Obesity

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					CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE OBESITY COURSE CP 130                                                                  YEAR FALL      2002
  SUBJECTIVE/OBJECTIVE                                       ASSESSMENT                                                                              PLAN
          PROBLEM
       SUBJECTIVE &                                                EVALUATE NEED FOR THERAPY;                       RECOMMEND DRUG                      GOALS & MONITORING
         OBJECTIVE                                                 EVALUATE CURRENT THERAPY;                             TREATMENT;                          PARAMETERS
          EVIDENCE                           ETIOLOGY                      THERAPY OPTIONS                             FURTHER TESTS                   (TOXIC & THERAPEUTIC)                PATIENT EDUCATION
 Obesity is excessive body         Genetic                         Yes. To prevent CAD, HTN,                 Combination of LCD, behavior        Goals                                       ↓ fat intake
fat secondary to poor appetite     Metabolic                      dyslipidemia, type 2 diabetes, stroke,    therapy & increased physical             o    Prevent further wt. gain           ↓ calorie intake
regulation and ↓ed energy          Environmental                  gallbladder disease, osteoarthritis,      activity is MOST EFFECTIVE for           o    ↓ body wt.                         30 min moderate
metabolism.                        Medications                    sleep apnea, respiratory problems,        wt. loss & maintenance. MUST be                     o     Obese: Loss of        exercise each day
                                      Glucocorticoids            caner (endometrial, breast, prostate,     tried for @ least 6 months before                         10% of baseline
Subjective                            Insulin                    colon), death, stigmatization,            considering pharmacotherapy                               wt., @ rate of 1-2
     Lower back & knee               Sulfonylureas              discrimination.                                                                                     lb/wk; energy deficit
      pain                             (Glimepiride, Glipizide,                                              Phentermine                                              of 500-1000 kcal/d
     Unable to move                   Glyburide)                   Treat if:                                8mg TID or 15-37.5 mg QD                                 in 6 mo
      without significant joint       Progestins                   Overweight: BMI 25-29.9 kg/m2 OR                                                            o     Overweight: ½
      & back pain                     Antidepressants (SSRIs, waist circumference > 102 cm (men) Sibutramine                                                         lb/wk, energy deficit
                                       TCA, Mirtazapine, MAOIs) or > 88 cm (women) AND ≥ 2 risk              10 mg Qam, may be ↑ed to 15 mg                           of 300-500 kcal/d in
Objective                             Mood stabilizers (Lithium, factors                                   QD if do not lose > 4 lbs w/in 4 wks                      6 mos to 1 yr.
     Overweight: BMI 25-              Valproate)                   Obese: BMI ≥ 30 kg/m2                                                            o    Maintain a lower body wt,
      29.9 kg/m2                      Antipsychotics (clozapine                                             Orlistat                                     over a long period of time (wt.
     Obese: BMI ≥ 30                  > olanzapine > quetiapine    Options                                  120 mg TID w/ or up to 1 hr after            will equilibrate after 6 mos for
      kg/m2                            > riseridone > haloperidol 1. Combination Therapy                    fatty meal. Skip meal dose is meal            most ppl; additional wt. loss
     Extreme Obesity: BMI             > ziprasidone)                        Low Calorie Diet (women: does not contain fat                               requires additional energy
      > 40 kg/m2                   Physical inactivity                        1000-1200 kcal/d & men:                                                     deficits)
     Waist circumference          Hi TGs ( > 200mg/dL)                       1200-1500 kcal/d)
      (correlation w/                                                   (+) Most effective for weight loss
                                   Risk Status: To determine            (-) Requires incorporation into a                                        Monitor
      abdominal fat content
      unless BMI ≥ 35             absolute risk of M & M from           weight loss/management                                                   o   Wt (Baseline, 6 mos, 1 yr)
      kg/m2):                     being overweight or obese             program (adherence problem)                                              o   BMI
           o     Men > 102        requires assessment several                Physical activity ( 30 min+                                        o   Progress
                 cm (> 40 in)     factors                                     moderate activity on                                               o   SEs of pharmacotherapy ( if used)
                                                                              most/all days of week)                                             o   RFs for dz
           o     Women >              Preexisting disease
                 88 cm (> 35                                            (+) Prevent further weight gain                                          o   Tx failure
                                       conditions (coronary
                 in)                   heart dz, atherosclerotic        (+) ↓ CV and DM risks
                                       dz, type 2 diabetes, sleep       (+) ↑ HDL
                                                                        (-) Does NOT produce                                                     DDI
                                       apnea)
                                                                        substantial weight loss                                                  Phentermine
                                      Other obesity-related
                                                                        (-) Must be in combo w/ LCD                                                  o     TCA use. Do not use w/ or
                                       conditions (gynecological
                                       abnormalities,                        Behavioral Therapy ( self-                                                   w/in 2 wks of D/C of MAOIs.
                                                                              monitoring habits, sress                                                     Avoid use w/ SSRIs. May ↓
                                       osteoarthritis, gallstones &                                                                                        efficacy of clonidine,
                                       complications, stress                  management, stimulus
                                                                              control, problem solving,                                                    guanethidine, methyldopa.
                                       incontinence)                                                                                                       May ↑ effect of thyroid
                                                                              contingency management,
                                      CV RFs (smoking, HTN, ↑                                                                                             hormones.
                                                                              cognitive restructing, social
                                       LDL, ↓ HDL, impaired
                                                                              support)
                                       fasting glucose, family hx                                                                                Sibutramine
                                                                        (+) Help to comply w/ LCD &
                                       of premature CHD, age)                                                                                        o     Do not use w/ or w/in 2 wks
                                                                        physical activity
                                                                        (+) Helpful for wt. loss &                                                         of D/C of MAOIs. Avoid use
                                                                        maintenance                                                                        w/ SSRIs, decongestants or
                                                                        (-) Dependent on pts’ motivation                                                   other agents known to ↑ BP.
                                                                        & adherence                                                                        Ketoconazole, erythromycin
                                                                        (-) Takes time                                                                     may inhibit metabolism.
CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE OBESITY COURSE                                                             CP 130     YEAR FALL     2002
SUBJECTIVE/                                     ASSESSMENT                                                                                        PLAN
 OBJECTIVE
 PROBLEM
SUBJECTIVE                             EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                                      GOALS & MONITORING
     &                                                   THERAPY OPTIONS                                                                             PARAMETERS
 OBJECTIVE                                                                                                                                      (TOXIC & THERAPEUTIC)              PATIENT
 EVIDENCE                                                                                                                                                                        EDUCATION
              2.    Weight Loss Agents                                                                                                       Orlistat                       Phentermine
                      Fenfluramine (one of ingredients in “FenPhen”)                                                                            o    Warfarin—anticoagulant D/C use & contact
                      Dexfenfluramine (isomer of fenfluramine)                                                                                       effect may ↑ due to ↓ MD if:
                            o   Both ↑ satiety by ↑ 5HT in CNS                                                                                        Vit. K absorption.          o     Dyspnea
                            o   Both associated w/valvular heart dz & pulmonary HTN                                                                   Cyclosporine—case           o     Angina
                            o   Both w/drawn by FDA in 1997                                                                                           reports of ↓ levels         o     Syncope
                      Phenylpropanolamine                                                                                                                                        o     ↓ exercise
                            o   Synthetic catecholamine found in OTC products (Acutrim, Dexatrim), decongestants (Contac,                                                               tolerance
                                Dimetapp)                                                                                                                                    Take 30 min b/f
                            o   ↑ satiety by ↑ NE, DA in feeding center in hypothalamus                                                                                     meals (TID schedule)
                            o   ↑ risk of hemorrhagic stroke in women                                                                                                       or before breakfast or
                            o   FDA requested voluntary w/drawal in 10/00                                                                                                   1-2 hr after bkfst (QD
                                                                                                                                                                            schedule)
              3.   Pharmacologic Agents                                                                                                                                      Last dose should be
                   o  Sympathomimetics: Benzphetamine, diethylpropion, mazindol, phendimetrazine, phentermine                                                               4-6 hrs before
                   o  Phentermine (Adipex-P) (stimulate release of NE, DA in hypothalamic feeding center & suppress appetite):                                              bedtime
                      Short-term treatment
                          (+) 5-15% weight loss in 60% pts                                                                                                                    Sibutramine
                          (-) Dry mouth, insomnia, nervousness, constipation, HTN; physical, psychologic addiction, tolerance                                                  Baseline BP, HR
                          (-) TID dosing (compliance problem)                                                                                                                should be taken
                          (-) Caution: anxiety d/o                                                                                                                           before therapy
                          (-) Potential for rebound binge eating, wt. gain, lethargy, & depression when stop medication                                                      initiation & after every
                          (-) C/I: moderate-severe HTN, CV dz, substance abuse                                                                                               dose change
                   o  Sibutramine (Meridia) (inhibit reuptake of NE, 5HT, DA (to lesser extent) resulting in satiety): Long-term tx.
                          (+) 5% weight loss in 40%; peak wt. loss in 6 mo, maintained for at least 1 year                                                                    Orlistat
                          (+) Improvements in cholesterol, LDL, TG                                                                                                             Low-fat diet to ↓ GI
                          (+) QD dosing                                                                                                                                      sx
                          (-) Slower wt. loss than sympathomimetics                                                                                                            Take MVI QD while
                          (-) Metabolized by CYP 3A4 (lots of DDI)                                                                                                           taking medication (2
                          (-) ↑ BP & HR, dry mouth, anorexia, insomnia, constipation, HA                                                                                     hrs before or after
                          (-) C/I: history of poorly controlled HTN, CAD, CHF, arrhythmias, stroke                                                                           orlistat dose)

                         Note (Sibutramine): Don’t use w/ other antidepressants, Li, antimigraine, opioid analgesics, centrally acting
              appetite suppressant/sympathomimetics.

               FYI: Why can’t we use SSRIs? Because it’s only selective at inhibiting 5HT reuptake. Appetite suppression requires ↑
              NE, DA. Fluoxetine have been shown to ↓ binge eating, but not always associated w/ wt. loss (you see wt. loss up to 6
              months, but pt. regains the wt. in 1 year). Fluvoxamine & citalopram don’t help w/ wt. loss. Sertraline prevents additional
              wt. loss 1st 6 wks only.

               FYI: Why can’t we use TCA & mirtazapine (blocks 5HT 2A/2C/β receptors)? Cause sedation and ↑ appetite & wt.
CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE OBESITY COURSE                                                                  CP 130     YEAR FALL    2002
SUBJECTIVE/                                                                 ASSESSMENT                                                                                       PLAN
 OBJECTIVE
 PROBLEM
SUBJECTIVE                                    EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                                            RECOMMEND      GOALS &
     &                                                          THERAPY OPTIONS                                                                                  DRUG       MONITORING
 OBJECTIVE                                                                                                                                                    TREATMENT;   PARAMETERS    PATIENT
 EVIDENCE                                                                                                                                                      FURTHER       (TOXIC &   EDUCATION
                                                                                                                                                                TESTS      THERAPEUTIC)
                   o    Orlistat (Xenical) ( Inhibit gastric, carboxdylester, lipoprotein, pancreatic lipase, resulting in ↓ fat absorption): Long-term tx.
                             (+) 9% wt. loss in 1st year
                             (+) 18-34% pts maintained ≥ 10% wt. loss after 2 yrs
                             (+) ↓ed RFs assoc. w/ obesity
                             (+) no CNS effects
                             (+) improve LDL & insulin levels
                             (+) can reduce diabetic & statin dose
                             (+) most effective if combined w/ ↓ fat & LCD
                             (-) TID dosing
                             (-) GI sxs: loose stools, abdominal pain (bloating & cramping), oily spotting, fecal urgency, flatulence w/discharge, fatty
                             stools, fecal incontinence, ↑ defecation)
                             (-) Malabsorption of fat soluble vitamins (ADEK)
                             (-) C/I: Cholestasis, malabsorption syndrome
                             (-) Caution: h/o of hyperoxaluria or calcium oxalate nephrolithiasis

              4.   OTC products, herbs, dietary supplements
                   o  Ephedrine (sympathomimetic)
                            (+) Modest short-term wt. loss w/ diet programs
                            (-) Not to be used as monotherapy or in children
                            (-) May cause hypertensive crisis in pts on MAOI
                            (-) ↑ed risk of arrhythmias may occur if pt is on cardiac glycosides, quinidine, or TCAs
                            (-) ↑ BP & HR
                   o  Caffeine
                   o  Benzocaine
                   o  Chromium
                   o  Psyllium
                   o  Chitosan
                   o  Ma Huang (Ephedra sinica)
                            (+) ↑ energy expenditure causing wt. loss
                            (-) see ephedrine
                   o   St. John’s Wort (Hypericum perforatum)
                   o   Guarana ( Paulinia cupana)
                   o   Kola nut (Cola nitida, Cola acuminata, Garcinia cola)
                   o   Hydroxicitric acid ( Garcinia cambogia)

              Note:
                  o     Ma huang, ephedrine, guarana, kola nut → stimulant properties, ↑ BP & HR
                        Avoid in CV dz, HTN, thyroid dz, DM
                   o    MAOI → avoid PPA (phenylpropanolamine), ephedrine-like products, St. John’s wort
                   o    Avoid Ma huang & St. John’s wort combo → “herbal fen-phen”
CP-130 SERIES CLINICAL PHARMACY SOAP FORM WORKSHEET CASE OBESITY                                                              COURSE CP 130   YEAR   FALL 2002
SUBJECTIVE/                                                                ASSESSMENT                                                                            PLAN
 OBJECTIVE
 PROBLEM
SUBJECTIVE                                    EVALUATE NEED FOR THERAPY; EVALUATE CURRENT THERAPY;                                                     GOALS &
     &                                                          THERAPY OPTIONS                                                                       MONITORING
 OBJECTIVE                                                                                                                                           PARAMETERS          PATIENT
 EVIDENCE                                                                                                                                              (TOXIC &         EDUCATION
                                                                                                                                                     THERAPEUTIC)
              5.   Surgery
                   o   Gastric bypass (Roux-en-Y)
                           (+) significantly more effective for wt. loss than others ( e.g. gastric restriction/vertical gastric banding)
                           (+) shown to ↓ 2/3 of excess wt. w/in 2 years post-surgery w/ most wt. lost w/in the 1st 6 mo
                           (-) stapling can be undone
                           Note: All other measures must have been tried & failed & pt has obesity-related complications
                                  BMI > 40 or BMI ≥ 35 w/ comorbid conditions


              6.   Special Treatment Groups
                   o   Smokers: Smoking cessation should be main priority. Major barrier: wt. gain in 80% of those who quit. Benefit of cessation
                       outweighs risk of wt. gain!
                   o   Elderly: Weigh risks & benefits
                   o   Diverse: Treatment outcome is highly variable; treatment options should be highly invidualized

				
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