1. JESSICA FORDHAM, MSN, APRN, FNP-C MISSISSIPPI UNIVERSITY FOR WOMEN 12/02/14 TREATING OBESITY PHARMACOLOGICALLY

2. THE DREAM

3. BACKGROUND Obesity is caused by an imbalance among food intake, absorption, and energy expenditure. Underlying organic causes may be psychiatric disturbances, hypothyroidism, hypothalamic disorder, insulinoma, and cushing syndrome Medications: corticosteroids, neuroleptics, and antidepressants

4. EPIDEMIOLOGY More than one-third of U.S. adults are obese Non-Hispanic blacks have the Highest age adjusted rates of obesity Obesity is higher among middle age adults, 40-59 years old

5. RISK FACTORS Parental obesity Sedentary lifestyle Calorie dense foods Low socioeconomic status >2 hours a day of television viewing

6. MEDICAL CONDITIONS ASSOCIATED WITH OBESITY

7. HEALTHCARE FINANCIAL BURDENS RELATED TO OBESITY Medical cost of obesity in the U.S was 147 billion dollars in 2008 (Center for Disease Control, 2014) Medical costs for people who are obese were $1,429 higher than those of normal weight in 2006 (CDC, 2014) North Americans spend $60 billion annually trying to lose pounds

8. METHODS TO DECREASE OBESITY National Institution of Health guidelines suggest non- pharmacologic treatment for at least 6 months which includes: Diet – Limitation of carbohydrates, Tracking of po intake (women 1200-1500kcal/day and Men 1500-1800kcal/day) Exercise- Encouraging at least 30 minutes of physical activities a day or 1 hour sessions 3x/week Behavior therapy and cognitive-behavioral methods to overcome barriers of weight loss Use of Commercial weight loss programs (ex: weight watchers)

9. WHAT TO DO WHEN ALL THE NON- PHARMACOLOGIC METHODS FAILS????

10. DRUG THERAPY Patient with BMI ≥30, or BMI ≥27 with other risk factors (eg, hypertension, diabetes, dyslipidemia), who did not lose weight after 6 months of non- pharmacologic treatment. Dietary therapy, physical activity, and behavioral therapy should be used cohesively with drug therapy

11. FIRST LINE DRUG IN WEIGHT MANAGEMENT Orlistat Brand Names: Xenical, Alli (OTC) Xenical: 120mg po 3 times daily with each main meal containing fat (during or up to 1 hour after meal) Suggested to omit dose if no fat in diet Alli: OTC Labeling: 60mg 3 times daily with each main meal containing fat

12. ORLISTAT XenicalAlli

13. BACKGROUND Lipase Inhibitor- Inhibits pancreatic lipase and fat absorption from the intestine. In April 1999, the FDA approved orlistat for long term use Is not an appetite suppressant and has a different mechanism of action; it blocks about one-third of fat absorption

14. INDICATION Rx: Obesity Management: encourage weight loss, weight management, reduce risk for weight regain after prior weight loss OTC: Enabling weight loss in overweight adults. Should be used cohesively with a reduce low calorie diet

15. SIDE EFFECT/RISK Abdominal bloating Abdominal pain and cramping Steatorrhea Fecal incontinence

16. DRUG MANAGEMENT /MONITORING BMI should be monitored- healthy weight loss is 1- 2lbs week Diet (calorie and fat intake) Thyroid Function- thyroid disease Liver function tests- especially patients exhibiting hepatic dysfunction Serum Glucose- diabetics Weight loss in diabetics may affect glycemic control

17. WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS Gallbladder Disease Malabsorption Disorders Impaired Liver Disease Pancreatic Disease

18. RELEVANCE TO NURSE PRACTITIONER PRACTICE Low Adverse Reactions Alternative to phentermine containing drugs Not a scheduled drug Allow NPs in prescriptive restrictive states to offer the medication

19. QSYMIA Phentermine 3.75mg/topiramate 23mg po daily for 14 days. Phentermine 7.5mg/topiramate 46mg po once daily for 12 weeks Phentermine 11.25mg/topiramate 69mg po for 14 days Phentermine 15mg/topiramate 92mg po once daily

20. BACKGROUND Sympathomimetic and anticonvulsant; Appetite suppressor Satiety enhancer

21. INDICATION Chronic weight management Adjunct to reduced calorie diet and increased physical activity, in patients with the following: BMI ≥30 or ≥27 and at least one weight-related comorbid condition (HTN, Dyslipidemia, type 2 diabetes )

22. WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS Cardiovascular effects CNS effects Glaucoma Hyperthermia Hypokalemia Hypotension Metabolic acidosis Renal calculi Suicidal ideation Abuse potential Withdrawal symptoms

23. SIDE EFFECTS Constipation Xerostomia Insomnia Paresthesia Dysgeusia Diarrhea Asthesnia Mood changes Concentration, memory, and speech difficulties

24. RELEVANCE TO NURSE PRACTITIONER PRACTICE Increase risk for an adverse reaction in patients with co-morbid diseases (cardiovascular disease, diabetes, stroke, and etc) Scheduled Drug C-IV NPs in prescriptive restrictive states will not be able to offer the medication to their patients

25. BELVIQ Belviq 10mg po twice daily Serotonin 5-HT2c receptor agonist; Leads to simulation of neurons in the hypothalamus, causing a decrease in food intake Anorexiant

26. INDICATION Chronic weight management Adjunct to reduced calorie diet and increased physical activity in patients with the following: BMI ≥30 or ≥27 and at least one weight-related comorbid condition (HTN, Dyslipidemia, type 2 diabetes )

27. WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS CNS effects Hematological effects Hyperprolactinemia Priapism Primary pulmonary hypertension Psychiatric disorders Serotonin Syndrome Valvular heart disease

28. SIDE EFFECT/RISK Dyspepsia Xerostomia Constipation Back pain Rhinitis

29. RELEVANCE TO NURSE PRACTITIONER PRACTICE Overall, has a low risk for adverse reactions. However, there is an increase risk for serotonin syndrome Scheduled Drug C-IV NPs in prescriptive restrictive states will not be able to offer the medication to their patients

30. CONTRAVE Naltrexone 8mg/bupropion 90mg po once daily Week 2 increase to 1 tablet twice daily Week 3 increase to 2 tablets in the morning and 1 tablet in the evening Week 4 and onward 2 tablets twice daily

31. BACKGROUND Anorexiant Antidepressant, dopamine/noreqpinephrine- reuptake inhibitor Opioid antagonist

32. INDICATION Adjunct to reduced calorie diet and increased physical activity in patients with the following: BMI ≥30 or ≥27 and at least one weight-related comorbid condition (HTN, Dyslipidemia, type 2 diabetes )

33. WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS Black Boxed Warning: Not approved for use in the treatment of major depressive or psychiatric disorders; it contains bupropion the same active ingredient in some other antidepressant medication. Antidepressants increase the risk of suicidal thinking and behavior in children, adolescent, and young adults with major depressive disorder and other psyciatric disorders

34. WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS Do not prescribed to individuals with the following: Chronic opioid Opiate agonist Acute opioid withdrawal Uncontrolled hypertension Seizure disorder Abrupt discontinuation of alcohol, benzodiazepines, and antiepileptic drugs

35. SIDE EFFECTS Nausea Constipation Headache Vomiting Dizziness Trouble sleeping Dry mouth Diarrhea Mood changes

36. RELEVANCE TO NURSE PRACTITIONER PRACTICE Increase risk for an adverse reaction in patients with mental illness and chronic pain. May causes seizures and increase blood pressure. Scheduled Drug C-IV NPs in prescriptive restrictive states will not be able to offer the medication to their patients

37. AFTER CONSIDERING ALL THE ANTI-OBESITY MEDICATIONS ON THE MARKET… DOES THE RISK OUTWEIGH THE BENEFITS? ARE THEY WORTH IT??