Using New Guidelines to Improve Best Practices in Obesity Management

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1 Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including sponsor and supporter, disclosures, and instructions for claiming credit) are available by visiting: Released: 03/31/2016 Valid until: 03/31/2017 Time needed to complete: 15 Minutes ReachMD info@reachmd.com (866) Using New Guidelines to Improve Best Practices in Obesity Management Narrator: Welcome to CME on ReachMD. This segment: Using New Guidelines to Improve Best Practices in Obesity Management, is sponsored by the Endocrine Society, developed by Vindico Medical Education and supported by an educational grant from Novo Nordisk. This activity focuses on the evidence-based guidelines for the management of obesity and how they can effectively be used in practice. Your host and moderator is Dr. John Russell, who is the Director of the Family Medicine Residency Program at Abington Memorial Hospital in Abington, Pennsylvania. Dr. Russell will speak with Dr. Caroline Apovian, Professor of Medicine and Pediatrics at Boston University School of Medicine in Boston, Massachusetts. Dr. Apovian is also the Director of the Nutrition and Weight Management Center at Boston Medical Center and the Director of Nutrition and Support Service at Boston Medical 2017 ReachMD Page 1 of 8

2 Center. Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements, as well as the learning objectives, or if you're listening to this as a podcast, go to this activity on ReachMD.com/CME on your computer, Smartphone or tablet device. Obesity is a chronic disease. In the United States, 69% of adults are overweight or obese. However, few receive anti-obesity treatment, only about 1 to 2% of patients. So, doctor, last year the Endocrine Society published clinical practice guidelines for the pharmacologic management of obesity. So what was the background and rationale for these guidelines? That's a very good question. As we all know, obesity is quite a problem in the United States and elsewhere, 69% percent of the population is overweight or obese with roughly 33% of adult Americans having obesity. Primary care providers and other healthcare practitioners desperately need guidelines for how to help their patients lose weight and keep it off. That was really the rationale for the guidelines. As many know, the American College of Cardiology and American Heart Association and the Obesity Society did publish obesity treatment guidelines in However, at that time -- and I was a member of that panel -- there was not enough data in the literature to make statements regarding adjunctive tools for behavioral treatment, which means medications were left off those 2013 guidelines. So the Endocrine Society guidelines were a response to those 2013 guidelines, and we specifically discussed medications that will help patients lose weight, and we also discussed medications that may promote weight gain and obesity and how to avoid those medications, and we suggested alternatives for those medications. That set of guidelines became the Endocrine Society Clinical Practice Guidelines for pharmacological management of obesity. So, is it the medications that make these guidelines unique, and how do they differ than the other obesity guidelines we've seen over the years? Well, yes. So, the endocrine guidelines came out a few months after most of the medications that we currently have available were approved by the FDA, so these are the only guidelines that talk about 2017 ReachMD Page 2 of 8

3 how to use the chronic weight management medications. There are 6 of them, and it provides a roadmap for clinicians considering medications for chronic weight management for patients who are not finding enough success with lifestyle change and diet and exercise. And diets were covered in the 2013 guidelines; so was bariatric surgery, as a matter of fact. So, the difference between the 2013 TOS guidelines and the Endocrine Society guidelines that were published in 2015 really are the fact that we highlight the medications, and specifically, the medications that are currently approved for the treatment of obesity. So, are there any other key recommendations in these new guidelines that you want to mention? Yes. Of course, we highlight the medications, so with the medications it includes a guidance for prescribing medications that promote weight loss, how to use these medications, what patients would you consider using these medications, and how to follow patients taking these medications. We provide clinicians with the recommended medications and the dosage, as well, based on the obesityrelated comorbidities. What are those comorbidities? Type 2 diabetes is the major one, but also cardiovascular disease, hypertension, osteoarthritis, gout, cholecystitis, PCOS, and even certain cancers. So there are certain medications that you would prefer to use in patients, let's say, for example, with obesity and hypertension, with obesity and heart disease, with obesity and type 2 diabetes. And we also highlight in these guidelines medications that can promote weight gain and how to approach a patient who is on these medications, and we really underscore shared decision-making with patients and provider and the expertise that we can give to that provider and to the patient. And these are all unique guidelines that really are the first of its kind because we promote decision-making and decision, and shared decision-making with other providers. So, Dr. Apovian, with so much obesity in the United States, who qualifies for medications for chronic weight management? Well, first of all, we always say that patients who have a body mass index over 25, they are considered overweight. If they have no comorbidities and they have a BMI over 25, over 25 to about 30, they really are not a candidate for medications until they have failed diet and exercise and behavior modification. So, most patients who come in to a weight management center have tried many diets and exercise 2017 ReachMD Page 3 of 8

4 programs in the past, so that's really not a problem. The guidelines state, and they haven't changed now since 1998, that you're a candidate for medication if you're a patient and your BMI is over 30 or over 27 with at least one comorbidity that's related to obesity such as diabetes, heart disease, hypertension, sleep apnea, and on and on, and osteoarthritis or even prediabetes. But, if there is no comorbidity, BMI should be over 30. And those are the basic baseline eligibility of the patient. Now, for example, if the patient had a BMI of 30 and with diet and exercise went down to 28, and is now having trouble staying at 28, they still are eligible for a medication even though they don't have comorbidities because their baseline BMI was 30. So there are nuances that we can talk about where it's not really black and white anymore, but the baseline is BMI over 30. Yes, if there's a comorbidity, you can go down to a BMI of 27 or higher to be eligible for one of these medications. So, what if in my primary care practice I start a patient on medication for chronic weight management but after a few months they really don't lose any weight, what do the new guidelines recommend for a patient who does not respond to treatment? That's also very important to know. So, if a patient is started on a medication and after 3 months there is no weight loss or less than 5% of total weight is lost, you should stop the treatment and switch to a different agent. So, for example, a patient who weighs 250 pounds, 10% of that is 25 pounds. If the patient we're talking has to make at least 5% in 3 months -- so you really have to do the math, and 5% is going to be about 12 pounds. If they don't lose that 12 pounds and they weigh 250 in 3 months, then technically, you should think about a different agent. Now, some people would think that 12 pounds is fantastic, but that's really barely 5% of the total weight, which was 250 pounds. Very quickly a patient will tell you whether or not they are doing well with the medication. Some patients who don't do well with medications will have some side effects that they're really not willing to hang on with and overcome. Insomnia tends to be a big problem with some medications, palpitations, headaches, a feeling of fogginess and nausea. If it's mild nausea, patients generally can overcome it, and after a while it will go away. If it's persistent nausea, then again, you're going to have to try a new medication. If you're just tuning in, you're listening to CME on ReachMD. I'm your host, Dr. John Russell, and today I'm speaking with Dr. Caroline Apovian, Professor of Medicine and Pediatrics at Boston University 2017 ReachMD Page 4 of 8

5 School of Medicine, and we're speaking about the guideline recommendations for the treatment of obesity. Doctor, you mentioned before that the Endocrine Society guidelines give specific recommendations for patients with overweight or obesity and also have co-morbid conditions. So, let's say I have a patient with type 2 diabetes who's on metformin but I need to add in a second medication. What would the guidelines recommend for this particular patient? So, John, that's a very good question also, because very often we will have patients who have obesity, but also have type 2 diabetes. They should already be on metformin. If they are not on metformin, that's really your first-line agent for type 2 diabetes and obesity, and the guidelines state that. You should then really address the obesity and talk about diet intervention and exercise intervention. If the hemoglobin A1c and blood glucose are still too high and they require a second medication, then it's very important to pick the weight-losing and weight-neutral medications first, first and second-line, and discuss the weight effects of those medications with your patients. So, for example, there are a few GLP-1 receptor agonists that have come out recently such as exenatide and liraglutide, and these are fantastic second additions after metformin for patients who have type 2 diabetes and obesity because they will assist in weight loss for that patient; so those would be second-line. Other second-line agents to consider are SGLT-2 inhibitors, so those are very beneficial to get even more weight loss in patients who are already on metformin and are losing a little bit of weight but need more help. So, those 3 agents: metformin, GLP-1 receptor agonists and SGLT-2 inhibitors, should be thought of first in the patient with type 2 diabetes and obesity. Now, in case your patient is already on insulin, make sure metformin is maximized. So, what's maximal metformin? It's 1,000 mg twice a day. Consider using pramlintide as an additional agent to mitigate the weight gain that the insulin has caused and get the patients to start losing weight. You can also consider adding a GLP-1 agonist at that time to try to get some of the insulin reduced. And the first-line insulin that you should use if you have to use insulin should be a basal insulin. So, again, what we're trying to do is to reduce the use of insulin and also reduce the use of sulfonylureas and TZDs because these 3 agent classes cause weight gain, and either replace with a GLP-1, SGLT-2 inhibitor, metformin, or add on pramlintide, especially pramlintide, because pramlintide is indicated in patients who are on insulin. So, what would be the recommendations for the patients with overweight or obesity and that are 2017 ReachMD Page 5 of 8

6 hypertensive? All right, that's another very frequent category of patients that you're going to see in your practice, overweight or obesity with hypertension. So, our guidelines recommend, of course, that the overweight or obesity should be treated because you may need less hypertensive agents in the end, but if you do have to use an antihypertensive agent, we recommend the use of ACE inhibitors, ARBs and calcium channel blockers as first-line therapy, and we do not recommend the use of beta blockers for the treatment of hypertension. Of course, the treatment of congestive heart failure in the setting of myocardial history is different, and in those patients, they have to be on a beta blocker as well, but if it's hypertension and obesity, we do not recommend the use of beta blockers because beta blockers can cause weight gain. Now, having said that, ACE inhibitors, ARBs and calcium channel blockers, try to use them first. In patients who have uncontrolled hypertension and a history of CVD, heart disease, you're going to be very careful with sympathomimetic agents. So, what are the sympathomimetic agents that we use at times for weight loss? It's phentermine and diethylpropion. We don't recommend using those agents because they can cause high blood pressure and palpitations. Better agents for patients with CVD and obesity, try to use agents with no sympathomimetic action, so that would be lorcaserin and orlistat. Lorcaserin is another appetite suppressant, as is phentermine and diethylpropion. Orlistat is a fat blocker because it inhibits pancreatic lipase. So, those are some of the highlights that are in the endocrine guidelines for managing obesity and diabetes and obesity and hypertension. So, what do you think are the main challenges for implementing the Endocrine Society guidelines into primary care offices? Well, the challenges are that we know that in a primary care practice, primary care physicians are very, very challenged in terms of treatments and getting all of the screening recommendations and other guidelines into their 15-minute visit with the patient. So the primary challenge for the provider is to shift the focus on the comorbidities. So, what are the comorbidities? Hypertension, heart disease, type 2 diabetes, dyslipidemia, osteoarthritis. Shift the focus and right away tackle the obesity with lifestyle change and then a weight loss agent, these agents that also would mitigate weight gain with the other agents we just talked about. So, you really need a paradigm shift to treat the obesity first, and then, if necessary, tackle the other comorbidities ReachMD Page 6 of 8

7 Now, our guidelines always suggest that for the comorbidities, so the JNC 7 guidelines for hypertension talk about TLC, total lifestyle change, first, same for dyslipidemia, same for type 2 diabetes and prediabetes, but the challenge for the primary care provider is finding the time to do it. And in order to find the time to do it, you have to focus on treating obesity first with diet and exercise, use of a medication, if necessary and if needed, for the obesity, and then what the primary cares will find is that you can reduce the need for the other agents, for diabetes medications, for hypertensive medications, for dyslipidemia medications. So, Dr. Apovian, if you had to give 3 recommendations for someone like myself working in primary care, managing patients with overweight or obesity, what would those 3 pearls be? Three recommendations: Number 1, measure the BMI, the body mass index, and waist circumference at each visit. These are right in the 2013 guidelines. Apprise your patients of the risks that they have because of their BMI and waist circumference. The second recommendation would be to talk to your patient about lifestyle change, have handouts readily available with a dietary recommendation, with an exercise recommendation. For example, have a list of all of the popular diets available and a quickie on high protein diets, a quickie on the South Beach Diet, because it doesn't matter what diet your patient's going to be on; it matters what they can adhere to. So, that's the second recommendation. Have those handouts. Talk about the diet. It doesn't matter what diet they're on. The third recommendation would be if your patient has said that they have been having difficulty in losing weight and keeping it off, consider one of the medications for those patients with BMI over 30 or over 27. Be knowledgeable of the medications and knowledgeable about what is offered with the medication. For example, we have coupons that will help the patient reduce the cost of the medications, because very often they're not covered by insurance. So, those are the recommendations. You'll find, if you do that, that it will get easier and easier and less time-consuming, and you'll be able to avoid other medications for the comorbidities in your patients. Well, that's very, very helpful. So, thank you so much for being on the show. It's been great to talk to you ReachMD Page 7 of 8

8 I'd like to thank our guest, Dr. Caroline Apovian, for helping us to better understand the new guidelines for obesity management and how to implement them into practice. I'm your host, Dr. John Russell, and thank you for listening. Narrator: This segment of CME on ReachMD is sponsored by the Endocrine Society, developed by Vindico Medical Education and supported by an educational grant from Novo Nordisk. To receive your free CME or to download this segment, go to ReachMD.com/CME. Thank you for listening ReachMD Page 8 of 8

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