PHAR 840 Obesity Voskanian

Voskanian – Obesity Thursday, February 13, 2025 12:42 PM BMI • • • • • < 18.5 ➜ underweight range 18.5 to < 24.9 ➜ healthy weight range 25.0 to < 29.9 ➜ overweight range 30.0 or higher ➜ obesity range Frequently subdivided into subcategories: ○ Class 1: BMI of 30 to < 35 ○ Class 2: BMI of 35 to < 40 ○ Class 3: BMI of 40 or higher ○ Sometimes categorized as “severe” obesity Obesity classification by waste circumference • Men: more than 40 inches • Non-pregnant women: more than 35 inches Metabolic Syndrome • Associated conditions ○ Diabetes (T2DM) ○ Hypertension ○ Dyslipidemia ○ Coronary artery disease ○ Cancer ○ Premature death Non-pharmacological Treatment • Nutritional changes ○ Healthier eating w/ nutritious food options ○ Portion control • Increase physical activity ○ Consistent exercise ○ 150 minute of moderate intensity exercise per week Pharmacological Treatment Generic Brand Dose Side Effect Phentermine (C-IV) • Adipex-P • Reducing appetite secondary to CNS • Lomaira effects, including stimulation of the hypothalamus to release norepinephrine • 15 to 37.5 mg by mouth once daily • Lomaira: 8 mg by mouth three times daily • 30 minutes before meals • Tablets scored = may be divided in ½ • • • • • Phentermine + Topiramate ER • REMS required • Topiramate increases satiety and decreases appetite • Phentermine reduces appetite through sympathomimetic effects Dosing Schedule (titrate dose) • Weeks 1 – 2: ○ 3.75 mg/23 mg capsule by mouth once daily in the morning • Weeks 3 – 12: ○ 7.5/46 mg capsule by mouth once daily in the morning • Reevaluate at week 12: ○ If weight loss: Reduced by ≥ 3% from baseline: ▪ Continue current dose of 7.5 mg phentermine/46 mg topiramate by mouth once daily ○ If weight loss: Reduced by < 3% from baseline: ▪ After 12 weeks of therapy → increase dose • Weeks 13 – 14: ○ Increase to 11.25/69 mg capsule by mouth once daily in the morning • Weeks 15+: ○ 15/92 mg capsule by mouth once daily in the morning ○ Reassess weight after 12 weeks ○ If weight reduced by ≥ 5% from baseline → continue current dose ○ If weight only reduced by <5% → discontinue therapy ▪ patient unlikely to see further efficacy • CNS Depression • Tachycardia • Dry mouth Qsymia Naltrexone HCl/Buproprion HCl ER Contrave • Naltrexone decreases food cravings • Bupropion decreases appetite Dosing Schedule • • Week 1: 8/90 mg tablet by mouth once daily • Week 2: 8/90 mg tablet by mouth twice daily • Week 3: 8/90 mg tablet; 2 tablets by mouth in the morning and 1 tablet by mouth in the evening • Week 4: 8/90 mg tablet; 2 tablets by mouth twice daily ○ Consider discontinuation if weight loss is <4% to 5% of baseline after 3 months Dietary Considerations: • Do not administer with high-fat meals; may result in a significant increase in bupropion and naltrexone systemic exposure • • • • • • Orlistat • MOA: decreases absorption of dietary fats Xenical • Oral: 120 mg by mouth 3 times daily with each main meal containing fat (during or up to 1 hour after the meal) ○ Omit dose if meal is occasionally missed or contains no fat Alli (OTC) • Oral: 60 mg by mouth 3 times daily with each main meal containing fat ○ Maximum OTC dose: 180 mg/day • OTC: Alli • Rx: Xenical Increased blood pressure Tachycardia Agitation Delirium Mania Boxed Warning • Naltrexone/bupropion is not approved for use in the treatment of major depressive or psychiatric disorders; it contains bupropion the same active ingredient in some other antidepressant medications. • Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 to 24 years of age) with major depressive disorder (MDD) and other psychiatric disorders Nausea Vomiting Constipation Dry mouth Diarrhea Trouble sleeping • Stomach pain or diarrhea • Not able to control stools • Gas with discharge, oily spotting, and feeling the need to go to the bathroom • Fatty or oily stools • Upset stomach • Headache • Feeling tired or weak • Period (menstrual) changes • Signs of a common cold Liraglutide • Activating GLP-1 receptors in the pancreas resulting in enhanced insulin release and reduced glucagon release-responses Saxenda Dosing Schedule • Week 1: 0.6 mg once daily • Week 2: 1.2 mg once daily • Week 3: 1.8 mg once daily • Week 4: 2.4 mg once daily • Week 5: 3.0 mg once daily • Dose increase is dependent on toleration • Continue dose for additional week before increasing • Boxed Warning • Thyroid C-cell tumor risk • Constipation • Diarrhea • stomach pain • upset stomach • Vomiting • injection site reaction • Headache Administration: SubQ injection in upper arm, thigh, or abdomen without regard to meals • Rotate injection sites Missed dose • If ≤3 days ○ Resume once-daily dosing with the next prescribed dose; do not administer extra or doubled doses • If >3 days ○ Restart and repeat the initial dose to avoid GI symptoms Semaglutide • Activating GLP-1 receptors in the pancreas resulting in enhanced insulin release and reduced glucagon release-responses • Wegovy (obesity) • Ozempic (diabetes) • NOT FDA approved for weight loss but often prescribed Dose • Children ≥12 years + Adolescents <18 years: ○ Wegovy: 2.4 mg SubQ once weekly ○ Per manufacturer (if maintenance dose of 2.4 mg is not tolerated): ▪ Decrease to 1.7 mg once weekly ▪ If the weekly dose of 1.7 mg is not tolerated, discontinue Wegovy Administration: SubQ injection in upper arm, thigh, or abdomen without regard to meals • Rotate injection sites Missed dose • If one dose is missed and next scheduled dose is: ○ >2 days away ▪ ASAP ○ <2 days away ▪ Do not administer the missed dose ▪ Resume dosing on the regularly scheduled day of the week • If 2+ doses are missed: ○ Resume at the next regularly scheduled day of the week ○ Consider restarting and follow the dose escalation schedule Tirzepatide • Activating GLP-1 receptors in the pancreas resulting in enhanced insulin release and reduced glucagon release-responses • Zepbound • Mounjaro Zepbound Dosing Schedule • Week 1 – 4: 2.5 mg once weekly ○ Dose not effective for weight loss, taper is to reduce GI symptoms ¡ • Week 4+: increase to 5 mg once weekly ○ May further increase dose in 2.5 mg/week increments every 4 weeks ○ Maximum weekly dose: 15 mg/week • Note: If changing the day of administration is necessary, allow at least 72 hours between 2 doses Missed dose: • < 4 days ○ Administer ASAP then resume usual schedule thereafter • Boxed Warning • Thyroid C-cell tumor risk • Adverse Reactions (significant) • Acute kidney injury • Diabetic retinopathy • Gallbladder disease • Medullary thyroid carcinoma • Pancreatitis • Side Effects • Abdominal pain • Nausea • Diarrhea • Vomiting • Constipation • Decreased appetite, dyspepsia, dysgeusia (metallic taste) • Boxed Warning • Thyroid C-cell tumor risk • Adverse Reactions (significant) • Acute kidney injury • Diabetic retinopathy • Gallbladder disease • Medullary thyroid carcinoma • Pancreatitis • Side Effects • Abdominal pain • Nausea • Diarrhea • • >4 days ○ Skip the missed dose and resume administration at the next scheduled weekly dose Mounjaro Dosing Schedule • Week 1 – 4: 2.5 mg once weekly • Continue to 5 mg once weekly for at least 4 weeks • Additional dose increases: ○ 7.5 mg ○ 10 mg ○ 12.5 mg ○ 15 mg → stay on current dose for at least 4 weeks • Vomiting • Constipation • Decreased appetite, dyspepsia, dysgeusia (metallic taste)