Weight Management and Bariatric Care

Introduction

  • Stephanie Greco, nurse practitioner specializing in bariatrics at Einclane Hospital, part of Jefferson Health.
  • Presentation focused on weight management in primary care, which includes:
    • Weight loss medications and prescribing considerations.
    • Referral processes for bariatric surgery.
    • Overview of common procedures in the U.S.
    • Management of complications post-surgery.

Understanding Obesity

  • Body Mass Index (BMI) Classification:
    • Underweight: BMI < 18.5
    • Healthy: BMI 18.5 - 24.9
    • Overweight: BMI 25 - 29.9
    • Obese: BMI ≥ 30
    • Class 1: BMI 30 - 34.9
    • Class 2: BMI 35 - 39.9
    • Class 3 (Severe/Morbid Obesity): BMI ≥ 40
    • Super Severe Morbid Obesity: BMI > 60
  • Use of BMI for billing codes, particularly in geriatrics.

Weight Loss Medications

  • General Approach:

    • Address patient concerns in a sensitive manner.
    • Evaluate patient’s medical history before prescribing medications.
    • Maintaining patient relationships for open communication.

  • Medications Covered:

    1. Phentermine (Lomira)
    • Short term (3-4 months) appetite suppressant.
    • Start at 37.5 mg; increase based on patient stability.
    • Common side effects: insomnia, palpitations, dry mouth.
    • Cautions: avoid in patients with specific health issues (e.g. heart disease).
    1. Centramine Topiramate Extended Release
    • Effective for patients with significant weight loss potential (5-10% reduction).
    • Titration necessary; monitor for cognitive side effects.
    1. Naltrexone/Bupropion (Contrave)
    • Used for weight loss and smoking cessation.
    • Monitor side effects like nausea, headache, and insomnia.
    1. Liraglutide (Saxenda) and Semaglutide (Ozempic)
    • GLP-1 analogs for diabetes and weight loss management.
    • Titration necessary, especially for diabetic patients.
    1. Metformin
    • Recognized for PCOS management and weight loss in insulin-resistant patients.
    • Start at low dose and monitor for GI side effects.
    1. Clenity
    • New FDA-approved med designed to expand in the stomach.
    • Works for patients with hunger management needs.

Referral to Bariatric Procedures

  • Referral Criteria:
    • BMI ≥ 35 with comorbidities (e.g. hypertension, diabetes).
    • BMI ≥ 40 regardless of comorbidities.
  • Process: Verify insurance coverage prior to referral.
  • Common Surgical Procedures:
    • Laparoscopic Band (not commonly done anymore)
    • Sleeve Gastrectomy
    • Gastric Bypass
    • Single Anastomosis Duodenal Switch (SADY)
    • Duodenal Switch (BPD/DS)

Post-Surgical Management

  • Follow-up Care Includes:
    • Routine blood work and EKG.
    • Monitoring for deficiencies (e.g. vitamin B12, D).
    • Encourage compliance with vitamin regimens (particularly post-duodenal switch).
  • Complications to Watch For:
    • Nausea & Vomiting (potential strictures).
    • Long-term nutrient deficiencies (monitor iron, vitamin B12).

Other Important Considerations

  • Monitoring Medications:
    • Patients must return for consistent check-ins every 3 months to ensure stability and monitor any side effects.
  • Address potential psychological issues as weight management can be sensitive.
  • Importance of Communication: Keep lines open for patient concerns, especially concerning medication effectiveness or side effects.

Conclusion

  • Emphasis on the need for a comprehensive approach to weight management in primary care.
  • Collaboration with specialists in bariatric surgery when necessary.
  • Continuous education on new medications and procedures for effective patient management in weight loss.