Cardiology: obesity

what is considered BMI underweight?

<18.5

what is considered BMI healthy weight and the recommendation?

18.5-24.9, healthy meal plan and physical activity

what is considered BMI overweight and the recommendation?

25-29.9, LSM, reduced calorie healthy meal plan, physical activity, behavioral intervention

what is considered BMI obesity and the recommendation?

LSM + anti-obesity meds if LSM fails

what is considered BMI obesity class 1 and the recommendation?

30-34.9, LSM + antiobesity meds if target not met

what is considered BMI obesity class 2 and the recommendation?

35-39.9, LSM + AOM if target not met, consider bariatric surgery

what is considered BMI obesity class 3 and the recommendation?

>/=40, LSM + AOM if target not met, consider bariatric surgery

what is the current AOM landscape?

orlistat, phentermine/topiramate, phentermine, naltrexone/bupropion, GLP-1 agonists

Where do GLP-1 receptor agonists work?

GI tract, brain, pancreas

Where do GIP/GLP-1 dual agonists work?

adipose tissue, GI tract, brain, pancreas, stomach

Where does orlistat work?

GI tract, stomach (no brain!)

where does naltrexone/bupropion work?

brain

where does phentermine/topiramate work?

brain

what are the general considerations for AOM?

should not be used in pregancy, caution with DM on insulin (WL causes BG drops), HTN (bc WL can cause BP drops), pre-existing eating disorders (bulimia nervosa), extreme WL of <5% of baseline after 12 weeks, avoid concomitant use of AOM, MONITOR!!!

what is the MOA of phentermine (adipex-P, Lomaira)?

sympathomimetic (stimulant) - release of norepinephrine causing reduced appetite and decreased food consumption

what is the dosing strategy for phentermine (adipex-P, Lomaira)?

orally once to twice daily depending on dose

what are the side effects of phentermine (adipex-P, Lomaira)?

nausea, constipation, and increased BP/HR which leads to insomnia, headache, dry mouth, and irritability/anxiety

what are the contraindications of phentermine (adipex-P, Lomaira)?

CVD, hyperthyroidism, glaucoma, hx drug abuse, agitated states, use during/within 2 weeks of MAO-I

what is important about phentermine (adipex-P, Lomaira)?

BMI >30, controlled substance, need to monitor vitals, short term use only

What is the MOA of Orlistat (Xenical, Alli)?

binds to and inactivates gastric/pancreatic lipases in GI tract leading to inability to absorb/digest TG and a calorie deficit

what is the dosing strategy for Orlistat (Xenical, Alli)?

dose with each meal containing FAT (do not dose if meal is missed or contains no fat)

what are the side effects of Orlistat (Xenical, Alli)?

flatus with discharge, oily spots and stools, fecal urgency, steaorrhea

what are the contraindications of Orlistat (Xenical, Alli)?

chronic malabsorption syndrome, cholestasis

what is important about Orlistat (Xenical, Alli)?

need a multivitamin with fat soluble vits (A, D, E, K) separated by 2 hours, DI with levothroxyine and cyclosporine; relatively effective, but not well tolerated

what is the MOA of phentermine/topiramate ER (Qsymia)?

phenteramine: sympathomimetic cauing release of NE which reduces appetite/food consumption

topiramate: appetite suppression, satiety enhancement

what is the dosing strategy for phentermine/topiramate ER (Qsymia)?

once daily dosing, increase from starting dose after 2 weeks

what are the side effects of phentermine/topiramate ER (Qsymia)?

nausea, constipation, and increased BP/HR which leads to insomnia, headache, dry mouth, and irritability/anxiety AND paresthesia, dysgeusia (unpleasant taste in mouth), depression

what are the contraindications of phentermine/topiramate ER (Qsymia)?

CVD, hyperthyroidism, glaucoma, hx drug abuse, agitated states, use during/within 2 weeks of MAO-I

what is important about phentermine/topiramate ER (Qsymia)?

CNS effects (cognitive dysfunction/psych disturbances) are higher with rapid titration and higher doses - makes people feel dumber

what is the MOA of naltrexone/bupropion (Contrave)?

naltrexone: antagonizes the auto-inhibition of cells by B-endorphin

bupropion: activation of anorexigenic neurons in hypothalamus

what is the dosing strategy for naltrexone/bupropion (Contrave)?

titrate up to 2 tablets twice daily

what are the side effects of naltrexone/bupropion (Contrave)?

nausea, constipation, headache, dizziness, insomnia, increase in BP/HR

what are the contraindications of naltrexone/bupropion (Contrave)?

use with opioid agonists, partial agonists, during withdrawal, seizure disorder

what is important about naltrexone/bupropion (Contrave)?

consider in pts attempting smoking cessation, depression; need opioid free period before starting

which of the following should be used in a obese pt with financial instability?

A) orlistat

B) phentermine

C) phentermine/topiramate

D) naltrexone/bupropion

phentermine (dt it being the lowest cost)

which of the following is the most expensive?

A) orlistat

B) phentermine

C) phentermine/topiramate

D) naltrexone/bupropion

naltrexone/bupropion

what are the GLP-1 agonists?

Liraglutide (Saxenda), Semaglutide (Wegovy), Tirzepatide (Zepbound)

What is the MOA of GLP-1 agonists?

long acting incretin hormone that stimulate glucose-dependent insulin secretion, suppress glucagon release and reduce hepatic glucose production, slow gastric emptying, reduce appetite, and promote beta-cell growth.

what do GLP-1 directly act on?

kidney, immune cells, intestine, cardiovascular, brain, B cells, etc

How are GLP-1 agonists administered?

SubQ injection once a week

what is the dosing strategy of GLP-1 agonists?

start low, work up based on adverse effects

what do you need to monitor in GLP-1 agonists?

weight loss progression (including waist measurements), SE, pertinent comorbidities

what are the side effects of GLP-1 agonists?

constipation, diarrhea, nausea, heartburn, abdominal pain, pancreatitis/cholelithiasis/cholecystitis (uncommon)

what are the contraindications of GLP-1 agonists?

past/FH of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2

what is semaglutide (wegovy) also tx in addition to weight loss?

diabetes

what is semaglutide (wegovy)?

FDA approved drug for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity

how is semaglutide (wegovy) administered?

autoinjector into the abdomen, thigh or upper arm any time of day with or without food ("two clicks and the yellow bar disappears, built in needle)

how is semaglutide (wegovy) stored?

fridge, but can be at room temp for up to 28 days if uncapped

what is the evidence behind semaglutide (wegovy)?

decrease in CV disease/adverse CV events

what is tirzepatide (zepbound)?

FDA approved drug for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity

how is tirzepatide (zepbound) administered?

autoinjector into the abdomen, thigh or upper arm any time of day with or without food on the same day each week (needle included on autoinjector, press and hold button for "two clicks" until grey plunger visible)

how is tirzepatide (zepbound) stored?

fridge, but can be at room temp for up to 21 days if uncapped

what is the evidence behind tirzepatide (zepbound)?

ongoing study with promis to show reduction in morbidity/mortality in adults with obesity

what is recommendation for GLP-1 agonists in regards to treating pts?

titrate slowly until plateau then increase the dose

what GLP-1 agonist is covered by insurance with no co-pay?

Semaglutide (wegovy)

what is generally the cheaper options for AOM for obese pts regarding insurance coverage prices/coupons?

GLP-1 agonists

what do obesity and mental illness share?

pathogenic pathways, coping mechanisms, sociodemographic factors (reports of suicidal thoughts, but lack of evidence)

what is the FDA recommendation for GLP-1 agonists?

monitor/advise pts to report new or worsening depression, suicidal thoughts, or any unusual changes in mood or behavior

what are compounded GLP-1 agonists?

prevalent dt GLP-1 agonist shortages, not FDA approved, more adverse events

what happens when you stop taking GLP-1 agonists?

weight re-gain after discontinuation

how do you combat weight re-gain after discontinuation of a GLP-1 agonist?

slow down titrating dose, enrollment in lifestyle programs for support, trying another tx course of GLP-1 RA, diet and physical activity

which GLP-1 agonist has show the most weight loss?

Retatrutide