

Answer 20

It is an antagonist of the ACh nicotinic receptor. reduces the urge to smoke and symptoms of nicotine withdrawal

Question 21

What are some important points for bupropion?

Answer 21

Start 1 week before quitting, CI in history of seizures, anorexia/bulimia, do not use with MAOI; significant DIs with antidepressants and inhibits CYP2B6;
take in the morning to reduce sleep problems
swallow whole
avoid alcohol
can be used with NRT
caution in patients using drugs that lower seizure threshold (antipsychotics, antidepressants)
follow-up 2-3 weeks

Question 22

What drugs are used for alcohol withdrawal?

Answer 22

Benzodiazepines (gold standard) + B1 supplements
Acamprosate - reduces cravings, preferred when taking opiods for pain - start 7 days after last drink
Naltrexone - monitor liver fct, care when restarting opioids
Disulfiram - prevents alcohol metabolism, px must BAC 0 when starting treatment; not in renal and hepatic disease

Question 23

What is the pharmacist’s role in the Opioid Treatment Program?

Answer 23

Dispense daily and takeaway doses
Assess px for signs of intoxication and withdrawal
Supervise administration and compliance
Provide support
Maintain regular contact with the prescriber if the notice - intoxication/drug use, non-attendance for dosing, other problems

Question 24

What opioid agonists are available for treatment of opioid addiction?

Answer 24

Methadone - full agonist, oral liquid, rapid onset of action , long half life; severe and prolonged withdrawal
Buprenorphine - partial agonist, sublingual (film and tablet), slower onset but still within 1 h, long half life; less severe but still prolonged withdrawal

Question 25

What are the approaches when methadone or buprenorphine doses are missed?

Answer 25

1-2 - dose as normal
3 - consult prescriber and review dose
4 -5- consult prescriber and reduce dose
6 - refer to prescriber

Question 26

What are double or triple dosing of buprenorphine?

Answer 26

Dosing every 2 or 3 days.

Question 27

What is in Suboxone and what are the advantages for use?

Answer 27

buprenorphine and naloxone
makes dosing quicker and requires less supervision; comes in a sublingual film that sticks to the mucosa; less chance of misuse

Question 28

What is the rationale for naltrexone use?

Answer 28

Antagonist of the mu opioid receptor. Blocks the effect of opioid drugs. Can be used to prevent a relapse as the px won’t get the pleasurable effects of opioids. Works for 24-72 h.

Question 29

What dosage forms does naloxone come in?

Answer 29

Prefilled syringe and single use nasal spray.