jessica fordham, msn, aprn, fnp-c mississippi university for women 12/02/14 treating obesity...

J E S S I C A F O R D H A M , M S N , A P R N , F N P - CM I S S I S S I P P I U N I V E R S I T Y F O R W O M E N

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TREATING OBESITY PHARMACOLOGICALLY

THE DREAM

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

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

RISK FACTORS

• Parental obesity• Sedentary lifestyle• Calorie dense

foods• Low socioeconomic

status• >2 hours a day of

television viewing

MEDICAL CONDITIONS ASSOCIATED WITH OBESITY

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

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)

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

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

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

ORLISTAT

Xenical Alli

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

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

SIDE EFFECT/RISK

• Abdominal bloating • Abdominal pain

and cramping• Steatorrhea• Fecal incontinence

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

WARNINGS AND PRECAUTIONS/CONTRAINDICATIONS

• Gallbladder Disease• Malabsorption

Disorders• Impaired Liver

Disease• Pancreatic Disease

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

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

BACKGROUND

•Sympathomimetic and anticonvulsant;•Appetite suppressor•Satiety enhancer

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)


• Cardiovascular effects• CNS effects• Glaucoma• Hyperthermia• Hypokalemia• Hypotension

• Metabolic acidosis• Renal calculi• Suicidal ideation• Abuse potential• Withdrawal

symptoms

SIDE EFFECTS

• Constipation• Xerostomia• Insomnia• Paresthesia• Dysgeusia• Diarrhea• Asthesnia• Mood changes• Concentration, memory, and speech difficulties


• 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

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

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-



• CNS effects• Hematological effects• Hyperprolactinemia• Priapism• Primary pulmonary hypertension• Psychiatric disorders• Serotonin Syndrome• Valvular heart disease

SIDE EFFECT/RISK

•Dyspepsia•Xerostomia•Constipation•Back pain•Rhinitis


• 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


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

BACKGROUND

•Anorexiant•Antidepressant, dopamine/noreqpinephrine-reuptake inhibitor•Opioid antagonist

INDICATION

• Adjunct to reduced calorie diet and increased physical activity in patients with the following:• BMI ≥30 or ≥27 and at least one weight-



• 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


• 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

SIDE EFFECTS

• Nausea• Constipation• Headache• Vomiting• Dizziness• Trouble sleeping• Dry mouth• Diarrhea• Mood changes


• 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


AFTER CONSIDERING ALL THE ANTI-OBESITY MEDICATIONS ON THE MARKET… DOES THE RISK

OUTWEIGH THE BENEFITS? ARE THEY WORTH IT??

jessica fordham, msn, aprn, fnp-c mississippi university for women 12/02/14 treating obesity...

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