Treatment of Obesity: Diets, Drugs and Surgery

Transcription

1 Treatment of Obesity: Diets, Drugs and Surgery Disclosures None Michelle Guy, MD Professor Clinical Medicine University of California San Francisco Diplomate American Board of Obesity Medicine Objectives Understand provider barriers to treating patients with overweight and obesity Know the classifications of obesity Understand lifestyle modifications for weight loss Know which medications promote weight gain Review the FDA approved medications for weight loss Review the common weight loss surgeries Questions 1 True or False Answer the following question for yourself I have at some point during my career exhibited or expressed weight bias, either subtle or overt, towards a patient with overweight or obesity. 1) True or Yes 2) False or No

2 Weight Bias Negative attitudes toward persons with overweight or obesity Can be subtle or overt Can be verbal, physical or relational Stereotypes can lead to: stigma rejection prejudice discrimination Weight Bias in Healthcare Study of 2400 women with obesity 69% reported doctors were a source of weight bias 52% reported being stigmatized by a doctor multiple times Patient factors Stigmatized patients are more vulnerable to depression, anxiety or low self esteem May feel less motivated to adopt lifestyle changes May avoid or cancel appointments Provider factors, as BMI increases: Report less desire to help patients More likely to report that treating patient is a waste of time Express less respect for patient Obesity Action Coalition, Obesity Action Coalition, Body Mass Index (BMI)kg/m 2 Mortality and Morbidity of Obesity Normal Overweight Class I Class II Class III > 40.0 Greater BMI is associated with increased rate of death from all causes and cardiovascular disease There are currently over 200 comorbidities associated with obesity Even modest weight loss, 5% to 10%, improves comorbidities Whitlock G, Lewington S, Sherliker P, et al. Body mass index and cause specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373:1083. Illustration used with the permission of Elsevier Inc. All rights reserved.

3 *Potency includes many factors, such as the amount, rate, and sustainability of weight loss, and the long-term resolution of adiposopathy and fat mass disease. Current Treatment Options for Obesity Options for Obesity Question 2 Potency* Lifestyle Includes nutrition, physical activity, and behavioral programs Lifestyle + Medication Includes lifestyle, and antiobesity medications Risk/Cost Very Low Calorie Diet Surgery (In order of lowest risk/cost and potency): LAGB<VSG<RNY Potency varies greatly for each individual (i.e., long-term adherence to a lifestyle program can be as potent as gastric bypass surgery). Which of the following factors is the most important for determining successful weight loss? A) Exercise B) Macronutrient Composition (ie high protein diet) C) Goal Setting D) Caloric intake E) Stopping Weight Promoting Medications Obesity Algorithm Obesity Medicine Association. Reference/s: [1] Dietary Interventions Caloric Restriction, Reduce Energy Intake, Caloric Deficit self monitoring eliminate liquid calories stimulus control portion control intermittent fasting Macronutrient composition does not predict weight loss Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. Dansinger, JAMA 2005;293(1):43 The diet a patient can adhere to the longest, is the best diet for that patient Exercise Interventions Exercise has benefits independent of weight loss Attenuates diet induced loss of muscle mass Improves physical functioning Reduces risk of heart disease, stroke, diabetes and premature death Exercise is important for the primary prevention of obesity Exercise alone or added to diet has only modest effect on weight loss Studies have not shown additional benefits with use of activity trackers Exercise is important for preventing weight regain At least 30 minutes 5 days a week (150 minutes per week)

4 Case Mr Earl is a 45 y/o man who is concerned about his weight (BMI 38) and would like your help shedding a few pounds PMHx: Diabetes type 2, HTN, depression, neuropathic low back pain Medications: Glyburide, Glargine Insulin, Lisinopril, Atenolol, Bupropion, Paroxetine, Amitriptyline, Gabapentin How many of the above medications may be contributing to this patient s weight gain? Question 3 How many of his medications may be contributing to Mr. Earls weight gain? A) All 8 B) 7 C) 6 D) 5 E) 4 1) Glyburide 2) Glargine Insulin 3) Lisinopril 4) Atenolol 5) Bupropion 6) Paroxetine 7) Amitriptyline 8) Gabapentin Medications That Promote Weight Gain This is just part of the story Review timing of weight gain and initiation of medications Consider starting alternatives to weight promoting medications in patients with overweight and obesity Varying mechanisms responsible for weight gain: fluid retention, increased appetite, increased deposition of adipose tissue Medications That Promote Weight Gain CLASS GENERIC NAME POSSIBLE ALTERNATIVES Cardiovascular Beta Blockers Cardiovascular Calcium Channel Blockers Diabetes Hormones Alpha adrenergic agonists Propranolol, Atenolol, Metoprolol Nifedipine, Amlodipine, Felodipine Insulin, Sulfonylureas, Thiazolidinediones, Meglitinides Glucocorticoids, Estrogens, Progestins, Testosterone Prazosin, Doxazosin, Terazosin Carvedilol, ACE Inhibitors Verapamil Metformin, Glucagon like pepetide 1 agonists, Sodium glucose co transporter 2 inhibitors, Alpha glucosidase inhibitors Dutasteride, Proscar

5 Medications That Promote Weight Gain CLASS GENERIC NAME ALTERNATIVE MEDICATIONS Anti seizure Antidepressants Antipsychotics Carbamazepine, Gabapentin, Valproate Amitriptyline, Doxepin, Paroxetine, Mirtazapine Clozapine, Olanzapine, Risperidone, Lithium Lamotrigine, Topiramate, Zonisamide Bupropion, Sertraline, Duloxetine Aripiprazole, Haloperidol Hypnotics Diphenhydramine Trazodone, Benzodiazepines Chemotherapies Tamoxifen, Methotrexate, Aromatase Inhibitors Anti Obesity Medications Diet, exercise and behavioral modification must accompany all adjunct treatments Consider addition of anti obesity medications in patients who: have not been successful with diet and exercise and BMI > or = 27 and obesity related comorbidities or BMI > 30 need adjunct treatment for weight regain Anti obesity medications have only modest effects on weight Goal is to modify or improve comorbid conditions 5 10% weight loss may improve both metabolic and fat mass disease Obesity Algorithm Obesity Medicine Association. Conquer Study 1 year placebo controlled trial of 2487 patients with 2 or more morbidities 61% patients completed 1 year of treatment with absolute body weight change: 1 8 kg placebo 9 9 kg phentermine 7 5 mg plus topiramate 46 0 mg 12 9 kg phentermine 15 0 mg plus topiramate 92 0 mg Anti Obesity Medications MEDICATION LENGTH OF TRIAL TOTAL WEIGHT LOSS Phentermine HCL/Topiramate extended release (Qsymia) 1 year 10.2 kg Phentermine 13 weeks 6.4 kg Naltrexone HCL/Bupropion HCL 1 year 6.1 kg extended release (Contrave) Orlistat (Xenical and Alli) 1 year 5.3 kg Lorcaserin (Belviq) 1 year 5.8 kg Liraglutide (Saxenda) 24 weeks 2.8 kg Metformin 1 year 2.8 kg Gadde, KM. CONQUER. Lancet 2011;377: LeBlanc ES, O'Connor E, Whitlock EP, et al. Effectiveness of primary care relevant treatments for obesity in adults: A systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 155:434.

6 FDA Approved Anti Obesity Medications If < 5% weight loss after weeks discontinue medication If medication is effective, continue longterm Do not administer to women who are pregnant or trying to become pregnant Consider side effect profile and dual use in choosing medication Anti obesity Medications Approved in 1999 or Before Phentermine Orlistat (Xenical and Alli) Anti obesity Medications Approved in 2012 and Beyond Lorcaserin (Belviq) Phentermine HCL/Topiramate extended release (Qsymia) Naltrexone HCL/Bupropion HCL extended release (Contrave) Liraglutide (Saxenda) MEDICATION MECHANISM OF ACTION CONTRAINDICATIONS, SIDE EFFECTS and PEARLS Phentermine Norepinephrine releasing agent Not recommended for patient with heart disease or uncontrolled HTN Tachycardia, Insomnia, Overstimulation, Approved for shortterm use, DEA schedule IV Phentermine/Topiramate (Qsymia) Naltrexone/Bupropion (Contrave) Norepinephrine releasing agent, GABA receptor modulation agent Opioid antagonist/ Dopamine and norepinephrine reuptake inhibitor As above / Avoid in patients with glaucoma or CKD, can cause metabolic acidosis, increased creatinine, dry mouth, paresthesia Uncontrolled HTN, seizure disorders, anorexia/bulimia, chronic opioid use, headache, constipation, insomnia Lorcaserin (Belviq) 5HT2c receptor agonist Co administration with serotonergic agents has not been established, may cause serotonin syndrome, headache, fatigue, cough, memory disturbance and hypoglycemia in diabetics Orlistat (Xenical, Alli) Pancreatic and gastric lipase inhibitor Oily discharge from the rectum, flatus, fecal incontinence, cholelithiasis, kidney stones (oxalate), liver injury, decrease fatsoluble vitamin absorption Liraglutide (Saxenda) Glucagon like peptide 1 (GLP 1) receptor agonist Injectable, dose must be titrated over 4 weeks given significant dose dependent nausea and vomiting, diarrhea, hypoglycemia, increased lipase. Contraindicated in personal or family hx of MEN2 or thyroid cancer Question 4 Which of these patients is the least ideal candidate for bariatric surgery? 1) 30 y/o man BMI 42 but no obesity related comorbidities 2) 62 y/o woman BMI 38 and severe urinary incontinence 3) 28 y/o man BMI 52 who quit smoking 2 months ago 4) 39 y/o woman BMI 43 who plans pregnancy in next year 5) 55 y/o man BMI 35 and poorly controlled type 2 diabetes Who is Eligible for Surgery? 1) BMI > 40 Or BMI & Comorbidity And 2) Must have tried and failed other medically managed weight-loss programs 1991 NIH Consensus Panel Recommendations

7 Contraindications to Bariatric Surgery High Surgical Risk Severe cardiac disease with high risk for anesthesia Severe coagulopathy Poor Post-op Compliance Untreated major depression or psychosis Binge-eating disorders Current drug or alcohol abuse Inability to comply with post op diet and supplementations Question 5 Which intervention can lead to the largest percentage of sustained excess weight loss? 1) Sleeve Gastrectomy (SG) 2) Diet and Exercise 3) Laparoscopic Adjustable Gastric Banding (LAGB) 4) Biliopancreatic Diversion with Duodenal Switch (BPD/DS) 5) RNY Gastric Bypass (RYGB) Laparoscopic Weight Loss Surgery Lap Band Sleeve Gastrectomy Gastric Bypass

8 Laparoscopic Adjustable Gastric Banding (LAGB) Restrictive Only, Not Metabolic Ideal Candidate BMI 30*-40 kg/m2 Needs to lose pounds Benefits Fewer early risks than other procedures One hour procedure Fully Reversible/Removable Lowest risk of vitamin deficiencies Considerations/Risks Excess Weight Loss (EWL) 50% 10-year removal or reoperation rate is >25% Slower weight loss (1-2lbs/week) compared to other surgeries Appetite suppression may be difficult to achieve Least effective for resolving diabetes *FDA approved LAGB for pts w/ BMI Class I obesity and Type 2 diabetes or other obesity related comorbidity Sleeve Gastrectomy (SG) Restriction/Resection and Metabolic Ideal Candidate BMI kg/m2 Needs to lose lbs Benefits Excess Weight Loss 70 90% 1 2 hour procedure Recovery ranges from days to weeks Patients report early and lasting fullness Intestines stay intact No malabsorption May cure diabetes Considerations/ Risks Removal of a portion of the stomach is permanent The remaining pouch may expand over time Roux en Y Gastric Bypass (RNY or Bypass or RYGB) Restrictive/Malabsorptive & Metabolic Most common procedure performed Ideal Candidate BMI kg/m2 Needs to lose lbs May have severe or prolonged medical conditions Benefits Excess Weight Loss 70-90% 2 hour procedure Recovery of days to weeks Very effective for curing diabetes Approximately calories per day lost through malabsorption Procedure is reversible Considerations/Risks Greater risk for vitamin deficiencies Dumping syndrome Smoking, EtOH, NSAIDS use may lead to ulcers Biliopancreatic Diversion w/ or w/o Duodenal Switch (BPD/DS) Restriction, Resection, Malabsortive & Metabolic Ideal Candidate BMI > 60 kg/m2 Poorly controlled diabetic Benefits Has the highest cure rate for diabetes Excess Weight Loss 80 90% 3 4 hour procedure cal lost from malabsorption Considerations/Risks Not offered by most surgeons Stomach removal is permanent but bypass may be reversed Highest risk for vitamin and protein deficiencies, diarrhea and intestinal blockages

9 Take Home Points Consider what weight biases you may have Diet, exercise and behavior modification is the cornerstone of obesity treatment Consider alternatives to medications that promote weight gain Anti obesity medications may add 2.8 to 10.2 kg of weight loss vs placebo 5 10% weight loss may improve both metabolic and fat mass disease Bariatric surgery can have significant improvement on weight and obesity related conditions for those patients who are good candidates References Obesity Action Coalition, Obesity Algorithm Obesity Medicine Association Whitlock G, Lewington S, Sherliker P, et al. Body mass index and cause specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373:1083 Gadde, KM. CONQUER. Lancet 2011;377: Apovian et al Guidelines on Pharmacological Management of Obesity J Clin Endocrinol Metab, February 2015, 100(2): NIH Consensus Panel Recommendations for Bariatric Surgery LeBlanc ES, O'Connor E, Whitlock EP, et al. Effectiveness of primary care relevant treatments for obesity in adults: A systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 155: AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2013 Nov 7