Farah Farah Hasan MD, FRCP, Hasan MD, FRCP, FACE FACE Section Chief, Endocrinology Section Chief, Endocrinology Advocate Christ Medical Center Advocate Christ Medical Center Clinical Assistant Professor UIC Clinical Assistant Professor UIC Medical Management of Obesity
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Farah Hasan MD, FRCP, FACE Section Chief, Endocrinology Advocate Christ Medical Center Clinical Assistant Professor UIC Medical Management of Obesity.
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Farah Farah Hasan MD, FRCP, Hasan MD, FRCP, FACEFACE
Section Chief, EndocrinologySection Chief, EndocrinologyAdvocate Christ Medical CenterAdvocate Christ Medical CenterClinical Assistant Professor UICClinical Assistant Professor UIC
Medical Management of Obesity
Medical Management of Obesity
Overview of Obesity in the U.S.
CDC, NCHS Data brief, No 82, January 2012
Prevalence* of Self-Reported Obesity Among U.S. Adults 2012BRFSS, 2012
*
15-20% 20-25% 25-30% 30-35% >35%
Behavioral risk factor surveillance system, CDC
MUST BE REALISTIC
Goals of Therapy
Ideal is a return to normal body weight Not realistic*
Degree of weight loss First month 2 kg 3-6 mos 5-10% TBW
Improvement in risk factors Diabetes** Cardiovascular disease***
Goals of Therapy
*Foster, et al. J Consult Clin Psychol 1997;65:79**Knowler, et al. NEJM 2002;346:393.***Douketis, et al. Int J Obes 2005; 29:1153
Counsel all BMI >25 Diet, lifestyle and goal for weight loss
Pharmacologic therapy BMI >30 or BMI >27 with comorbidities Failed diet and exercise alone
Approach
Drugs than alter fat digestion Seratonin Agonists Sympathomimetic Drugs Antidepressants Hormones Combination Drugs
Pharmacologic therapy
Orlistat
Orlistat
Prescription
Pharmacologic therapy
Over the counter
Meta analysis of 12 trials* Orlistat + behaviour -5-10 kg (8%TBW) Placebo +behaviour -3-6 kg Difference of 3 kg Maintained for 24 to 23 months
Orlistat Efficacy
*Leblanc ES, et al. Ann Intern Med 2011; 155:434
37% reduction in conversion to diabetes from IGT* Improves systolic and diastolic blood pressure** Improves serum lipids***
Orlistat Efficacy
*Togerson JS, et al. XENDOS study. Diabetes Care 2004;27:155.**Siebenhofer A, et al. Cochrane Database Syst Rev 2013;3:CD007654.***Davidson MH, et al. JAMA 1999;281:235.
15-30% GI side effects* Cramps, fecal incontinence, oily spotting, flatus Can be avoided with diet <30% fat
Malabsorption of fat soluble vitamins ADEK and beta-carotene Give vitamin supplements
Severe Liver injury Rare Oxalate induced kidney injury**
Orlistat Side effects
*Padwal R, et al. Cochrane Database Syst Rev 2004;:CD004094**Courtney AE, et al. Nephrol Dial Transplant 2007;22:621
Serotonin reduces food intake Lorcaserin is a selective agonist of the serotonin 2C
receptor Nonselective serotonergic agonists such as
fenfluramine and dexfenfluramine enhanced weight loss but increased risk of valvular heart disease through serotonin receptor 2B
Serotonin Agonists
*Padwal R, et al. Cochrane Database Syst Rev 2004;:CD004094**Courtney AE, et al. Nephrol Dial Transplant 2007;22:621
Approved by FDA 2012
In addition to reduced calorie diet
BMI >30 BMI >27 with DM,
HTN, cholesterol, OSA
Lorcaserin
Original Article Multicenter, Placebo-Controlled Trial of Lorcaserin for
Weight Management
Steven R. Smith, M.D., Neil J. Weissman, M.D., Christen M. Anderson, M.D., Ph.D., Matilde Sanchez, Ph.D., Emil Chuang, M.D., Scott Stubbe, M.B.A., Harold Bays, M.D., William R.
Shanahan, M.D., and the Behavioral Modification and Lorcaserin for Overweight and Obesity Management (BLOOM) Study Group
N Engl J MedVolume 363(3):245-256
July 15, 2010
Lorcaserin Efficacy
Smith SR et al. N Engl J Med 2010;363:245-256
Lorcaserin Efficacy
Smith SR et al. N Engl J Med 2010;363:245-256
Lorcaserin Efficacy
Smith SR et al. N Engl J Med 2010;363:245-256
Beneficial effects on surrogate markers* Slight decrease in BP Heart rate Total and LDL cholesterol CRP, fibrinogen, fasting glucose and insulin levels
Beneficial effect on A1c and and fasting glucose in patients with DM**
Locaserin Efficacy
*Smith SR et al. N Engl J Med 2010;363:245-256**O’Neil, et al. Obesity 2012;20:1426
Headache, URI, nasopharyngitis, dizziness, nausea No significant increase in serotonin associated
valvulopathy by echo at 52 weeks
Locaserin Side Effects
*Smith SR et al. N Engl J Med 2010;363:245-256
10 mg BID Response to therapy should be evaluated by week
12 Discontinue if patients do not lose 5% of body
weight in 12 weeks* Do not use if individuals with CrCL<30 Do not use in pregnancy Do not use with other SSRI, SNRI, TCA’s, MAOI’s
Locaserin Dosing
FDA Highlights of prescrbing information :BELVIQ. http://www.accessdata.fda.gov
Stimulate the release of norepi or inhibit reuptake Phenteramine, diethylpropion, benzphetamine,
phendimetrazine
Block norepi and serotonin reuptake Sibutramine (Meridia, withdrawn from market)
Directly act on adrenergic receptors Phenylpropanolamin (withdrawn from market)
May increase blood pressure
Sympathomimetic Drugs
Potential for abuse Approved only for short term use (<12 weeks) Contraindicated
CAD HTN Hyperthyroidism History of drug abuse
Sympathomimetic Drugs
Average weight loss for 4 weeks was 0.23 kg/wk more than placebo*
In trials up to 25 weeks duration net weight loss with diethylpropion compared to placebo ranged from 1-10 kg**
Sympathomimetic Drugs Efficacy
*Scoville BA, et al. Obesity in Perspective. DHEW Pub No. (NIH 75-708). 1975:441-3**Bray GA, et al. Ann Intern Med 1993;119:707