Obesity Course Session Slides Fall 2023 STUDENT.pptx

Weight Management: Overweight and Obesity LYDIA C. NEWSOM, PHARMD, BCACP Objectives  Define overweight and obesity.  Calculate a patient’s body mass index (BMI).  Identify the three components of evidence-base lifestyle therapy.  Define when to initiate pharmacotherapy for weight loss as an...

Weight Management: Overweight and Obesity LYDIA C. NEWSOM, PHARMD, BCACP Objectives  Define overweight and obesity.  Calculate a patient’s body mass index (BMI).  Identify the three components of evidence-base lifestyle therapy.  Define when to initiate pharmacotherapy for weight loss as an adjunct to lifestyle therapy.  List common side effects, contraindications, and monitoring parameters for pharmacotherapy used for weight loss. Obesity Resources  For your review – Sheehan A, Chen JT, Yanovski JA. Obesity. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023. Accessed November 01, 2023. https://accesspharmacy.mhmedical.com/content.aspx? bookid=3097&sectionid=268555827 – MyPlate from US Dept of Agriculture: myplate.gov  Clinical Guidelines – ACC/AHA/TOS Overweight and Obesity Guidelines – Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline – AACE/ACE Clinical Practice Guideline for Medical Care of Patients with Obesity Prevalence of Self-Reported Obesity by State & Territory in the United States 2015 2011 CDC. New Adult Obesity Maps. Centers for Disease Control and Prevention. Published October 5, 2021. Accessed October 25, 2021. 2020 Prevalence of Self-Reported Obesity by Race and Ethnicity in the United States Date range: 2018 – 2020 Non-Hispanic Asian Non-Hispanic White Adults Adults Hispanic Adults Non-Hispanic Black Adults CDC. New Adult Obesity Maps. Centers for Disease Control and Prevention. Published October 5, 2021. Accessed October 25, 2021. What is Obesity?  Definition: Chronic disease characterized by increased or excess body fat (adiposity) that negatively impacts health, quality of life, and lifespan.  Body Mass Index (BMI): main tool used to screen Classification BMI for/classify Underweight obesity <18.5 kg/m2 Normal weight 18.5 - 24.9 kg/m2 Overweight 25 - 29.9 kg/m2 Obesity (Class 1) 30 - 34.9 kg/m2 Obesity (Class 2) 35 - 39.9 kg/m2 Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. Extreme obesity (Class ≥ 40doi:10.1503/cmaj.191707 kg/m2 Body Mass Index (BMI)bPeroatbip: You must Classification BMI = Mass(kg) [Height(m)]2 Underweight Normal weight OR BMI = Mass(lb) [Height(in)]2 Overweight x 703 Obesity (Class 1) Obesity (Class 2) calcu l le t o ate B MI! BMI <18.5 kg/m2 18.5 - 24.9 kg/m2 25 - 29.9 kg/m2 30 - 34.9 kg/m2 35 - 39.9 kg/m2 ≥ 40 kg/m2 Extreme obesity (Class  Pros of using BMI: easy to calculate and readily available, 3) identifies patients at risk for obesity-related disease states and complications  Cons of using BMI: often doesn’t provide a patient-specific assessment – Other important factors: genetic, physiologic, environmental, Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. doi:10.1503/cmaj.191707 Obesity Classification  Waist Circumference (WC) – Most narrow circumference between the last rib and the top of the iliac crest – Central obesity linked to hypertension, dyslipidemia, type 2 diabetes, and cardiovascular disease regardless of weight – Definition varies by race and ethnicity Elevated waist circumference Men Women > 40 in > 35 in AACE/ACE; Comprehensive Clinical Practice Guidelines Formedical Care of Patients with Obesity ScienceDirect. Accessed October 25, 2021. Pro tip: Don’t memorize this table. Understand the relationship of BMI, WC, and health. BMI, WC, and Health Risk AACE/ACE; Comprehensive Clinical Practice Guidelines Formedical Care of Patients with Obesity ScienceDirect. Accessed October 25, 2021. Obesity Classification  Metabolic Syndrome: Presence of ≥ 3 of the following criteria Abdominal obesity (Waist circumference) Elevated fasting blood glucose Elevated blood pressure Elevated triglycerides Low HDL cholesterol > 40 in for men > 35 in for women ≥ 100 mg/dL ≥ 130/≥85 mmHg ≥ 150 mg/dL < 40 mg/dL for men < 50 mg/dL for women Obesity, insulin resistance  Increased risk of cardiovascular disease, Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline | The Journal of Clinical diabetes, chronic kidney disease Endocrinology & Metabolism | Oxford Academic. Accessed October 25, 2021. What Causes Obesity? Genetics + Epigenetic s Environm ent Physiologi c Factors Sociocultu ral Factors Obesi ty Behavior Important driving factor: Caloric expenditure < caloric intake Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. doi:10.1503/cmaj.191707 Drug-Induced Weight gain Class Drugs Antidepressants Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCAs) Monoamine oxidase inhibitors (MAOIs) Olanzapine, clozapine Gabapentin, carbamazepine, valproic acid Non-selective β-blockers α-adrenergic antagonists Insulin, sulfonylureas meglitinides, thiazolidinediones Antipsychotics Anticonvulsants Antihypertensives Antihyperglycemic s Other Corticosteroids Hormonal contraceptives Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic. Accessed October 25, 2021. Impact of Obesity Pro ti p disea : These s called e states a re relat weighte or co d diseas e mpli catio s ns  Obesity increases risk of all-cause and cardiovascular mortality  Increased risk of morbidity from chronic disease in overweight and obese patients  Diabetes mellitus  Polycystic ovary type 2 syndrome  Hypertension  Female infertility  Dyslipidemia  Male hypogonadism  Cardiovascular  Depression  Nonalcoholic fatty disease  Sleep apnea liver disease  Asthma  Osteoarthritis AACE/ACE; Comprehensive Clinical Practice Guidelines Formedical Care of Patients with Obesity - ScienceDirect. Accessed October 25, 2021. https://www-sciencedirect-com.proxy-s.mercer.edu/science/article/pii/S1530891X20446300?via%3Dihub Management of Overweight & Obesity  General weight loss goal with diet and exercise: 5 – 10% in 6 – 12 months – Loss of 3-5% body weight can positively impact health**  Benefits of weight loss – Improved health: decreased blood glucose, blood pressure, and improved lipid panel – Improved quality of life: less joint pain, difficulty breathing – Increased life expectancy: lower incidence of certain cancers AACE/ACE; Comprehensive Clinical Practice Guidelines Formedical Care of Patients with Obesity ScienceDirect. Accessed October 25, 2021. Pro tip: These are great counseling points for Treatment Comprehensiv e Lifestyle Therapy Nutrition Physical Activity Behavior Pharmacother apy Bariatric Surgery Pro tip: All three components are vital for success. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. doi:10.1503/cmaj.191707 Nutrition  Caloric intake < Caloric expenditure – 500-750 kcal/day deficit can be recommended – Options: restrict overall calories based on body weight or restrict certain food types  Key factors: patient’s current lifestyle, cultural preferences, health literacy  Additional support: referral to http://www.choosemyplate.gov/print-materials-ordering/graphic-resources.html Nutrition Consume:  Fruits and vegetables  Whole grains  Low-fat or fat-free dairy products  Lean meats or non-meat protein sources Avoid or minimize:  Saturated/trans fats, cholesterol, added sugars, sodium, and excessive alcohol http://www.cnpp.usda.gov/DietaryGuidelines Exercise  Overall goal: 30 – 60 minutes of moderate to vigorous exercise most days per week (≥ 150 min/week of aerobic physical activity) – Can promote weight loss and cardiometabolic health – Positive impact on mood, psychiatric disorders, and quality of life Pro tips: • Set a SMART goal that is patient centered • Consider patient disease states and current activity level Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020;192(31):E875-E891. doi:10.1503/cmaj.191707 Behavioral Therapy  Comprehensive lifestyle program – “Multicomponent psychological intervention”  Behavior modification based on the patient needs and values  Focus on goal setting, self-monitoring, problem solving, self- efficacy, and motivation  Role of the pharmacist: motivational interviewing, patient education, SMART goal setting – Could be provided by a patient’s healthcare provider or could include referral to obesity management clinic or program – Long term program (≥ 6 months) of independent or group intervention is most successful Pharmacotherapy Comprehensiv e Lifestyle Therapy Pharmacother apy Bariatric Surgery  Candidacy: BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with ≥ 1 obesity-related comorbidity – In addition to a comprehensive lifestyle intervention – Should be used in patients unable to lose and sustain 5% body weight loss for 6 months with lifestyle changes  Other guideline recommendations: FDA-approved agent, benefits outweigh risks – Short term use: phentermine and other sympathomimetics alone – Long term use: GLP-1 agonists, phentermine-topiramate ER, naltrexone-bupropion, orlistat Sympathomimetic Agents  Phentermine (Adipex-P, Lomaira) – Others: Diethylpropion, Phendimetrazine, Benzphetamine Mechanism Dose Adverse effects Contraindications (CI) Appetite 15 – 37.5 mg/day in suppression: one or two divided increasing doses norepinephrin Lomaira: 8 mg PO e, dopamine in TID before meals central nervous system MAOI: Monoamine oxidase inhibitors  Clinical Pearls Common: Increase BP/HR (Arrhythmias) Constipation Dry mouth Insomnia Glaucoma* Hyperthyroidism* Uncontrolled HTN Cardiovascular disease Pregnancy/Lactation MAOI use with 14 days Pro tip: You do not – Short term use only (FDA-approved: 12 weeks) need not memorize – Schedule IV controlled substance (abuse potential) doses, but should – Monitoring: BMI, HR, BP, side effects know frequency Glucagon-like peptide-1 (GLP-1) Receptor Agonists  Liraglutide (Saxenda), Semaglutide (Wegovy) Contraindications (CI) Appetite Liraglutide: 0.6 mg SubQ Common: Medullary thyroid suppression DAILY increased wkly by Nausea/vomiting carcinoma* : slowed 0.6 mg as tolerated Diarrhea/ Multiple gastric (max: 3 mg) constipation endocrine emptying, Decreased neoplasia Semaglutide: 0.25 mg increased appetite syndrome type 2 SubQ WEEKLY x 4 wks, satiety (MEN type 2)* increased Q4 wks as Rare, but serious: Pregnancy/  Clinical tolerated (max: 2.4 mg) Pearls pancreatitis, Lactation – First line, but expensive gallbladder – CAN be used in cardiovasculardisease disease ?Pancreatitis – Inject subcutaneously in the abdomen or thigh – Monitoring: BMI, GI side effects, abdominal pain (pancreatitis, http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm427913.htm gallbladder disease) Mechanism Dose Adverse effects Phentermine/Topiramate ER (Qsymia) Mechanism Dose Appetite suppression 3.75 mg/23 mg DAILY x 14 days then 7.5 mg/46 mg daily Adverse effects Common: Increased HR/BP Dry Mouth Constipation Insomnia Specific, gradual Paresthesias titration based (topiramate) on patient response Contraindications (CI) Glaucoma* Hyperthyroidism* Kidney stones* Phentermine: (topiramate) previous slide Uncontrolled HTN Topiramate: Cardiovascular anticonvulsant, disease appetite Pregnancy/ suppression Lactation through many MAOI use within Max 15 mg/92 mechanisms 14 days  Clinical Pearls mg daily – Restricted access program (REMS) due to teratogenicity – Schedule IV controlled substance (abuse potential) – Patient population considerations FOR use: migraine – Monitoring: BMI, HR, BP, changes in mood, side effects Naltrexone/Bupropion (Contrave) Mechanism Dose Appetite suppression, 8 mg/90 mg PO reward system DAILY modulation Titrated weekly Naltrexone: opioid to 2 tablets antagonist BID as tolerated Bupropion: (max dose=32 norepinephrine, mg/360 mg per dopamine reuptake day in divided inhibitor doses)  Clinical Pearls Adverse effects Common: Nausea/ vomiting Headache Constipation Increase HR/BP Contraindications (CI) Chronic opioid use* Seizure disorder* Uncontrolled HTN Cardiovascular Disease Pregnancy/ Lactation MAOI use within 14 days – Do not take dose with a high fat meal – Patient population considerations FOR use: desire for tobacco cessation Orlistat (Xenical, Alli) Mechanism Dose Decrease fat 60 mg TID (OTC) absorption (20 – 120 mg TID (RX)* 30%): gastric and - recommended pancreatic lipase inhibitor  Clinical Pearls Adverse effects Contraindications (CI) Common: Abdominal pain Flatulence Fecal urgency or incontinence Cholestasis Calcium oxalate kidney stones Pregnancy/ Lactation – Omit dose if meal skipped or contains no fat – May impair absorption of other drugs: cyclosporine, warfarin, oral contraceptives, levothyroxine, fat soluble vitamins – Take multivitamin at bedtime containing vitamins A, D, E, K during therapy (separate from orlistat dose) – High discontinuation rate due to side effects General Monitoring  Factors – Efficacy goal for pharmacotherapy: weight loss of ≥ 5% of body weight at 3 months** – Safety and Tolerability: side effects, drug interactions, adverse events  Frequency: Monthly for three months, then at least every 3 months while on therapy  Duration of therapy – Long term risks for many agents unknown – Patients with cardiovascular disease and age > 65 years were excluded from many clinical trials Surgery Comprehensiv e Lifestyle Therapy Pharmacother apy Bariatric Surgery  Candidacy – BMI ≥ 40 kg/m2 OR BMI ≥ 35 kg/m2 with obesity-related comorbidities – Motivated to lose weight – Insufficient weight loss with behavioral therapy ± pharmacotherapy  Complications – Surgical complications – Nutrient deficiencies – Changes in drug absorption A. Vertical-banded gastroplasty B. Adjustable gastric banding C. Roux-en-Y gastric bypass Miller, DA et al. Am J Health Syst Pharm. 2006;63(19):1852-1857. http://www.medscape.com/viewarticle/545489_3. Access August 27, 2014 https://www.fda.gov/consumers/consumer-updates/medical-devices-weight-loss-and-weight-management-what-know. Medical Devices Pro you tip: Th r onl inform is is fo y at i o r n  Table 167.5 – Sheehan A, Chen JT, Yanovski JA. Obesity. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023. Accessed November 01, 2023. https://accesspharmacy.mhmedical.com/content.aspx? bookid=3097&sectionid=268555827