The role of the pharmacist in weight loss

Theroleofthepharmacist
in weight loss and
inweightlossand
maintenance
HenryA.PalmerC.E.Finale2011
Presentedby:
StefanieC.Nigro,PharmD,BCACP,C‐TTS,CNWC
AssistantClinicalProfessor
UniversityofCT– SchoolofPharmacy
1
Facultydisclosure
 StefanieC.Nigrohasnoactualorpotential
conflictsofinterestassociatedwiththis
presentation
2
1
Self‐assessmentquestions
 HowmanypeopleintheUSareconsidered
obese(BMI>30kg/m
obese
(BMI >30 kg/m2)?




10‐20%
20‐30%
30‐40%
>50%
3
Self‐assessmentquestions
 Whichofthefollowingmedicationsis/are
associated with weight gain?
associatedwithweightgain?



I.amitriptyline
II.paroxetine
III.fluoxetine
 A.Ionly
 B.IIIonly
 C.IandIIonly
 D.IIandIIIonly
4
2
LearningObjectives
 Attheconclusionofthepresentation,attendees
will be able to:
willbeableto:




DescribeobesityanditsprevalenceintheUnited
States
Compareandcontrastavailableweightloss
medicationswithrespecttoefficacyandadverse
events
Explainhowbariatricsurgeryaffectsmedication
absorptionandotherpharmacokineticparameters
Givenapatientcase,recommendappropriatenon‐
pharmacologicandpharmacologictreatmentplans
forweightloss
5
TheObesityEpidemic
6
3
Didyouknowthat…
 Approximately33.8%ofUSadultsareobese

68%
68%overweightorobese
i ht
b
 Approximately17%ofchildrenand
adolescentsaged2‐19yearsareobese
 Directandindirectcostsoftreatingobesity‐
approximately$147billion
 Obesityratesvaryperstate




CT– 22.5%
MA– 23%
RI– 25.5%
NY– 23.9%
7
Self‐assessmentquestions
 HowmanypeopleintheUSareconsidered
obese(BMI>30kg/m
obese
(BMI >30 kg/m2)?




10‐20%
20‐30%
30‐40%
>50%
8
4
ObesityTrends*AmongU.S.Adults
BRFSS, 1990,2000,2010
(*BMI30,orabout30lbs.overweightfor5’4”person)
1990
2000
2010
NoData<10%10%–14%
15%–19%20%–24%25%–29%≥30%
9
Source:BehavioralRiskFactorSurveillanceSystem,CDC
DefiningObesity
 Definedintermsofbodymassindex(BMI)


Basedonweight(kg)andheight(m)only
B
d
i ht (k ) d h i ht ( ) l
BMI=(kg/m2)
Category
BMI
Underweight
<18.5kg/m2
Normal
18.5 ‐ 24.9kg/m2
Overweight
g
25– 29.9kg/m
g/ 2
Obese
>30kg/m2
Morbidlyobese
>40kg/m2
10
5
BodyMassIndex(BMI)
7
BMIbodycomparison
RememberthatBMIscanbemisleading!
12
6
Othermeasuresofobesity
 Waist‐to‐hipratio(WHR)




B d
i
f
f i t d hi
Basedoncircumferenceofwaistandhips
WHR=waist/hip
Greaterpredictorofcardiovasculardisease
Goals:


Women< 0.80
Men<0.90
M
0 90
 Waistcircumference


Highrisk:Men> 40inches(103cm)
Highrisk:Women> 35inches(88cm)
13
Medicalcomplicationsofobesity
14
Source:obesityonline.org
7
Top10LeadingCausesofDeath
intheUS
Rank
CauseofDeath
%of TotalDeaths
1
Heart Disease*
27.2%
2
Cancer*
23.1%
3
Stroke*
6.3%
4
Chroniclowerrespiratorydiseases
5.1%
5
Motor vehicleandotheraccidents
4.7%
6
DiabetesMellitus*
3.1%
7
Alzheimer’ssdisease
Alzheimer
disease
2 8%
2.8%
8
Influenza andpneumonia
2.5%
9
Kidneydisease
1.8%
10
Infectionsof theblood
1.4%
* Indicatesconditionsinwhichobesityisariskfactor
15
Source:CDC,NationalVitalStatisticsReport,2007;availableatwww.cdc.gov/nchs
Strategiesforweightloss
 Diet&exercise

For all obesepatients
obese patients
Forall
 Pharmacotherapy

Offeredtothosewho
failedtoachievegoals
throughdietandexercise
alone
 Surgery

Canbeconsideredfor
thosewithBMI>40who
faileddiet/exerciseor
whohavecomorbid
conditions
16
Source:Snow,etal.AnnInternMed.2005;142:525‐531.
8
Weight‐lossinterventionsin
clinicalpractice
 Multi‐center,randomizedcontroltrial
 415obesepatientswithatleast1cardiovascularrisk
415 obese patients with at least 1 cardiovascular risk
factor
 Controlgroup
 Remoteweightlosssupport
 In‐personsupport
 Duration:24months
 Baselineweight:103.8kg
 ‐0.8kgcontrolgroup
 ‐ 4.6kgremoteweightlosssupport(p<0.001)
 ‐ 5.1kgin‐personsupport(p<0.001)
17
Source:Appel,etal.NEJM.2011;365:1959‐68.
Obesityinprimarycare
 Multi‐center,randomizedcontroltrial
 390obesepatients
390 obese patients
Usualcare
 Brieflifestylecounseling
 Enhancedlifestylecounseling
 Duration:24months
 86%ofpatientscompletedthestudy
86% of patients completed the study
 Enhanceslifestylecounselingwassuperiortoother
interventionsregardingweightloss


Evenaftersibutraminepatientswereexcludedfromthe
analysis
18
Source:Wadden,etal.NEJM.2011;365:1999‐79.
9
WHATISTHEROLEOFTHE
PHARMACIST?
19
Practicingevidencebased
medicine
JNC‐7
ADA2011
NCEP‐ATPIII
20
10
Pharmacistassistedweightloss
 Measureweight,heightandcalculateBMI
 Evaluatepotentialobesityrelateddiseases
E l
i l b i
l d di
whileperformingmedicationtherapy
management(MTM)
 Identifymedicationsthatcauseweightgain
 Recommend(orinitiate)atreatmentplanfor
obesity,includingdrugtherapywhennecessary
b
l d
d
h
h
 Counselpatientsonlifestylemodifications
 Anticipatemedicationchangess/pbariatric
surgery
21
Medicationinducedweightgain
DrugorDrugClass
Possible Alternatives
AntidiabeticAgents
Insulin
Meglitinides
 Nateglinide, repaglinide
Sulfonylureas (SU)
 Glipizide,glyburide
Acarbose,exenatide,liraglutide,glimeperide,
metformin, sitagliptin,saxagliptan,linagliptan
Thiazolidinediones (TZD)
 Pioglitazone,rosiglitazone
PsychiatricAgents
Antidepressants
 SSRIs(paroxetine,citalopram)
 TCAs
 Mirtazapine
Bupropion
Desipramine
Atypicalantipsychotics
 Clozapine,olanzapine
Aripiprazole,zisprasidone
Anticonvulsants
 Carbamazepine,valproic acid
Topiramate,lamotrigine,zonisamide
22
Source:MaloneM.AnnPharmacother2005;39:2046‐55.
11
Self‐assessmentquestions
 Whichofthefollowingmedicationsis/are
associated with weight gain?
associatedwithweightgain?



I.amitriptyline
II.paroxetine
III.fluoxetine
 A.Ionly
 B.IIIonly
 C.IandIIonly
 D.IIandIIIonly
23
Pharmacotherapy
 ClinicalPearls





Weightlossismodestwhencomparedto
W
i ht l
i
d t h
dt
placebo
Longtermsafetydataislacking
Noevidenceofmortalitybenefit
Obesitystudiestypicallyhavehighdropout
rates
Pharmacotherapyshouldonlybeusedin
combinationwith,NOTasasubstitutefor,
lifestylemodifications
24
12
OverviewofFDAapproved
pharmacotherapy
Phenteramine**(Adipex‐P,® Ionamin®)
• MOA:Appetitesuppressant;sympatheticamine
MOA: Appetite suppressant; sympathetic amine
• ADE:Cardiovascular,gastrointestinal
Diethylpropion**(Tenuate®)
• MOA:Appetitesuppressant;sympatheticamine
• ADE:Palpitations,tachycardia,insomnia,gastrointestinal
Orlistat (Xenical®,Alli®)
• MOA:Lipaseinhibitor,decreasedabsorptionoffat
• ADE:Diarrhea,flatulence,bloating,abdominalpain,
dyspepsia
**IndicatesDEAscheduleIVcontrolledsubstance
25
Source:Snow,etal.AnnInternMed.2005;142:525‐531.
Sibutramine(Meridia®)pulled
frommarket
 November1997– sibutramineapproved
 November2009–
N
b 2009 FDAreviewscardiovascular
FDA
i
di
l
safetydata
 October2010– voluntarywithdrawalfrom
market



BasedondatafromtheSCOUTtrial
16%increaseinriskofmajoradverse
cardiovasculareventsinpatientstreatedwith
sibutraminecomparedtopatientstakinga
placebo
Harmoutweighedbenefit
26
13
Medicationswithweightloss
propertiesbut…
 NotFDAapprovedforweightloss








Exenatide(Byetta
E
tid (B tt ®)
Liraglutide(Victoza®)
Pramlinatide(Symlin®)
Topiramate(Topamax®)
Lamotrigine(Lamictal®)
Zonisamide(Zonegran®)
Fluoxetine(Prozac®)
Bupropion(Wellbutrin®,Zyban®)
27
Phenteramine
(Adipex‐P,® Ionamin®)
 Efficacy
 Shortterm
Sh t t
 3.6kglossonaverage
 Safety
 ADE:tachycardia,
elevatedBP,
insomnia,,
constipation
 CI:MAOIusew/i14
days,hxofCHF,
stroke,glaucoma,
arrhythmias
 EaseofUse
 15–
15 37.5mgpoTID
37 5
TID
beforemeals
 15– 30mgpoqam
(resin)
 Cost
 Availableasgeneric
g
28
14
Diethylpropion
(Tenuate®)
 Efficacy
 Shortterm
Sh t t
 3kglossonaverage
 Safety
 ADE:constipation,
insomnia,
constipation
p
 CI:MAOIusew/i14
days,HTR,CAD,
glaucoma,pulmonary
HTN,hxofsubstance
abuse
 EaseofUse
 25mgpoTID(1hour
25
TID (1 h
beforemeals)or75
mgCRpoam
 Cost
 Availableasgeneric
29
Orlistat
(Xenical®,Alli®)
 Efficacy
 Shortterm
Sh t t
 2.5‐4kgloss
 Safety


ADE:Oilyspotting,fecal
urgency,bloating,
cramping,nutritional
deficiencies
CI:Chronic
malabsorption
syndromes,cholestasis,
pregnancy,lactation
 EaseofUse
 60or120mgpoTID
60 120
TID
within1hourofeach
fatcontainingmeal
 ~15gramsoffat
 Cost
 AvailableOTC/Rx
/
 Brandnameonly
30
15
SURGICALINTERVENTIONS–
WHATISTHEROLEOFTHE
PHARMACIST?
31
Candidatesforbariatricsurgery
 NHLBI1998Guidelines


BMI>40*
BMI
40*
BMI35‐40*withhighriskco‐morbidconditions
 USPTF2005Guidelines

BMI>40*whopresentwithobesityrelatedco‐
morbidconditionsincludingHTN,IFG,OSA,HLD
a d DM
andDM
*Andwhohaveinstitutedandfailed
dietandexerciseinterventions(with
orwithoutadjunctpharmacotherapy)
32
16
Typesofsurgery
Roux‐en‐Ygastricbypass
 30‐40kgweightlossmaintainedfor
10years
 0‐1%postsurgicalmortality
 Significantnutritionaldeficiencies
Laparoscopicbanding
 20‐30kgweightlossmaintainedfor
5years
 FDAapprovedforBMI> 30
33
Source:VirjiA,MurrMM.AmFamPhy2006;73:1403‐8
Pharmacistassistedweight
maintenance
 Recommendalternatedosageformsfor
improvedmedicationabsorption
improved
medication absorption
 Recommendnutritionalsupplementationwhen
appropriate
 Counselpatientsonmedicationstoavoid
 Initiateorrecommendtherapeuticdrug
monitoring
34
17
Considerationsforthe
pharmacist
 Remember,gastricbypass…

Alt
Altersabsorptionof:
b
ti
f

Medications
 Timetoabsorption/bioavailability
 Reducedsurfaceareainsmallintestine
 Entericcoated(EC),ER,XL,SR,CR

Nutrients
 B12,folate,iron,calcium,ADEK,thiamine

Changesgastricemptyingtime
35
Selectmedicationswithpotential
decreasedabsorption
Unknown site of absorption:
Unknownsiteofabsorption:
Quetapine,zolpidem,simvastatin,
ramipril
AbsorbedinthestomachOR
duodenum:
Olanzapine,ketoconazole,
lamotrigine,niacin,metoprolol
tartrate,metformin
Source:MillerAD,SmithKM.AmJHealth‐SystPharm.2006;63:1852‐7
18
Dosageformconsiderations
 Recommendalternativedosageformswhen
appropriate





Liquid
Sublingual;buccal
Rectal
Transdermal
IM
 Considercrushingordissolvingmedication

Openandmixwithsoftfood(i.e.pudding,
applesauce)
37
Nutrientrecommendations
 Calciumcitrate1500– 2400mgincombination
withvitaminD
with
vitamin D
 Multivitaminsupplementation

withthiamine
 Folicacid1‐2mgdaily
 Ironsupplementation(avoidferroussulfate
salts)
 VitaminB12350‐500mcgdaily

Considernasalorparenteralifneeded
Source:Bariatricsurgeryandmedicationuse.Pharmacist’sLetter/Prescriber’s
Letter2009;25(11):251101.
38
19
Drugstoavoid(whenpossible)
 NSAIDs,salicylates&corticosteroids
 Bisphosphonates
Bi h
h
 Ethanol
 Liquidmedicationswith>2gramssugar

Fructose,cornsyrup,lactose,honey,etc
 MedicationsthatcauseGERD

CCB,BB,anticholonergics,etc
 Extended‐releaseorcontrolled‐release
 Medicationsthatcauseweightgain
Source:Bariatricsurgeryandmedicationuse.Pharmacist’sLetter/Prescriber’s
Letter2009;25(11):251101.
39
Puttingitalltogether
40
20
PatientCase
 MNisa34yearoldfemalewhopresentstoyourclinicforaninitial
visit.Shehasalwaysbeenheavybuthasgainedanadditional20
poundsoverthepastyearafterakneeinjurywhichhaslefther
moresedentary.Uponinterview,MNdescribeseatingfastfood
everymorningforbreakfastwithherofficemates.Shedenies
excessivealcoholintakebutadmitstodrinkingsociallyonthe
weekends.Shedoesnotsmokeoruseillicitdrugs.HerPMHis
significantforhypertension(HTN)only.Onphysicalexamination,
sheis64inchestallandweighs285lbs.HercalculatedBMIis48.9
m/kg2 withawaistcircumferenceof50inches.Herbloodpressure
with a waist circumference of 50 inches Her blood pressure
todayis152/88mmHg.ShecurrentlytakesHCTZ25mgdailybut
admitstonottakingitforthepastweekduetoforgetfulness.All
otherlabsarewithinnormallimits.
41
Question1
 Whatisthemostappropriateinterventiontomanage
MN sobesityatthistime?
MN’s
obesity at this time?
 A.Startphenteramine15mgbymouth3timesaday
withmealsinconjunctionwithalowcarbohydrate
diet
 B.Anexerciseprescriptionof60minutesofrunning
5timesaweekinconjunctionwithalowfatdiet
 C.Startorlistat60mgbymouth3timesadaywith
C St t li t t 60
b
th 3 ti
d
ith
mealswithcalorierestricteddiet
 D.Acalorierestricteddietlowinsaturatedfatsand
refinedsugarsinconjunctionwithaprogressive
exerciseprescription
42
21
Question2
 MNreturnstoclinic6monthslaterwitha15lbweight
loss.Althoughsatisfiedwithherprogress,sheis
loss.
Although satisfied with her progress, she is
interestedinpharmacotherapyforfurtherassistance.
Whichofthefollowingagentswouldbemost
appropriateforMN?
 A.Fluoxetine20mgbymouthinthemorning
 B.Orlistat60mgbymouth3timesadaywithmeals
 C.Diethylpropion25mgbymouth3timesaday
C Di th l
i 25
b
th 3 ti
d
before(1hourbeforemeals)
 D.Exentatide5mcginjectedsubcutaneouslytwicea
day(1hourbeforemeals)
43
Summary
 Theprevalenceofobesitycontinuestorisein
the United States
theUnitedStates


66%ofadultsareoverweightorobese
33%ofadultsareobese
 Pharmacistsareuniquelypositionedandwell
trainedtoassistpatientsintheirquitattempts



Evaluation
E
l
Drugtherapy
Monitoring&follow‐up
44
22
QUESTIONS?
45
23