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26 Cards in this Set

  • Front
  • Back
Obesity Increases risk of:
HTN
Type 2 diabetes
coronary heart disease
gallbladder disease
certain cancers
dyslipidemia
stroke
osteoarthritis
sleep apnea
Overweight/Obese BMIs
Overweight 25-29.9
Obese > 30

BMI = weight (kg) / height (m2)
Waist circumference high risk for men and women
Men > 40 inches
Women > 35 inches
Assessment of Weight
BMI
Waist
Disease conditions (CHD, DM, OSA)
other obesity associated sieases (gynecological abnormalities, osteoarthritis)
CV risk factors
Other risk factors (inactivity, high TG)
Management goals
prevent further weight gain
reduce body weight
maintain lower body weight over long term
Realistic Target Weight Goals
Short term: 5-10 percent loss (1-2 lbs a week)
Interim goal: maintenance
Long term: additional weight loss, maintenance

Decrease BW by 10%
Strategies for Weight Loss and Maintenance
Dietary therapy
physical activity
behavior therapy
combined therapy
weight loss surgery
Pharmacotherapy
Lipase Inhibitor
Orlistat-Xenical

GI lipases (gastric, pancreatic, carboxylester) are essential for LCT absorption
MOA of Lipase inhibitors
results in decreased FFA formation from dietary TG

lowers dietary fat absorption (need to have fat in food to exert effect)

30% decrease in fat absorption daily
SE of Lipase inhibitors
soft stools
diarrhea
ab pain/colic
fecal urgency
incontinence
most common in first 1-2 months

Malabsorption of fat soluble vitamins may occur
Drug Interactions: Lipase inhibitors
Cyclosporine--decrease in cyclosporine concentration
Noradrenergic-Serotonergic Agent
Sibutramine- Meridia
w/drawn from market--raises risk of HA and stroke, little benefit
Contrave
Combines naltrexone and buproprion to suppress food cravings
FDA asked for further trials to check for CV risk
Evidence Category B
BMI > 30 w/ no concomitant risk factors or disease
BMI > 27 w/ other risk factors or disease (HTN, dyslipidemia, CHD, DM, sleep apnea)
Evidence Category A interventions
caloric deficit diet
increased physical activity
behavioral treatment
ALLHAT Trial Implications
Systolic BP more difficult to control than diastolic
Avg 2 drugs required for BP control in 2/3 of patients, primarily to control systolic

Chlorthalidone decreased systolic most
Amlodipine decreased most diastolic
ACCOMPLISH Study Implications
In high risk pts with stage 2 HTN--ACEI + CCB seem better than diuretic + ACEI
But large number of diabetics in study, though same results for rest of the group
STITCH Study
4 Step algorithm for therapy:
1. low dose 2 drugs: ACEI-diuretic, ARB/diuretic
2. increase dose
3. Add CCB and increase
4. Add one of non first line
--alpha blocker, BB, spironolactone

more decrease in STITCH than guideline group
Cardio-SIS Trial
Analyzed if <140/90 is an appropriate goal--pushing < 140/90 does not reduce total mortality or other endpoints
J Curve
Minimum threshold may exist for BP, particularly in pts with heart disease
If less than 110-120 SBP and < 60-70 DBP increases risk of future CV events
ACCORD BP
Is < 130/80 optimal goal in pts with diabetes? Flaw in trial..didn't test 130/80 as goal
Elderly considerations in treatment
Low and slow
promote lifestyle modifications
Target < 140/90
AE more common
Diuretics in Elderly
low slow
decrease morbidity and mortality
greater reduction in SBP
Monitor electrolytes, lipids, glucose
Children and Adolescents
95th percentile is stage 1, 99th stage 2
Lifestyle modifications
Attempt to determine other causes of high BP and CV risk factors
BB preferred
Valsartan approved
Drugs started for Stage 2, stage 1 if asymptomatic or unresponsive to lifestyle changes
Pregnancy
differentiate between eclampsia and HTN
ACE and ARB contraindicated
Methyldopa recommended for HTN diagosed during pregnancy
BB (metroprolol, labetolol)
Diuretics: okay if prescribed before gestation and volume depletion avoided
Hydralazine: parenteral drug of choice
Causes for inadequate response to drug therapy
Pseudoresistance: white coat HTN, improper technique
Nonadherence
volume overload: salt intake, renal disease
drug related causes: dose, NSAIDs
associated conditions: smoking, sleep apnea, insulin resistance, ethanol, chronic pain