Treatment of Severe Obesity

Transcription

1 Treatment of Severe Obesity Louis J. Aronne, MD, FACP, FTOS, DABOM Sanford I Weill Professor of Metabolic Research Weill Cornell Medical College Comprehensive Weight Control Center Division of Endocrinology, Diabetes & Metabolism New York, New York April 6, 2017

2 Disclosures I am a consultant, speaker, advisor, or receive research support from: Aspire Bariatrics Eisai Inc. Ethicon Endo-Surgery Inc. GlaxoSmithKline Consumer Healthcare LP GI Dynamics Novo Nordisk Pfizer USGI Ownership Interest: BMIQ Myos Corporation Zafgen, Inc. Gelesis ERX Board of Directors: Myos Corporation Jamieson Laboratories VIVUS Inc. Zafgen Inc. As faculty of Weill Cornell Medical College, we are committed to providing transparency for any and all external relationships prior to giving an academic presentation.

3 What does it take to treat severe obesity? An Experienced Team: Bariatric Surgeon Gastroenterologist Obesity Medicine Specialist Registered Dietitians Psychologists Support Staff Treatments that work Lifestyle Medication Surgery Devices Insurance coverage for that treatment Often lacking or with barriers 3

4 Division of Metabolic and Bariatric Surgery 4

5 Comprehensive Weight Control Center 1165 York Avenue, New York, NY weillcornell.org/ weight Louis J. Aronne, MD, FACP, FTOS, DABOM Sanford I. Weill Professor of Metabolic Research Medical Director, Comprehensive Weight Control Center Jonathan A. Waitman, MD Assistant Professor of Medicine Internal Medicine, Clinical NutriGon, Obesity Medicine Rekha B. Kumar, MD, MS Assistant Professor of Medicine Endocrinologist Leon I. Igel, MD Assistant Professor of Clinical Medicine Endocrinologist Katherine H. Saunders, MD Instructor in Medicine Internal Medicine, Obesity Medicine Alpana P. Shukla, MD, MRCP (UK) Assistant Professor of Research Medicine Endocrinologist Devika Umashanker, MD Clinical Fellow in Obesity Medicine Joy Pape, MSN RN FNP-C CDE WOCN CFCN FAADE Clinical Nurse PracGGoner Wanda Truong, MS Clinical Research Coordinator Rachel A. Lustgarten, MS, RD, CDN Clinical DieGGan Janet L. Feinstein, MS, RD, CDN Clinical DieGGan Anthony J. Casper, BS Senior Research Aide Natasha Coughlin, MS Graduate Student (IHN) Morgan Dickison, MS Graduate Student (IHN) Ampadi Karan, BS Research Aide 5

6 Obesity Medicine: The newest specialty in medicine Certification of competence in obesity care based on CME and board examination Growing rapidly 6

7 Obesity Medicine: Fast Growing Area of Medicine 600 Number of Certificates Issued Per Year by Specialty 500 Gastroenterology Obesity Medicine 400 Infectious Disease 300 Endocrinology Rheumatology Geriatric Medicine

8 Weight Gain Why do people gain so much weight? Why is it so hard to get people to lose weight? Fattening food damages weight regulating neurons Weight-regulating pathways become less responsive to hormonal and neural signals This results in a system which is biased in favor of weight gain and against weight loss 8

9 Thaler PT, et al. J Clin Invest Jan 3;122(1): doi: /JCI Epub

10 McNay D, et al. J Clin Invest. 2012;122(1): doi: /jci43134.

11 Bad Habits Damage Hypothalamic Pathways Biases the weight regulating system towards weight gain Hypothalamic Injury AGRP: agouti-related peptide; α-msh: α-melanocyte-stimulating hormone; GHSR: growth hormone secretagogue receptor; INSR: insulin receptor; LepR: leptin receptor; MC4R: melanocortin-4 receptor; NPY: neuropeptide Y; POMC: proopiomelanocortin; PYY: peptide YY; Y1R; neuropeptide Y1 receptor; Y2R: neuropeptide Y2 receptor. Apovian CM, Aronne LJ, Bessesen D et al. J Clin Endocrinol Metab. 2015;100:

12 New Strategies Which Work In addition to surgery and devices Management of drug-induced weight gain Treatment with anti-obesity medications Surgery and Devices Use of intensive and intermittent dietary interventions 12

13 Drug-induced weight gain: Rethinking our choices Saunders K, Igel L, Shukla A, and Aronne L J Fam Pract November;65(11): , ,788 13

14 Patient AC 69-year-old M w BMI 35.7 kg/m2, DM2 (HA1c 6.2), HTN, HLD S/p lap band 10 years ago lost 36 lbs, then regained all weight Medications 12/2014: pioglitazone 45 mg daily, metformin 500 mg daily, others Rx: low glycemic index diet, d/c d pioglitazone, increased metformin to 1000 mg BID, added liraglutide 0.6 mg daily titrated up to 1.8 mg daily 14

15 Patient AC 63 Lb Weight Loss, highest weight to lowest Pounds 238 lbs 5/2004 Lap band 249 lbs 12/2014 Initial visit Pioglitazone 45 mg Metformin 500 mg 186 lbs 9/2015 Metformin 2000 mg Liraglutide 1.8 mg 15

16 Patient CM 43-year-old F with initial BMI 56 kg/m 2 and bipolar disorder 2004: 313 lbs à lap band in Greece 2006: 288 lbs à lap band removed, RYGB 2007: 231 lbs 2009: 245 lbs à RYGB banded 2011: 275 lbs à metformin, topiramate, liraglutide 2015: 140 lbs Current medications: Bupropion 300 qd Metformin 500 mg BID Topiramate 200 mg qhs Liraglutide 1.2 mg daily 16

17 Patient CM 173 Lb Weight Loss Pounds 313 lbs 9/2004 RYGB RYGB banded Meds started 140 lbs 10/2015 Lap band Metformin 500 mg BID Topiramate 200 mg daily Liraglutide1.8 mg daily 17

18 We use weight loss medications after bariatric surgery Review of patients treated at MGH and WCMC Table 4. Mean Weight Change after Treatment by Subgroup Subgroup Weight Change All patients (n=317)* (SD=21.1) -7.6 (SD=7.8) Patients prescribed medication at weight plateau (n=68, 21.5%)~ Patients prescribed medication at weight regain (n=249, 78.5%)~ Surgery Type (lbs) (%)^ (SD=27.8) -6.9 (SD=8.8) (SD=19.0) -7.7 (SD=7.6) Sleeve Gastrectomy (n=61) -9.8 (SD=13.5) -4.3 (SD=5.7) Roux-En-Y Gastric Bypass (n=256) (SD=22.2) -8.3 (SD=8.1) Patients who lost 5% total body weight with treatment (n=172, 54%) Patients who lost 10% total body weight with treatment (n=96, 30.3%) Patients who lost 15% total body weight with treatment (n=49, 15.4%) (SD=21.9) (SD=7.2) (SD=23.7) (SD=6.7) (SD= 27.7) (SD=6.2) P-value a a ~ Plateau defined as weight that is within 3% above or below nadir weight postoperatively before medication. If above 3% patient defined as starting medication at weight regain ^Calculated this number as [(weight at nadir post medications) (weight at start of medication)]/ (weight at start of medication) RNYGB weight loss > Sleeve Same wt loss but TBWL > if meds started at plateau than weight regain 54% lost 5%, 30% lost 10% Stanford, FC, et al. The utility of weight loss medications after weight loss surgery. SOARD In press 18

19 Treatment Gap in Mid-BMI Range New drugs and devices can reduce weight and weight-related comorbidities More Drug options: Lorcaserin Liraglutide Diet and Lifestyle & Drugs prior to 2012 Orlistat Phentermine Combination Pharmacotherapy Phen/top Nalt/bup Less Invasive Procedures Vagal block therapy Endoscopic sleeve Sleeve gastrectomy Gastric Lap Band Bypass BPD Bariatric Surgery + Obesity Medicine Treatment Gap Treatment Gap 0% 5% 10% 15% 20% 25% 30% 35% Weight Loss This gap is being filled NOT EFFECTIVE enough for many people After Aronne L. FDA VI-0521 EMDAC TOO RISKY for many people 19