TREATING OBESITY WITH MEDICATION
Treah Haggerty MD, MS - Associate Professor | WVU Department of Family Medicine - Obesity Medicine Physician | WVU Medical Weight Management
OBJECTIVES
1. Participants will understand obesity is a disease.
2. Participants will be able to list necessary components of the clinical encounter for anti-obesity medications.
3. Participants will be able to identify and understand the use of antiobesity medications.
RX ANTI OBESITY MEDICATIONS (AOM)
o Effective Adjunct to treatment of patient with obesity
o May improve metabolic complications of obesity
OBJECTIVE TO AOM o Treat disease
o May help manage eating behaviors
o Slow progression of weight gain
o Lifestyle benefits (movement, quality of life, pain)
OBESITY AS A DISEASE
o The AMA defined obesity as a disease in 2013.
o Obesity has genetic, biological, and environmental factors which play a role in the resistance to treatment
Treatment of obesity, weight loss, has many benefits
o Risk factor improvement
o Prevention of comorbidities
o Improvement in feeling and function
OBESITY AS A DISEASE
Table from Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, Ryan DH, Still CD. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2015 Feb 1;100(2):342-62.
OBESITY AS A DISEASE Figure is from Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, Ryan DH, Still CD. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2015 Feb 1;100(2):342-62.
POMC/CART
o Anorexigenic (Promote Satiety)
o Located in the Arcuate Nucleus
o Stimulated by multiple hormones (leptin, GLP1, PYY…)
NPY/AgRP
o Orexigenic (Promotes Eating)
o Located in the Arcuate Nucleus
o Stimulated by Ghrelin
Leptin
o Released by adipose tissue
o Stimulates on POMC/CART -> stimulates MC4R
o Inhibits NPY/AgRP
o STOP EATING (Anorexogenic)
Grelin
o Released by the stomach
o Stimulates NPY/AgRP -> stimulates Y1R
o START EATING (orexogenic)
o Increases with time since eating
OBESITY AS A DISEASE Weight Reduction
o Food restriction is counteracted by biological responses to weight loss
o We see a drop in energy expenditure and increase in appetite with weight loss
OBESITY AS A DISEASE
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. 2011 Oct 27;365(17):1597-604.
OBESITY AS A DISEASE
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. 2011 Oct 27;365(17):1597-604.
OBESITY AS A DISEASE
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. 2011 Oct 27;365(17):1597-604.
OBESITY AS A DISEASE
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. 2011 Oct 27;365(17):1597-604.
OBESITY AS A DISEASE
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine. 2011 Oct 27;365(17):1597-604.
AOM IMPORTANT PRINCIPLES
o Variable weight loss
o Variable time frame
o Expect 5-10% weight loss for most
WHO ARE WE PRESCRIBING
o Diagnosis of Obesity (BMI > 30)
o BMI >= 27 and one adiposity complication
Adiposity Complication High Blood Pressure High Cholesterol Type 2 Diabetes Coronary Heart Disease Stroke Osteoarthritis Sleep Apnea / Restrictive Lung Diseases
WHO ARE WE PRESCRIBING
o Diagnosis of obesity
o Build rapport
o Ask permission
o Use appropriate terms
ANTI-OBESITY MEDICATIONS
o Phentermine o Orlistat o Locarsarin o Liraglutide oNaltrexone/Bupropion oPhentermine/Topiramate
PHENTERMINE
DEA Schedule IV Stimulant (Sympathomimetic amine)
Norepinephrine reuptake inhibitor
Approved for short term use (12 weeks)
Expect about a 5% loss in some patients
Side Effects: Headache, high blood pressure, rapid or irregular heart rate, overstimulation, tremor, insomnia
Contraindications: Overactive thyroid, Uncontrolled high blood pressure, seizure disorder, cardiovascular disease, glaucoma, active drug abuse, agitated state
Interactions: MAO inhibitors, sympathomimetics, alcohol, adrenergic neuron blocking drugs
PHENTERMINE
Dose: Phentermine Resin = 37.5mg/day.
Advantages: Inexpensive
Disadvantages: Extensive side effect profile
ORLISTAT
Gastrointestinal Lipase Inhibitor
Approved for OTC (lower dose than prescription)
Expect about 5% loss
Side Effects: Oily discharge from rectum, promote gallstones and kidney stones, malabsorption of fat soluble vitamins (A,D,E,K)
Contraindications: Malabsorption syndrome and cholestasis
Recommendation: Take a multivitamin daily
Interactions: Cyclosporines, hormone containing contraceptives, seizure medications, thyroid hormones, warfarin
ORLISTAT
Dose: 120mg three times daily Advantages: Not systemic (also a disadvantage), cheaper. Can help with constipation Disadvantage: Side effects
LIRAGLUTIDE
Glucagon-like peptide 1 receptor agonist
Normally used in Type 2 diabetes at half the dose (1.8 mg)
Approved for weight loss at 3 mg daily dose
Adverse Effects: Nausea, hypoglycemia, diarrhea, vomiting, headaches, decreased appetite, dyspepsia, fatigue, dizziness, abdominal pain, increase lipase, renal insufficiency.
Contraindications: Family history of medullary thyroid cancer or type 2 multiple endocrine neoplasia syndrome
Interactions: May slow gastric emptying so could impact absorption of other medications.
LIRAGLUTIDE
Dosing: 3 mg daily (Prescribed as 0.6 once daily for a week then 1.2mg once daily for a week, then 1.8mg once daily for a week, then 2.4mg once daily for a week, then 3mg daily.)
Advantages: Low side effect profile
Disadvantage: Injection, Cost ($$$$$)
LIRAGLUTIDE
Effects:
o Delays gastric emptying
o Decrease liver glucose production
o Increase insulin secretion (glucose dependant)
o Increases glucose uptake by muscles.
NALTREXONE/BUPROPION
Opioid antagonist and reuptake inhibitor of dopamine and norepinephrine
Normally used in depression and opiate use disorder
Adverse Effects: Naltrexone (Nausea, constipation, headaches, vomiting, dizziness) Bupropion ( increase suicidal thoughts, insomnia)
Contraindications: uncontrolled High Blood Pressure, Seizure disorder, or drug/alcohol withdrawal
Interactions: Opioid pain medications, anti seizure medications. MAO inhibitors
NALTREXONE/BUPROPION
Dose: 8 mg/90 mg 2 tablets twice daily. Increased by 1 pill per day each week till max dose (32/360mg daily)
Advantages: Helps with food addiction
Disadvantage: Cost
PHENTERMINE/TOPIRAMATE
DEA Schedule IV Stimulant (Sympathomimetic amine)
GABA receptor modulation (Topiramate) plus norepinephrine reuptake inhibitor
(Phentermine)
Adverse Effects: Nausea, dry mouth, constipation, paraesthesia, dizziness, dysgeusia (distortion of taste), Headache, high blood pressure, rapid or irregular heart rate, overstimulation, tremor, insomnia
Contraindications: Pregnancy or breastfeeding, hyperthyroidism, glaucoma
Interactions: MAO inhibitors, sympathomimetic amines,
PHENTERMINE/TOPIRAMATE
Dose: 3.75/23mg ER QD (starting dose). 7.5/46 mg ER daily (recommended dose)
Advantages: Robust weight loss (>5% in studies)
Disadvantage: Expensive, teratogenic
MONITOR AOM
Medication specific
Monitor patients for clinical improvement across 12-16 weeks. If not hitting a 5% loss from baseline body weight, consider switching increasing current medications dose or switching to a new medication
Take pregnancy plans into consideration
Image from World Obesity Federation
MONITOR AOM
o Monitor patients for efficacy and safety monthly for 3 months
o After determined safe and effective, monitor once every 3 months.
o If a patient’s response to a weight loss medication is deemed effective (weight loss 5% of body weight at 3 mo) and safe, we recommend that the medication be continued. If deemed ineffective (weight loss 5% at 3 mo) or if there are safety or tolerability issues at any time, we recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered. (Endocrine society recommendation)
RESOURCES
Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, Ryan DH, Still CD. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2015 Feb 1;100(2):342-62.
The Obesity Algorithm. https://obesitymedicine.org/
Pictures:
https://www.worldobesity.org/resources/image-bank
http://www.uconnruddcenter.org/media-gallery
https://www.obesityaction.org/get-educated/public-resources/oac-image-gallery/
QUESTIONS? Treah Haggerty, MD, MS [email protected] 304-598-4890 – Medical Weight Management 304-598-4000 – Ask to page me Website: www.WVUMedicine.org/weightmgmt Facebook Support Group: https://www.facebook.com/groups/wvumedweightloss/