Antiobesity

• Definitions
  • Normal Weight: 18.5-24.9 kg/m^2
  • Overweight: 25-29.9 kg/m^2
    • Measure waist + co-morbidities
    • 25-26.9 + co-morbidities: Lifestyle
    • 27-29.9 + co-morbidities: Lifestyle + Pharmacotherapy
  • Obese: ≥30 kg/m^2
    • Class 1: 30-34.9 kg/m^2
      • Lifestyle + Pharmacotherapy
    • Class 2: 35-39.9 kg/m^2
      • ≥5-10% over 6m goal
      • Healthy: Lifestyle + Pharmacotherapy
      • With co-morbidities: Bariatric Surgery
    • Class 3: ≥40 kg/m^2
      • Bariatric Surgery
• Bariatric Surgery
  • Resolves T2DM in 73%, HTN 63%, OSA 78%, fertility, decreased 4.5y mortality
  • Roux-en-Y gastric Bypass = best, 1yr: 31.2% reduction of weight, 25.5% at 5y
  • Sleeve: 1yr: 25.2% reduction of weight, 18.8% at 5y
  • Adjustable gastric band: 1yr: 13.7% reduction of weight, 11.7% at 5y
  • Thiamine: 12-50mg daily, B12 500mcg daily or 1000mcg monthly, Folate: 400-800mcg daily, vitamin A:5000-10000 IU daily, Vitamin E: 15mg daily, VitK: 90-120mcg daily, D3: 3000IU daily, Calcium: 500-600mg TID, Iron: 18mg-60mg daily, Zinc: 8-22mg daily, Copper 1-2mg daily (8 to 1mg with zinc to prevent copper deficiency)
    • Labs 3-6m in 1st year, Q6 after
    • CBC, CMP, pre-albumin, b12, thiamine, folate, vitamin A and D, PTH, iron, ferritin
• Lifestyle
  • Reduction in 500-750 kcal/day = 1-2 lbs per week
  • 150 up to 300 minutes per week
• Orlistat (Xenical, Alli)
  • Indicated for use ≥3 months
  • Lipase Inhibitor
    • Lowers BP ~10mmHg, reduces total cholesterol, LDL, triglycerides, risk of progression to diabetes, reduces need for diabetes meds
  • 60mg TID to 120mg TID
  • -2.6kg at 6m, -2.9kg at 12m
  • SE: Liver injury, Diarrhea, flatulence, fecal urgency, dyspepsia
• Phentermine/Topiramate (Qsymia/Qnexa)
  • Approved for use ≥3m and <3m
  • Appetite suppressant
    • Positive effect on CV outcomes, Lowers BP and decreases need for BP meds, increases HR slightly at max dose, reduces need for diabetes meds
  • 8mg TID to 37.5mg daily
  • 5/46mg daily recommended, 15/92mg daily max
    • 1kg at 12m at recommended, -10.2 kg at 12m at max
  • SE: constipation, xerostomia, dizziness, seizure, insomnia, depression, hypohidrosis, angle closure glaucoma, birth defects
• Naltrexone/Bupropion (Contrave)
  • Approved for use ≥3m
  • Appetite suppressant, opioid antagonist/aminoketone antidepressant
    • No CV benefits, reduces waist circumference, triglycerides, and HDL, reduces need for diabetes meds
  • 16/180mg BID
  • -4.1kg at 12m
  • SE: Nausea, constipation, headache, vomiting, seizures, hepatotoxicity, increased BP and HR
• Liraglutide (Saxenda)
  • Appetite suppressant; GLP-1 receptor agonist
    • reduces waist circumference, Lowers BP, reduces LDL and triglycerides, risk of progression to diabetes
  • Approved for use ≥3m
  • 3mg subq daily
  • -4.5kg at 12 months
  • SE: Nausea, hypoglycemia, diarrhea, constipation, headache, pancreatitis, GB disease, thyroid carcinoma, Thyroid tumors
• Semaglutide (Wegovy)
  • Appetite suppressant; GLP-1 receptor agonist
  • Approved for use ≥3m
  • 4mg subq weekly
  • -15.3kg at 14 months
  • SE: Nausea, hypoglycemia, diarrhea, constipation, headache, pancreatitis, GB disease, thyroid carcinoma, Thyroid tumors
• Diethylpropion
  • FDA approved for <3m
  • 25mg TID
  • SR: 75mg daily
• Phendimetrazine
  • FDA approved for <3m
  • 5-70mg BID to TID
  • SR: 105mg daily
• Benzphetamine
  • FDA approved for <3m
  • 20-50mg daily to TID
• Cetilistat
• Lorcaserin (Belviq)
• Metformin
• Exenatide