Zoe Schilling, PharmD. Candidate 2022
8/23/21
The United States prevalence of obesity was 42.4% in 2017 – 2018. From 1999 –2000 through 2017 –2018, U.S. obesity prevalence increased from 30.5% to 42.4%. The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008. Overweight & obese patients have increased risk of all-cause mortality.
Increased morbidity from high blood pressure, high cholesterol, diabetes, heart disease, gallbladder disease, sleep apnea, and certain types of cancer.
The pathophysiology of obesity is complicated and could be very complex. Obesity may involve genetic factors, lifestyle, nutritional, behavioral, socioeconomic factors, and more.
What can we control?
Lifestyle (diet and exercise)
Medications
Stress
Smoking
Medications known to promote weight gain:
Insulin, glipizide, glyburide, glimepiride, pioglitazone, rosiglitazone (diabetes medications)
Olanzapine, clozapine, risperidone, aripiprazole (mood medications)
Gabapentin, pregabalin, valproic acid, and vigabatrin (anti-seizure medications)
Prednisone and other steroids
Amitriptyline, mirtazapine, paroxetine, escitalopram, sertraline, duloxetine, and citalopram (mood medications)
Note: this is not a comprehensive list; there may be other indications for these medications. Talk to your doctor or pharmacist if you think one of your medications may be causing weight gain
Highlights of Obesity Management Guidelines:
• Nutritional, exercise & behavioral modifications are always preferred over pharmacotherapy
• Pharmacotherapy only plays a supportive role. Most patients most meet a BMI requirement to initiate drug therapy
• Emphasis should be on the patient as a whole while creating sustainable lifestyle changes
• Identification of food triggers, emotional eating, stress management
• Obesity management should focus on improved well-being, not just weight loss
• General exercise goal is for aerobic activity (30– 60 min) on most days of the week
• Weight loss achieved with lifestyle changes is about 3%–5% of body weight, which can result in meaningful improvement in obesity-related comorbidities
• Sustainable, caloric restriction is a major key to successful weight loss
• Patients generally should drink more water
• Always include protein & veggies at every meal
• Stress the importance of adequate sleep
• Encourage patients not to skip meals, especially breakfast
Patients should be encouraged to consume more:
• Whole grains (whole wheat, steel cut oats, brown rice, quinoa)
• Vegetables (a colorful variety-not potatoes)
• Whole fruits (not fruit juices)
• Nuts, seeds, beans, and other healthful sources of protein (fish and poultry)
• Plant oils (olive and other vegetable oils)
• Use fiber supplements in patients when necessary
Patients should be encouraged to consume less:
• Sugar-sweetened beverages (soda, sports drinks)
• Alcoholic beverages
• Fruit juice (no more than a small amount per day)
• Refined grains (white bread, white rice, white pasta)
• Potatoes (baked or fried)
• Red meat (beef, pork, lamb) and processed meats (salami, ham, bacon, sausage)
Other highly processed foods, such as fast food
Common Medications:
Note: Always talk to your doctor and/ or pharmacist before considering drug therapy.
Remember most medications need a prescription and you have to meet a certain BMI criterion to qualify for drug therapy.
If lifestyle changes fail to produce a result in six months, FDA-approved pharmacotherapy is recommended as an adjunct in high-risk patients
This recommendation is limited to patients with a BMI ≥ 30, or ≥ 27 with obesity-related risk factors or diseases present
Drugs should only used as adjuncts; patients must be exercising, with dietary changes & behavioral modification
Only Medication that can be bought over-the-counter (OTC):
Orlistat (Alli):
– Available with a prescription in a dose of 120 mg and was recently approved for a 60 mg dose available over the counter
–Patients on orlistat should take a multivitamin supplement
– To reduce the risk for regaining weight after prior weight loss
– For obese patients with initial BMI ³30 kg/m2 or ³27 kg/m2 in the presence of other risk factors (ex. hypertension, diabetes, dyslipidemia)
– Contraindicated in patients with chronic malabsorption syndrome or cholestasis and in patients with known hypersensitivity to orlistat
– Most commonly reported side effects include fecal urgency, flatulence, increased defecation, fatty/oily stool
Prescription Medications May Include:
Naltrexone/Bupropion (Contrave):
– Contraindicated with a history of seizure disorder, opioid treatment, pregnancy
– Common side effects include: nausea, vomiting, diarrhea, insomnia, headache
Topiramate:
– Used off-label for weight loss
–May decrease the impulses that binge eaters experience to help with weight loss
– Side effects: can cause birth defects (avoid in pregnancy), paresthesia, dizziness, anxiety, impaired memory, increased risk for kidney stones
Phentermine:
– Only indicated for short-term use
– Common side effects include: high blood pressure, tachycardia, nervousness, insomnia, stimulation, withdrawal, potential abuse, dependence, and possible diversion
Phentermine/Topiramate (Qsymia):
– Used for obesity without hypertension or chronic artery disease
– Common side effects include tachycardia, anxiety, insomnia, cognitive effects, paresthesia, dry mouth, gastrointestinal upset
Liraglutide (Saxenda):
– Generally, will produce mean 5-10% weight loss from baseline, though some patients lose >10% from baseline
– Contraindicated in thyroid cancer, multiple endocrine neoplasia syndrome type 2, pregnancy (or planned pregnancy)
– Common side effects include nausea, vomiting, and diarrhea, hypertension, headache, dizziness, constipation
Semaglutide (Wegovy):
– Used as an adjunct to a diet & exercise for chronic weight management in adults with a BMI ≥30 kg/m2, or ≥27 kg/m2 in the presence of at least 1 weight-related comorbid condition (hypertension, type 2 DM, dyslipidemia) & pediatric patients ≥12 with body weight >60 kg & initial BMI ≥30 kg/m2
– Generally, will produce mean 5-10% weight loss from baseline, though some patients lose >10% from baseline
– Contraindications: Personal or family history of medullary thyroid carcinoma; patients with multiple endocrine neoplasia syndrome type 2
–Common side effects: abdominal pain (6-11%), nausea (11-20%), vomiting, and injection side reactions
References:
1.) Centers for Disease Control and Prevention. Overweight and obesity: Adult obesity facts. Available at: https://www.cdc.gov/obesity/data/adult.html (Accessed on August 15, 2021).
2.) Perreault L. Obesity in adults: Prevalence, screening, and evaluation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. Available at: https://www.uptodate.com/contents/obesity-in-adults-prevalence-screening-and-evaluation (Accessed on August 15, 2021).
3.) Hamdy O, Uwaifo GI, Oral EA. Obesity: Practice essentials. Medscape e-Medicine, June 9, 2021. Available at: https://emedicine.medscape.com/article/123702 (Accessed on August 15, 2021).
4.) Kumar RB, Aronne LJ. Iatrogenic obesity. Endocrinol Metab Clin North Am. 2020;49(2):265–273.
5.) Mayer SB, Graybill S, Raffa SD, Tracy C, Gaar E, Wisbach G, Goldstein MG, Sall J. Synopsis of the 2020 U.S. VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity. Mil Med. 2021 Apr 27:usab114. doi: 10.1093/milmed/usab114. Epub ahead of print. PMID: 33904926.
6.) 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
7.) Mayer SB, Graybill S, Raffa SD, Tracy C, Gaar E, Wisbach G, Goldstein MG, Sall J. Synopsis of the 2020 U.S. VA/DoD Clinical Practice Guideline for the Management of Adult Overweight and Obesity. Mil Med. 2021 Apr 27:usab114. doi: 10.1093/milmed/usab114. Epub ahead of print. PMID: 33904926.
8.) 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
9.) Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline [published correction appears in J Clin Endocrinol Metab. 2015 May;100(5):2135-6]. J Clin Endocrinol Metab. 2015;100(2):342-362. doi:10.1210/jc.2014-3415
10.) Lexicomp Online [Internet]. Hudson (OH): Lexi-Comp, Inc. c2019. [updated 2021August 23; cited 2021 August 23]; Available from: http://online.lexi.com.onu.ohionet.org
Zoe Schilling wrote this blog in reference to Dr. Darrell Hulisz’s obesity presentation on her August pharmacy APPE rotation.
Darrell Hulisz, RPh, PharmD is an Associate Professor of Family Medicine & Community Health in the School of Medicine at Case Western Reserve University in Cleveland, Ohio. He also holds a clinical faculty appointment at Ohio Northern University, College of Pharmacy. Darrell has published over 80 papers in the medical and pharmacy literature, has lectured extensively both locally and nationally and has served as an investigator in several clinical trials. He also serves on several national advisory panels and serves as a referee for several peer reviewed journals. Darrell currently practices as a clinical pharmacy specialist with University Hospitals Medical Group, Family Medicine Residency Program, where he works in consultation with family physicians, both on inpatient and outpatient services. Darrell teaches trainees from multiple disciplines, including resident physicians, medical, pharmacy and physician assistant students in didactic and clinical settings. Darrell has received multiple awards in areas such as excellence in didactic teaching, excellence in precepting, humanitarian work, interprofessional education & outstanding achievement. Darrell leads an interprofessional team of trainees in community health outreach programs and has devoted most of his career to the successful integration and collaboration of pharmacy and medical training in clinical settings.