FM Weight Management

Phentermine

• Brands:
  • Adipex-P, Fastin Dose:
    • 15-37.5 mg/day give in 1-2 divided doses
      
    • Administer before breakfast or 1-2 hours after breakfast
  • Lomaira dose:
    • 8 mg, 30 minutes before each meal (3x daily)
• MOA:
  • Increase NE and DA release = decrease appetite (NE suppresses hunger)
• Adverse Reactions:
  • Insomnia (due to increased NE), HTN, palpitations, arrhythmias, dry mouth, constipation
    
  • ~ all related to the sympathomimetic effect
• FDA approved for:
  • Short-term monotherapy (< 12 weeks)
• Contraindications:
  • CVD hx
    
  • Hyperthyroidism
    
  • Pregnancy

Orlistat

• Brands:
  • Xenical Dose:
    • 120 mg TID with each meal containing fat
  • Alli dose (OTC):
    • 60 mg TID with each meal containing fat
• Timing:
  • Take during or up to 1 hour after the meal
• Adverse Reactions:
  • GI effects, oily spotting, fecal urgency/incontinence, Cholelithiasis
  • Commonly discontinued due to Adverse reactions (stomach problems)
• Contraindications:
  • Malabsorption syndrome
    
  • Gallbladder disease/cholestasis
• Weight loss benefits:
  • 3.45 kg (7.6 pounds)
• Benefits:
  • approved in adolescents (12-16 years of age)
  • improves lipid profile, BP and glucose control
• Drug Interactions:
  • Warfarin and malabsorption of fat-soluble vitamins (Vitamins ADEK required 2 hours before/after dose)
• Stopping rules:
  • No guidance; no tapering required

Contrave

• Chemical:
  • Naltrexone/Bupropion
  • 1 tablet = 8/90 mg
• Dosing titration with Contrave:
  • 4-week titration
  • 1 tablet (8/90 mg) once daily (in AM) x 1 week
    
  • Then 1 tablet in the AM and 1 tablet in PM x 1 week = 16/180 mg)
    
  • Then 2 tablets (16/180 mg) in the AM and 1 tablet (8/90 mg) in the evening x 1 week
    
  • Finally = 2 tablets BID (16/180 mg in the morning and PM) (Total = 32/360 mg daily)
• Adverse Reactions:
  • N/V, depression, insomnia, constipation, HA, Suicide ideation, mood swings, seizures (bupropion)
• Effectiveness:
  • 4.1 kg (9 lbs) –> little better than phentermine, orlistat, and lorcaserin
• Contraindications:
  • Chronic opioid use (will precipitate withdrawal), history of seizures (bupropion), anorexia or bulimia (bupropion), uncontrolled HTN, and pregnancy
    
  • MAOIs (14 day washout period)
• Black Box Warning:
  • Suicidal ideation
• Patient tolerance: 
  • Not well (1 out of 9 discontinued because of ADRs)
• Stopping rules:
  • d/c if < 5% weight loss achieved at 12 weeks

Surgical Indications to lose weight

• Surgical procedures for weight loss should be reserved for patients in whom medical weight loss treatment has failed, and who are suffering from complications of extreme obesity.
• Bariatric surgery
  • can be considered an option for patients with a BMI ≥ 40, or ≥ 35 if cardiovascular risk factors or comorbidities are present such as DM. 
• Gastric bypass
  • has been shown to be more effective than gastric banding for weight loss and requires fewer surgeries for revision, but has more side effects.

Underweight

• High-­fat foods do not necessarily help an underweight person gain weight because they cause the person to feel full for long periods and therefore can act as an appetite suppressant
• Snacks or small frequent meals may help and should be taken at least two hours before the next meal
• Adding calories without adding volume to liquids consumed may be effective (e.g., adding powdered milk to regular milk to increase protein calories)