Ptx 1 Obesity Disorders

Front 1

Name 4 drug/drug types that have been used for wt loss?

Back 1

Amphetamins, adrenergic, fenfluramine, & orlistat

Front 2

What are the SE of amphetamines?

Back 2

Euphoria & addiction

Front 3

SE of adrenergic agents?

Back 3

HTN & arrhythmogenic

Front 4

SE of fenfluramine & orlistat?

Back 4

Valvular effects & steatorrhea

Front 5

What will long term treatment of obesity likely to require?

Back 5

Multiple drugs aimed at different targets

Front 6

A 35 year old female presents to her primary care physician seeking treatment for weight loss. She has tried several “fad diets” which incorporate the intake of low carbohydrates and has failed at each attempt. She states that she does exercise” when she finds the time”.

BMI = 32; Waist Circumference = 38 inches, BP = 167/99 and HR = 82
Labs:
TC 253 mg/dl
LDL 154 mg/dl
HDL 33 mg/dl
TG 267 mg/dl
ALT 23 IU/l
HgA1c 6.8 %
Gluc 109 mg/dl

What is the most appropriate weight loss goal for this patient?
a. 5-10% of body weight
b. 15-20% of body weight
c. 20-25% of body weight
d. BMI < 25

Back 6

The correct answer is a. By achieving 5-10% body weight loss, a significant change in comorbid conditions, such as her hypertension, may be accomplished. Although the other goals may be desirable, particularly to the patient, they may not be realistic and can set the patient up for what they consider failure and relapse. See objective 4.

Front 7

The patient is amenable to another attempt at lifestyle modifications. Which diet would be the most appropriate for this particular patient?
a. Low Fat
b. Low Carbohydrate
c. Balanced low calorie diet
d. A or C

Back 7

d. A or C
The correct answer is d. We know the patient has failed several attempts at a low carb diet. The one diet recommended for individuals is the one they will best adhere to. Therefore, either A or C may be a good choice for the patient. See objective 4.

Front 8

Once the diet has been implemented, is this patient also a candidate for weight loss medication?
a. Yes, she her BMI is greater than 27 and she has two comorbid conditions
b. No, her BMI is greater than 27, but she does not have two comorbid conditions
c. Yes, her BMI is greater than 30
d. No, her BMI is not greater than 35

Back 8

c. Yes, her BMI is greater than 30

Front 9

27. If Pharmacotherapy is deemed appropriate which medication below would be most correct to recommend?
a. Sibutramine
b. Orlistat
c. Phentermine
d. A or C

Back 9

b. Orlistat

The correct answer is b. We would rule out both sibutramine and phentermine given the fact that the patient has uncontrolled hypertension. See objective 4.

Front 10

Which of the following statements is FALSE?
a. If a patient being treated for obesity does not lose 2 lbs within the first 4 weeks of drug therapy, it is unlikely that drug therapy will be successful
b. Obesity-related risk factors include: coronary heart disease, Type 2 diabetes, hypertension and sleep apnea
c. Ghrelin regulates food intake and energy expenditure by acting as a satiety signal to decrease appetite in the CNS
d. Pharmacotherapy is indicated for patients who have a BMI > 30 or a BMI > 27 with concomitant obesity-related risk factors or diseases.

Back 10

c. Ghrelin regulates food intake and energy expenditure by acting as a satiety signal to decrease appetite in the CNS

Ghrelin is a neurotransmitter that stimulates food intake.

Front 11

Which of the following statements is FALSE?

a. Patients taking orlistat should be counseled to expect gastrointestinal side-effects such as oily spotting, abdominal pain, flatus with discharge; which should improve over time
b. Sleep deprivation, viruses, and toxins are potential environmental factors that may contribute to obesity
c. The goals of therapy for obesity include: prevent further weight gain, reduce body weight by 10% in the first 6 months, and maintain a lower body weight, long term
d. Sibutramine is a safe drug therapy for treatment of obesity in patients with uncontrolled hypertension

Back 11

d. Sibutramine is a safe drug therapy for treatment of obesity in patients with uncontrolled hypertension

Answer d is correct. Sibutramine has the potential to raise blood pressure and therefore should be avoided in patients with uncontrolled hypertension.

Front 12

Ms. White is a 42 year-old white female with a medical history significant for hypertension and sleep apnea. Her current body weight is 190 lbs, BMI is 33 and waist circumference is 37 inches. Ms. White’s blood pressure today is 148/92 mmHg. Current medications include: lisinopril 20 mg qd, HCTZ 12.5 mg qd and Yasmin (an oral contraceptive pill containing ethinyl estradiol and drosperinone). Ms. White states that she has struggled with her weight and has been on and off diets all of her life. While she tries to eat healthy she admits that there are numerous high fat foods that she just “cannot give up”. She states that she power- walks during her lunch hour 5 days per week for 30 minutes. This has helped her keep her weight from going up. It is noted that Ms. White’s insurance does not cover prescriptions for weight loss. Dr. Albert has asked for your assistance in selecting a drug therapy.

Which pharmacological strategy is most appropriate for Ms. White?
a. Alli (Orlistat) 60 mg three times daily with fat-containing meals only
b. Phentermine 15 mg every morning
c. Sibutramine 10 mg every morning
d. Do not start drug therapy in this patient because she does not meet the National Institutes of Health obesity guideline criteria for pharmacotherapy.

Back 12

d. Do not start drug therapy in this patient because she does not meet the National Institutes of Health obesity guideline criteria for pharmacotherapy.

A, This patient does not have any contraindications to use orlistat; whereas, all other approved drug therapies for treatment of obesity may increase the risk to raise BP.
B, Phentermine would not be a good choice because of its potential to raise blood pressure and this patient has uncontrolled HTN
C, Sibutramine would not be a good choice because of its potential to raise blood pressure and this patient has uncontrolled HTN
D, This patient meets the criteria for drug therapy in that he has failed diet and exercise and has a BMI > 30 or BMI > 27 with risk factors (sleep apnea, HTN)

Front 13

Which of the following statements is FALSE ?
a. If a patient being treated for obesity does not lose 2 lbs within the 1st 4
weeks of drug therapy, it is unlikely that drug therapy will be successful.
b. Obesity related risk factors include: coronary heart disease, Type 2
diabetes, hypertension and sleep apnea.
c. Leptin regulates food intake and energy expenditure by acting as a satiety
signal to decrease appetite in the CNS.
d. Pharmacotherapy is indicated for patients who have a BMI ≥ 25 or a
BMI ≥ 27 with concomitant obesity related risk factors or diseases.

Back 13

d. Pharmacotherapy is indicated for patients who have a BMI ≥ 25 or a
BMI ≥ 27 with concomitant obesity related risk factors or diseases.

d. Pharmacotherapy is indicated in patients who have a BMI ≥ 30 or a BMI ≥ 27
with concomitant obesity related risk factors or diseases.

Front 14

Which of the following statements is FALSE?
a. Patients taking orlistat (xenical) should be counseled to expect GI sideeffects
such as oily spotting, abdominal pain, flatus with discharge; which
should diminish over time.
b. Sleep deprivation, viruses and toxins are potential environmental factors
that may contribute to obesity.
c. The goals of therapy for obesity include: prevent further weight gain,
reduce body weight by 10% in the first 6 months and maintain a lower
body weight, long term.
d. Sibutramine (Meridia) is a safe drug of therapy for treatment of obesity in patients with uncontrolled hypertension

Back 14

d. Sibutramine (Meridia) is a safe drug of therapy for treatment of obesity in patients with uncontrolled hypertension

d. sibutramine has the potential to raise blood pressure and therefore should be avoided in patients with uncontrolled hypertension.

Front 15

Mr. Fulmore is a 52 year old white male with a past medical history of Type 2
diabetes, hypertension, and sleep apnea. Current wt= 280 lbs, BMI = 38 and waist
circumference = 46”. Blood pressure today is 166/92 mmHg. Current medications
include: glucophage (Metformin) 850 mg tid, Glucotrol (glipizide) 10 mg qd and
pioglitazone (Actos) 30 mg qd. Mr. Fulmore has tried “every diet under the sun
(including the Dunkin Donuts only diet) ” over several years with little success. He
walks for 45 minutes/ 5 days per week. This has helped him lose 40 lbs. Dr. Albert
has asked for your assistance in choosing a drug therapy. Mr. Fulmore states that
he has a terrific health insurance plan through the state of Tennessee.
a. Orlistat (Xenical) 120 mg tid with high-fat meals only
b. Phentermine (Adipex) 15 mg q am
c. Sibutramine (Meridia) 10 mg q am
d. Do not start drug therapy in this patient because he does not meet the NIH
obesity guideline criteria for pharmacotherapy.

Back 15

a. Orlistat (Xenical) 120 mg tid with high-fat meals only

a. This patient does not have any contraindications to use orlistat; whereas, all other
approved drug therapies for treatment of obesity may increase the risk to raise
BP.
b. Phentermine would not be a good choice because of it’s potential to raise blood
pressure and this patient has uncontrolled HTN
c. Sibutramine would not be a good choice because of it’s potential to raise blood
pressure and this patient has uncontrolled HTN
d. This patient meets the criteria for drug therapy in that he has failed diet and
exercise and has a BMI > 30 or BMI > 27 with risk factors (HTN, Type 2 DM,
sleep apnea)

Front 16

Mr. Fulmore is a 52 year-old white male with a past medical history of Type 2 diabetes mellitus, hypertension, sleep apnea and cholestasis. Current weight is 280 lbs, BMI is 38 kg/m2 and waist circumference is 46 inches. Blood pressure today is 166/92 mmHg. Current medications include: metformin 850 mg tid, glipizide 10 mg qd and pioglitazone 30 mg qd. Mr. Fulmore has tried “every diet under the sun (including the Dunkin’ Donuts only diet)” over several years with little success. He walks for 45 minutes for 5 days per week which has helped him lose 40 lbs. Dr. Albert has asked for your assistance in choosing a drug therapy for this patient. Mr. Fulmore states that he will pay cash for any medications needed to help him lose weight. What would be the most appropriate choice for this patient?
A. Orlistat 120 mg tid with high-fat meals only
B. Diethylpropion CR 75 mg qam
C. Sibutramine 10 mg qam
D. Do not start drug therapy in this patient because he does not meet the NIH obesity guideline criteria for pharmacotherapy.

Back 16

Answer A is correct.
A. This patient does not have any contraindications to orlistat use; whereas, all other approved drug therapies for treatment of obesity of the risk to increase blood pressure.
B. Diethylpropion would not be a good choice because of its potential to raise blood pressure and this patient has uncontrolled hypertension
C. Sibutramine would not be a good choice because of it’s potential to raise blood pressure and this patient has uncontrolled hypertension
D. This patient meets the criteria for drug therapy in that he has failed diet and exercise and has a BMI > 30 or BMI > 27 with risk factors (hypertension, Type 2 diabetes mellitus, sleep apnea)
Note: this patient needs to be started on antihypertensive therapy.

Front 17

w/ current available pharmacologic therapies, what is the % of wt loss? Maximal effect occurs when?

Back 17

4-6% w/ maximal effect occurring w/n the 1st yr

Front 18

Do these meds work for everyone who takes them?

Back 18

No significant portion experiencing no wt loss.

Front 19

What is the criterion for the current available wt loss meds?

Back 19

Criterion of a 4 lb loss in 4 wks

Front 20

If this criterion is not met, what does it mean? What should be the next step?

Back 20

Then this is good evidence that the meds are not working & therefore should be stopped

Front 21

To consider the Rx medically effective, many MDs require what amount of wt loss?

Back 21

A minimum of 4 lb a month for 3 months

Front 22

Upon cessation of Tx, % who regain the wt?

Back 22

>90% regain the wt

Front 23

Wt loss meds are usually reserved for who?

Back 23

For those who have failed diet & exercise combo

Front 24

What are the meds that have been approved by the FDA specifically for wt loss?

Back 24

Phentermine, sibutramine, & orlistat

Front 25

What is the MOA of phentermine?

Back 25

It’s an adrenergic reuptake inhibitor; it’s thought to promote wt loss by activation of the sympathetic nervous system

Front 26

Phentermine has been approved by the FDA for what length of time to be used?

Back 26

3 months

Front 27

What is the brand name of phentermine?

Back 27

Adipex-P, Oby-Cap, T-Diet, Zantryl

Front 28

What are the SE of phentermine?

Back 28

Since it’s an adrenergic agonist, it can be associated w/ tachycardia & HTN

Front 29

What should be done w/ patients on phentermine therapy?

Back 29

It is good practice to monitor the pulse and blood pressure of patients closely during the first few weeks of phentermine therapy.

Front 30

w/c drug is the most prescribed wt loss therapy? Why?

Back 30

Phentermine b/c it’s the least expensive since there are several generic formulations available

Front 31

What are the 2 major forms of phentermine?

Back 31

Phentermine resin (lonamin) & phentermine HCl

Front 32

Therapeutic response of phentermine is considered how much wt loss?

Back 32

4 lbs/4wks for at least the first 8-12 wks

Front 33

Name the 5 drugs approved by the FDA for other indications but exhibit wt loss promoting effects? Know the generic & brand names?

Back 33

Generic Name: bupropion (byoo PRO pee on)
Brand Names: Aplenzin, Budeprion, Wellbutrin, Zyban

metformin (glucophage), Generic Name: exenatide (ex EN a tide)
Brand Names: Byetta Prefilled Pen

Generic Name: topiramate (toe PYRE a mate)
Brand Names: Topamax, Topamax Sprinkle, Topiragen

Generic Name: zonisamide (zoe NIS a mide)
Brand Names: Zonegran

Front 34

w/c wt loss drugs or drugs that have wt loss effects should not be given to pts taking MAO inhibitors?

Back 34

Generic Name: phentermine (FEN ter meen)
Brand names: Adipex-P, Oby-Cap, T-Diet, Zantryl

Generic Name: sibutramine (si BUE tra meen)
Brand Names: Meridia

bupropion

Front 35

bupropion is CI in w/c pts?

Back 35

Bipolar dz & those taking MAO inhibitors

Front 36

MOA of sibutramine?

Back 36

It’s MAO inhibitor, enhances adrenergic, serotonergic, & dopaminergic signaling in the brain

Front 37

Brand name of sibutramine?

Back 37

Meridia

Front 38

What is the avg loss w/ sibutramine?

Back 38

5-8%

Front 39

What happens w/ sibutramine extension therapy for up to 2 yrs?

Back 39

It’s associated w/ an avg regain of approximately ½ the wt lost initially

Front 40

What is the normal dosing for sibutramine in adults?

Back 40

10-15 mg/d taken once daily.

Front 41

Sibutramine is currently approved by the FDA for up to ______ ________ of treatment (amount of time)?

Back 41

Up to 1 yr

Front 42

What are the SE of sibutramine?

Back 42

Relate to its adrenergic properties such as HTN but <3% of pts stop the drug for uncontrolled HTN. Some may experience tachycardia so this med should be avoided in those pts who have uncontrolled tachycardia or won’t tolerate it

Front 43

What is CI w/ sibutramine?

Back 43

SSRI b/c it increases the risk of serotonin syndrome

Front 44

What is serotonin syndrome?

Back 44

Marked by combo of flushing, diarrhea, & hypotension

Front 45

MOA of orlistat?

Back 45

It’s an inhibitor of pancreatic & intestinal lipases present in the intestinal lumen so it prevents the breakdown of ingested TG into absorbable FA & monoacylglycerols.

Front 46

What is the brand name of orlistat?

Back 46

Xenical, alli

Front 47

How should orlistat be taken?

Back 47

Should be taken w/ meals 3x/day

Front 48

What are the SE of orlistat?

Back 48

Flatulence, steatorrhea, increased stool frequency, fecal incontinence, & oily rectal discharge. There is an associated malabsorption of DAKE vitamins

Front 49

What should be given to patients who are taking orlistat?

Back 49

Supplement enriched w/ DAKE w/c should be given at least 2 hours before or after each orlistat dose.

Front 50

What should be measured before starting orlistat? Why?

Back 50

Because of the higher rate of vitamin D deficiency in people with obesity and the associated risk of metabolic bone disease, vitamin D levels should be measured before starting orlistat and periodically (eg, every six months) during therapy.

Front 51

What is the MOA of lorcaserin?

Back 51

Selective agonist of the 5-HT2C serotonin R

Front 52

MOA of naltrexone? Used for what?

Back 52

Opioid R antagonist that has been used as an adjunctive therapy for substance abuse Tx & addiction

Front 53

Naltrexone along w/ what other drug has been shown to have significan wt loss?

Back 53

Along w/ bupropion

Front 54

What other drug combo have been shown to have wt loss effects?

Back 54

Phentermine & topiramate

Front 55

What dosage has been given of the phentermine/ topiramate combo for wt loss?

Back 55

Doses given were lower than the typical doses used for monotherapy w/ each drug.

Front 56

What are some drugs that have been discredited for wt loss?

Back 56

Fenfluramine & dexfenfluramine

Front 57

brand name of dexfenfluramine

Back 57

(Redux)

Front 58

What were the major complications of ephedrine & pheylprpanolamine?

Back 58

Increased risk of CV complications including strokes & life threatening arrhythmias

Front 59

Name the drugs that are in the reading that are associated w/ wt gain?

Back 59

Steroid hormones, thiazolidinediones, DM agents, psychotropic drugs

Front 60

What are the psychotropic meds that cause wt gain?

Back 60

Olanzapine, valproic acid, lithium, phenothiazine, AD

Front 61

What drugs maybe used in conjunction w/ bypass gastric surgery? What should not be used?

Back 61

Phentermine, sibutramine, & topiramate. Orlistat is not recommended

Front 62

How much is lost after Roux-en-Y gastric bypass?

Back 62

65-70% w/n 1-2yrs

Front 63

Know the BMI & their classifications?

Back 63

Front 64

3. Know the BMI category for children?

Back 64

Front 65

How do you calculate BMI?

Back 65

Pt’s wt in kg/height in meters squared

Front 66

Define BMI for obesity?

Back 66

BMI > or equal to 30

Front 67

When looking at ethnic groups, who has the highest prevalence for being over wt?

Back 67

native americans

Front 68

W/c ethnic group has the lowest over wt prevalence?

Back 68

Asian

Front 69

Formula to calulate BMI

Back 69

BMI = ( Weight in Pounds / ( Height in inche )2) x 703 OR Weight (kg) / (Height (m))2

Front 70

How is weight calssified in infants

Back 70

Weight for length; overweight is 95%

Front 71

What are the contributing factors for obesity

Back 71

genetic/in-utero; energy intake>expenditure, poor diet

Front 72

What are the secondary causes for obesity

Back 72

Hypothyroidism, Cushing’s syndrome, Lesions of the hypothalamus, Medications (Diabetes treatment, Antipsychotics)

Front 73

What are the complications of obesity

Back 73

CV, diabetes, asthma, gallbladder disease, PCOD, osteoarthritis, sleep apnea, fatty liver, psychological

Front 74

What are the clinical criteria for pharmacologic therapy

Back 74

BMI >30 or BMI>27 with medical complications , failure of behavioral approaches, no strong contraindications, 4-pound weight loss per month for each of the first 3 months, waist circumference (>35” in women, >40” in men)

Front 75

At what stage in the treatment of children, is medication an option, what is the medication

Back 75

Stage 4, Orlistat for 12+yo

Front 76

Most common FDA approved medication for weight loss

Back 76

Phentermine (Brand names: Adipex-P, Atti Plex P, Ionamin, Kraftobese, Panshape M, Phentercot, Phentride, Pro-Fast, Raphtre, Supramine, Tara-8, Teramine, Termene)

Front 77

In phentermine therapy, what drug is contraindicated

Back 77

MAO inhgibitors

Front 78

Brand: Amphetamine/Dextroamphetamine

Back 78

Adderall

Front 79

Brand: Benzphetamin

Back 79

Didrex

Front 80

Brand: Phendimetrazine

Back 80

Bontril

Front 81

Brand: Diethylpropion

Back 81

Tenuate

Front 82

Brand: Methampetamin

Back 82

Desoxyn

Front 83

Brand: Dextroamphetamine

Back 83

Dexadrine

Front 84

Brand: Naltrexone-buropion

Back 84

Contrave (not approved by FDA)

Front 85

Brand: Phentermine-topiramate

Back 85

Qnexa (not approved by FDA)

Front 86

Brand: Sibutramine

Back 86

Meridia

Front 87

Why was Fenfluramine removed

Back 87

cardiac valvular defects

Front 88

Why was Ephedrine and phenylpropanolamine removed

Back 88

increased risk of cardiovascular complications

Front 89

Why was Sibutramine removed

Back 89

increased risk of uncontrolled hypertension

Front 90

What is currently in a SCOUT

Back 90

Sibutramine; (Sibutramine Cardiovascular OUTcomes) trial

Front 91

Brand and primary indication: Bupropion

Back 91

Aplenzin, Budeprion., Buproban, Wellbutrin, Zyban; Depression

Front 92

Brand and primary indication: Metformin

Back 92

Fortamet, Glucophage, Glumetza; Type 2 Diabetes

Front 93

Brand and primary indication: Exenatide

Back 93

Byetta injection; Type 2 Diabetes

Front 94

Brand and primary indication: Topiramate

Back 94

Topamax, Topiragen; Seizure disorder, migraine headaches

Front 95

Brand and primary indication: Zonisamide

Back 95

Zonegran; seizure disorder

Front 96

Steriod hormones associated with weight gain

Back 96

Glucocorticoids, Progesteron

Front 97

Neurotropic and psychotropic medication associated with weight gain

Back 97

Olanzapine (Zyprexa), Clozapine (Clozaril), Valproid acid (Depakote), Lithium, Phenothiazines

Front 98

Diabetes treatment associated with weight gain

Back 98

Sulfonylureas, Insulin, Thiazolidinediones (Actos, Avandia)

Front 99

OTC treatment of obesity; approved

Back 99

Alli (Orlisatat ); 18+yo

Front 100

OTC treatment of obesity; removed

Back 100

Phenylpropanolamine (PPA), Ephedra (Ma Huang or Heartleaf)

Front 101

OTC treatment of obesity; other (with minimal effect)

Back 101

Fiber (Glucomannan and psyllium), caffiene (Methylxanthine, Dexatrim ephedra free formula), Green Tea (Dexatrim Green Tea Formula, Dexatrim ephedra free formula), Bitter orange, Chitosan, Chromium, laxatives, diuretics, hoodia gordonii

Front 102

What product is typically abused by teenage girls for weight loss

Back 102

Syrup of Ipecac

Front 103

What is the future for development of new obesity drugs

Back 103

Central Melanocotin Pathway, neurons which control appetite and energy expenditure

Front 104

What is currently undergoing study fior the future of wieght loss medication

Back 104

1. Ciliary Neutrophic Factor
2. Melanocortin-4 receptor agonist
3. Ghrelin
4. Neuropeptide Y antagonists
5. Melanin-concentrating hormone agonists
6. Peptide YY

Front 105

know the drugs associated w/ wt gain?

Back 105

Front 106

a combo of fenfluarmine & what other drug was shown to have improved wt loss effects?

Back 106

phentermine

Front 107

who needs to be treated for obesity?

Back 107

Front 108

what are the non PTX treatments that can be used for obesity?

Back 108

Front 109

Surgery for obesity is reserved for w/c group of people?

Back 109

Surgery for people who have BMI >40

Front 110

is there any drug interactions w/ orlistat?

Back 110

Will interfere w/ DAKE vitamins & will decrease [ ] of cyclosporin

Front 111

how can u treat the SE of orlistat?

Back 111

w/ low fat meals & psyllium

Front 112

What is the generic for Adipex-P?

Back 112

phentermine

Front 113

Adipex can suppress appetite for how many hours?

Back 113

12-14 hours

Front 114

Adipex P is considered what schedule drug?

Back 114

Schedule IV

Front 115

What are the DI for sibutramine?

Back 115

SSRIs, MAOIs, dextromethorphan, sumatriptan, meperidine, fentanyl, lithium

Front 116

What are the SE of sibutramine?

Back 116

Insomnia, constipation, dry mouth, increase in BP & pulse

Front 117

Sibutramine is CI in w/c group of people?

Back 117

Those w/ uncontrolled HTN, seizure disorders, narrow angle glaucoma, severe renal & hepatic dysfunction, CHF, arrhythmias, stroke, Hx of substance abuse

Front 118

Orlistat is approved by the FDA for what age of children?

Back 118

12 years & older

Front 119

what is the age group for Alli?

Back 119

18 years & older

Front 120

How does caffeine work in wt loss?

Back 120

Increases lypolysis, circulating FA levels, & oxygen consumption.

Front 121

This weight loss product may increase bleeding time?

Back 121

Green tea so it should be stopped 24 hours before surgery

Front 122

This product works in wt loss by increasing thermogenesis of brown adipose tissue?

Back 122

Bitter orange