Module 13: Obesity (c)

Question 1

Obesity

-Goals of Therapy

Answer 1

1. Weight Loss of 4-8% (6-12 months) — Weight loss of 5-10 % can substantially reduce development of T2DM in those w/ pre-DM and ⬇️HTN
2. Weight is expected to rise after D/C of drug therapy
3. Weight Loss should
   - Exceed 1lb/wk during 1st month of drug therapy
   - Fall more than 4-5% below baseline between 3-6 months
   - Remain at this level to be considered effective
4. Improve health status
   - Measurable or perceived improvement in — Physical function, co-morbidities, and/or sense of well-being
   - Minimize A/Es of drug therapy

Question 2

Obesity Pharmacotherapy **

-Examples

Answer 2

1. Orlistat (Alli, Xenical) — Alters fat digestion
2. GLP-1 RA (“Glutides”) — Semaglutide (Wegovy) had MOST weight loss **
3. Sympathomimetic — Phentermine
4. Combination drugs
   - Sympathomimetic + anticonvulsant — Phentermine + Topiramate, Qsymia)
   - Antidepressant + Opioid receptor antagonist — Bupropion-Naltrexone, Contrave)

Question 3

FDA approved Meds for Long-term treatment of Obesity

-Examples

Answer 3

1. Orlistat (Xenical)
2. Liraglutide 3 mg (Saxenda)
3. Wegovy 2.4 mg
4. Phentermine/Topiramate ER — Qsymia
5. Naltrexone ER/Bupropion ER — Contrave

Question 4

Obesity Pharmacotherapy

-FIRST Line

Answer 4

1. GLP-1 RA — Semaglutide or Liraglutide are 1st LINE treatments
2. Orlistat — 2nd Line if GLP-1RA is inappropriate — Available OTC

Question 5

Obesity Pharmacotherapy

-GLP-1 RA

Answer 5

1. Semaglutide (Wegovy)
2. Liraglutide (Saxenda)
3. Drugs approved for weight loss are the injectable options
   - Pros — Demonsntrated benefits w/ regard to cardio metabolic risk factors, glycemic, and quality of life
   - Cons — GI effects N/V, injectable & cost
4. AVOID w/ history of pancreatitis
5. Contraindicated in
   - Pregnancy
   - Personal or family hx of medullary thyroid cancer BBW

Question 6

Obesity Pharmacotherapy

-Orlistat (Xenical, Alli)

Answer 6

1. Pros
   - Effective for weight loss
   - Demonstrated benefits to glycemic, lipids, and BP
   - Cholesterol lowering benefits INDEPENDENT of its weight reducing effect
   - Long-Duration trials (4 yrs)
   - Reassuring CV safety profile
2. Cons
   - Unpleasant GI effects — Do not exceed 30% fat with meal TEST
   - Absorption of fat-soluble vitamins may be reduced (Especially Vitamin D)
   - GI Sx’s include — oily spotting, flats w/ d/c, fecal urgency and incontinence

MOA — Alters fat digestion by inhibiting pancreatic and gastric lipases

NO OBESITY MEDICATION in pregnancy or breast feeding

Question 7

Obesity Pharmacotherapy

-Phentermine

Answer 7

1. Sympathomimetic — Increase norepinephrine, dopamine release
2. Only approved for short-term use — MAX 12 WEEKS**
3. R/t Amphetamines — Controlled substance requiring DEA — Schedule IV drug — Abuse potential
4. Contraindicated in pt w/ h/o of abuse

Question 8

Obesity Pharmacotherapy

-Combination Therapy — Phentermine/Topiramate (Qsymia)

Answer 8

1. Phentermine — Sympathomimetic
2. Topiramate — Anticonvulsant, migraine therapy
3. Controlled substance requiring DEA — Schedule IV drug
4. Topiramate is teratogenic — NEGATIVE Pregnancy test prior to and during treatment PLUS 2 forms of contraception necessary for women of child-bearing potential

A/Es

• May cause neuropsychiatric S/Es (Depression, anxiety, inattention) — Monitor for depression or suicidal thoughts
• Paresthesia and dry mouth
• Tachycardia

5. D/C if ineffective by 12 weeks with GRADUAL TAPER over at least a week**TEST
   - Abrupt DC can cause seizures
6. Contraindicated w/
   - Pregnancy
   - Hyperthyroidism
   - Glaucoma

Question 9

Obesity Pharmacotherapy

-Combination Therapy Bupropion-Naltrexone (Contrave)

Answer 9

1. NOT recommended as 1st line therapy
2. Bupropion — NDRI indicated for depression and for use in prevention of weight gain during smoking cessation
3. Naltrexone
   —Opioid-receptor antagonist used to treat alcohol and opioid dependence
   —Reward-center of brain; may have fever cravings
   —AVOID for patients on opioids

BBW — SUICIDALITY

4. Contraindications
   - Uncontrolled HTN, Seizure disorder, eating disorder
   - Use of other bupropion-containing products, chronic opioid use, pregnancy/breastfeeding

Question 10

Obesity Pharmacotherapy

-Monitoring Considerations

Answer 10

1. Baseline labs — BP, HR, Wt, Waist circumference, CV/Pulmonary exams
2. ALWAYS obtain a pregnancy test (ALL weight loss meds are CONTRAINDICATED w/ pregnancy
3. Best weight loss outcomes occur w/ frequent face to face visits — 16 visits per year **