Allen - Evaluation and Treatment of Obesity

6/21/2016
Presented by
Evaluation and Treatment
of Obesity
Robert F. Allen, MD
July 1‐3, 2016
Sandestin Golf & Beach Resort
Neurology Evaluations, PC
Evaluation
and
Treatment of
Obesity
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Robert F. Allen, MD
Weight Management Clinic
( A division of Neuro-Eval, P.C. )
105 N. Pontiac Ave, Suite 1
Dothan, AL 36303-3959
rfa7255 @ hotmail.com
Our Prescribing Seminar includes
Obesity Management because:
1) Obesity is a major health issue
2) Numerous risks & co-morbidities
3) Anorexiants are Schedule III-IV
4) FDA / DEA laws and guidelines
5) Alabama Board Medical Examiners
“Rules for Prescribing Anorexiants”
(540-X-17), in force January, 2012
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OUTLINE OF TOPICS
------------------------------------------------------------------------
1) Definitions
2) Measurements
3) Demographics 4) Contributors
5) Adipose Cells 6) Comorbidities
7) Mortality risks 8) Evaluations
9) Treatments 10) Anorexiants
11) ABME Rules 12) Limitations
I.
OBESITY
DEFINITIONS
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June 18, 2013
”Obesity
is a disease state with
multiple pathophysiology
aspects, requiring a range of
interventions to advance
treatment and prevention.”
MY BEST DEFINITION:
Obesity is a multi-factorial
complex disease state
which encompasses
genetic, environmental,
metabolic, physiological,
behavioral, psychological,
social & cultural factors …
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… and is associated with
increased risks of numerous
medical conditions:
diabetes mellitus type II, dyslipidemias,
hypertension, coronary artery disease,
TIA/stroke, renal disorders, cancers,
obstructive sleep apnea, asthma,
gall bladder diseases and surgery,
arthritis, gout, DJD spine/hips/knees,
PCOS, reproductive disorders, etc.
II.
OBESITY
MEASUREMENTS
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 Underwater Weighing
 Skinfold Calipers
 Dual-Energy X-ray
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Absorpitometry (DXA / DEXA)
Bio-Impedance Analysis (BIA)
Near-Infrared Reflectance (NIR)
Body Mass Index (BMI)
Abdominal Girth Measurement
Waist-to-Hip Ratio (W:HR)
Underwater
Weighing
Hydrostatic testing
Basis: Fatty tissue floats
Lean tissue sinks
This is the gold standard for
“Body Fat Percentage”
in clinical obesity research.
But: Clearly, not practical
in a clinical office setting.
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Skinfold Calipers
Measure skin-fold thickness
over several (9 to 24) areas.
Measurements are entered in
tables or formulas to yield a
body fat analysis.
Limitations of calipers:
1) Time-consuming (measures & data entry);
2) Subject to human variability in technique;
3) Wide range of values (>90 formulas).
DXA (Dual-Energy
X-ray Absorpitometry)
A direct measure of minerals
and thus, primarily a bone
density study (osteopenia).
Also measures lean mass.
Fat tissue mass is obtained
by calculation: Total mass
- mineral and lean mass
= body fat mass
(An accurate but expensive method)
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Near-Infrared
Reflectance
A fiberoptic probe sends
an Infrared light signal
through a muscle. The light
is reflected off the underlying
bone and back to the signal
detector.
Reflectance
is proportional to the degree
of underlying fat content.
Sources of error in NIR: 1) edema; 2) dehydration;
3) skin color; 4) patients in the higher obesity range;
5) technician’s applied pressure on the probe.
Bio-Impedance
Analysis (BIA)
Painless electrical current
passes through grounded body.
1) Lean tissues (skin, muscles,
bone) conduct the current.
2) Fatty tissues act as insulation,
do not conduct the current.
Yield= BODY FAT PERCENT
Operator-independent, safe and
easy to use. Floor models are
affordable ($1,800-2,500);
hand-held models less reliable.
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Body Mass
Index (BMI)
A calculation:
total body weight (TBW)
___________________________________________________________________
body surface area (BSA)
BSA is estimated by the
square of the height.
BMI is based on TBW, and
cannot distinguish fatty
tissue from lean tissue.
Calculating the BMI
National Institutes of Health, Consensus Conference, 1991
Metric: BMI = Wt (Kg) / Ht (M2)
English: BMI = Wt (Lb) x 704 / Ht (In2)
Example:
A 5’6” female weighs 196 pounds.
BMI = 196 pounds x 704
66” x 66”
= 136,788 / 4,356 =
31.6
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BMI Chart
National Institutes of Health, Consensus Conference, 1991
CALCULATED BMI
> 40.0
35.0 – 39.9
30.0 – 34.9
27.0 – 29.9
25.0 – 26.9
18.5 – 24.9
< 18.5
CLASSIFICATION
Obese III
Obese II
Obese I
Overweight II
Overweight I
Normal
Underweight
Advantages of BMI
over other obesity rating methods:
 Inexpensive (requires no special equipment)
 Anyone can perform (you only need the
patient’s weight, height, and a calculator)
 Convenient
(many scales are equipped to
perform the BMI calculation at weigh-in)
 Patient progress easily followed over time
 Correlates closely with body fat
(vs. underwater weighing) in ~92% of people
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Inaccuracies in BMI
 BMI may over-estimate body fat when:
NUMERATOR (total body weight) is larger but non-fat:
 Athletes / body builders  extra weight from muscle
 Edematous states  extra weight is from fluid
 Pregnancy  extra weight of fetus, placenta, fluid
DENOMINATOR (height ²) is smaller < 5’2” (female)
or < 5’5” (male)
 BMI may under-estimate body fat in:
 Sarcopenic obesity – increase in abdominal fat,
coupled with a loss of muscle mass in the limbs
(a condition especially common in the elderly)
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Abdominal Girth
Measurement
BMI alone cannot
determine unhealthy
central fat content.
The largest girth of
the abdomen gives
a good estimate of
intra-abdominal fat.
BE CONSISTENT:
I always measure
with the patient in
a seated position,
to avoid “holding in.”
DANGER LEVELS:
NIH Expert Panel Report, Am J Clin Nutr 1998; 68:899-917
Females: >35”
Males:
>40”
Waist-to-Hip Ratio (W:HR)
“apple”
“pear”
or
android
(male-like)
Males
> 1.0
0.96 – 1.0
< 0.95
or
gynoid
(female-like)
Health Risks Based
Solely on W:HR
Higher Risks
Moderate Risks
Lower Risks
Females
> 0.85
0.81 – 0.85
< 0.80
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The Take-Home Message on Measurements
“ BMI’s and Belly Size ”
It should take about one (1) minute to:
a) obtain the weight and height,
b) calculate the BMI (body mass index),
c) measure the abdomen and hips,
d) calculate W:HR (waist-to-hip ratio),
e) enter these values in the record.
When used together, BMI, abdominal girth
and W:HR are the best predictors of
future health complications resulting
from excess central (abdominal) fat.
III.
OBESITY
DEMOGRAPHICS
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South Pacific Islands
Actual Postcards for Sale
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Highest Obesity Rates on Earth
Global Obesity Rates
Russia
and Former SSR’s
Iceland
UK
Canada
32% → USA
Mexico
Cuba
Central
America
South Pacific
Islands
Ireland
Spain
Portugal
Eastern
Europe
Middle
Dominica
Caribbean
Iran
East
Barbados
Venezuela
South
Pacific
Islands
Maldives
Ecuador
Seychelles
Australia
Chile
Uruguay
Argentina
Republic of
South Africa
New
Zealand
OBESITY (BMI>30) RATES
South Pacific Islands
Middle East
United States & Mexico
55-75%
> 60%
> 32%
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World Population Milestones
Population
1 billion
2 billion
3 billion
4 billion
5 billion
6 billion
7 billion
8 billion
9 billion
10 billion
Year
1804
1927
1959
1974
1987
1999
2011
est. 2024
est. 2037
est. 2050
Interval
dawn of humans
123 years later
32 years later
15 years later
13 years later
12 years later
12 years later
13 years later
13 years later
13 years later
As of July 2, 2016
World Population:
30% Overweight:
13% Obese:
USA Population:
7,463,000,000
2,230,000,000
970,000,000
324,500,000
68% Overweight:
220,000,000
32% Obese:
104,000,000
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USA Obesity Prevalence - 2016
>20%
>25%
>30%
2002
2004
2006
*47.6%
* * ** * *
*
2008
2010
2012
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Obesity Rate by County, 2012

IV.
CONTRIBUTORS
to
OBESITY
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Contributors to Weight Gain
DIETARY FACTORS
Consuming more calories than used
 Larger portions (restaurants, fast food, home)
 Eating with friends / family who overeat
 Reliance on “low fat” yet high-calorie foods
 Inadequate dietary fiber (= “not full”)
 Sugary sodas, sports drinks, beers, cocktails
 Eating too fast (belly  brain = 20 min)
 Skipping meals during the active hours,
only to overeat at the end of the work day

Contributors to Weight Gain
LIFESTYLE FACTORS
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Entrenchment in a sedentary lifestyle
(sitting: work, desk, computer, TV, traffic)
Lack of daily cardiovascular exercise
Marriage, moving, marital discord, divorce
Stopping smoking (avg gain 4-30 pounds)
Longer work hours, overtime, 2+ jobs
Shift work, sleep irregularities
Going on vacation (dietary changes?)
Paying for meals with credit cards
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Contributors to Weight Gain
MEDICAL FACTORS
Genetics (obese parents, other family)
 Overweight or obese as a child or young
teen (prepubertal obesity leads to an
increase in number and size of fat cells)
 Low BMR (basal metabolic rate) which
decreases ~1% per year after 30
 Hypothyroidism (up to 10% of women)
 Life stressors, anxiety, depression
 Cushing’s syndrome (cortisol effect)
 Sleep apnea or other insufficient sleep

Contributors to Weight Gain
MEDICAL FACTORS
Polycystic ovarian syndrome (PCOS)
 Menopause (+5-15 pounds, low abdominal)
 Essential fatty acid deficiencies
 Renal or hepatic insufficiency
 Hysterectomy, especially with bilateral
oophorectomy, > with hormonal therapy
 Fibromyalgia (and associated conditions)
 Rare syndromes (Prader-Willi, Bardet-Biehl,
Cohen, Albright, Fragile X, Carpenter)

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Drugs  Weight Gain
 Hormones – Depo-Provera®, estrogens, OCP’s
 Antidepressants – all Tricyclics, all MAOI’s,
most SSRI’s (Paxil, Zoloft, Celexa, Lexapro, Luvox),
Cymbalta, Lithium carbonate, Desyrel (trazodone),
Sinequan (doxepin), Effexor, Pristiq, Remeron
 Proton Pump Inhibitors (PPI’s) – (Prilosec,
Nexium, Prevacid, Aciphex, Protonix, Zegerid)
 Beta-blockers – propanolol, atenolol, metoprolol
 Medications for Diabetes – all insulins;
> sulfonylureas: Glucotrol (glipizide), Amaryl (glimeperide)
> glyburides: (DiaBeta and Glynase)
> thiazolidindiones: (Actos, Avandia, Regulin)
Weight Change in
Antidiabetic Therapy
Weight change (kg)
Insulin
7
6
5
Sulfonylurea
Glyburides
4
3
2
Diet alone
1
Metformin
0
Invokana®
-1
2
4
6
8
10
Years of treatment
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Drugs  Weight Gain
 Anticonvulsants – (Depakote, Neurontin,
Tegretol, Carbatrol, Trileptal, Lyrica, Vigabatrin)
 Calcium-channel blockers – verapamil
 Anti-Allergy meds – (mainly with chronic use) –
Periactrin, Claritin, Allegra, diphenhydramine
 Antineoplastics – tamoxifen, aromatase inhib’s,
methotrexate, cyclophosphamide, 5-fluorouracil
 Antiretrovirals – Protease inhibitors (all)
 Antipsychotics – Clozaril, Zyprexa, Thorazine,
Stelazine, Mellaril, Navane, Seroquel, Risperdal,
Haldol, Abilify, Permitil, Geodon)
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Drugs  Weight Reduction
 Metformin (Glucophage®): diabetes mellitus type II, PCOS;
ADA  Metformin can prevent clinical DM II if BMI > 35.
 SGLT2 inhibitors – (Invokana®, Farxiga® and Jardiance®);
glycosurics for treatment of diabetes mellitus type II.
 Exentanide (Byetta ®) and Liraglutide (Victoza®): DM-II;
delayed gastric emptying, stomach fullness, nausea.
 Buproprion (Wellbutrin®): depression, (Zyban®): smoking;



Choice antidepressant in obese; 100, 150, 200, 300mg.
Do not combine with dopaminergic anorexiant Tenuate®.
Fluoxetine (Prozac®): anxiety, (Sarafem®): pre-menstrual;
20-60 mg daily if taken alone; 10-40 mg daily if combined
with anorexiant, preferably Tenuate® (diethylproprion).
Topiramate (Topamax®): migraine prophylaxis, epilepsy;
weight reduction dose 50-100 mg daily; CNS side-effects.
Zonisamide (Zonegran®): anticonvulsant, anti-migraine;
weight loss often with preventive doses 100-200 mg daily.
V.
FAT CELLS
FUNCTIONS
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A Fat Cell – Classic View

___

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In 1950, there arose a mutant strain of mice with
excess eating, weight gain and diabetes, suggesting
the existence of a hunger-reducing hormone (Leptin).
Obese
mouse,
(ob-ob)
unable to
produce
Leptin
Normal
mouse,
able to
produce
adequate
Leptin
1994: the ob gene was isolated to mouse Chromosome 6
and human Chromosome 7q. Obese humans DO NOT have
leptin deficiency. Obese humans show desensitization of
leptin receptors in the arcuate nucleus of the hypothalamus.
Leptin is the most important hormone
produced by adipose cells, with a major role
in regulating hunger, appetite, eating behavior,
and energy expenditure.
 Leptin acts on receptors in the arcuate nucleus
of the hypothalamus (the “satiety center”) to
decrease appetite, meal size and frequency.
 Counteracts the hunger-producing effects of:
 ghrelin (the “hunger hormone”) from the gut
 neuropeptide-Y from hypothalamus and gut
 Aids metabolism and energy expenditure by
stimulating leptin receptors in the periphery
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INCREASED BODY FAT
Effects of Fat Mass
Distant Effects of Fat
Obstructive apnea
Fatty liver diseases
Added weight/inch²
on feet, ankles,
knees, hips, SIJ’s
DJD (weight-bearing joints)
Protrusion of the
center of gravity 
Low back pain/strain
Diabetes type II
Endothelial diseases:
CAD, MI, TIA, stroke
Hyperlipidemias
Solid cancers
Inflammatory arthritis
(NWBJ’s) and gout
Adult asthma
PCOS, infertility
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ADIPOSOPATHY
(“sick fat syndrome”)
Products of fat cells contribute to:

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

Hunger, appetite, caloric intake and satiety
Glucose regulation, transport and storage
Insulin regulation, sensitivity and resistance
Lipid absorption, metabolism and storage
Hypertension, vasoconstriction, vasodilation
Thirst, salt regulation and renal function
Inflammatory processes in many tissues
Endothelial malfunctions and CAD/CVD/PVD
Brain and nervous system malfunctions
Excessive Body Fat
 Alters the body’s response to insulin
 Potentially leads to insulin resistance
 Is widely present among diabetics:
77% of women and 64% of men
with DM type II are overweight or obese
 Creates a pro-thrombotic state
Associated with CAD, MI, stroke, TIA, PAD
 Creates a pro-inflammatory state
Associated with asthma, osteoarthritis, gout
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Metabolic Syndrome
Central adiposity:
belly circumference
Dyslipidemia:
triglycerides >150
Hypertension:
Hyperglycemia:
Hyperinsulinemia:
Insulin resistance:
Diabetes type II:
Males
>40 inch
Females
>35 inch
HDL <40 HDL <50
pressure >135/85,
or taking bp med
fasting glucose >110
or A1C > 7.0
fasting insulin >15
abnormal GTT
end-organ diseases
VI.
COMORBIDITIES
of
OBESITY
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Obesity and Diabetes type II
Risk in Women (Nurses’ Study)
100
115,195 women, studied for 14 years
93.2
75
54.0
50
40.3
27.6
25
15.8
4.3
5.0
8.1
1.0
2.9
<22
2222.9
2323.9
2424.9
2526.9
0
27- 2928.9 30.9
3132.9
3334.9
35+
BMI (kg/m2)
Colditz et al. Ann Intern Med 1995; 122: 481-6
Diabetes
by
county,
(2008)
___________________
Obesity
by
county,
(2008)
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Comorbidities of Obesity
ENDOCRINOLOGY
Diabetes mellitus type II
 Polycystic ovarian syndrome
 Menstrual disorders
 Infertility (female and male)
 Intrauterine fetal death
 Increased birth defects risks
(anencephaly, hydrocephaly, spina bifida,
heart defects, cleft palate, cleft lip)
 Pregnancy / delivery complications (C-section)

Comorbidities of Obesity
CARDIOVASCULAR


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

Hypertension
Coronary ischemic disease
Congestive heart failure
Atrial fibrillation / arrhythmias
Cardiomyopathy of obesity (adipositas cordis)
Elevation of triglycerides and
cholesterol, abnormal fractions
Elevation of serum triglycerides
Deep venous thrombosis
Pulmonary embolism
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Comorbidities of Obesity
NEUROLOGY
 Stroke and TIA
 Intracranial hypertension
(pseudotumor cerebri)
 Nerve compressions:
 Carpal tunnel syndrome (wrist)
 Meralgia paresthetica (thigh)
 Tarsal tunnel syndrome (ankle)
 Multiple sclerosis (esp in obese adolescents)
 Migraines (esp the chronic daily form in females)
 Dementia (increase of 42-80%) Johns Hopkins Univ, Sch Pub Health
“ Obesity Can Increase Dementia Risk By Up To 80 Percent,” Study, (May 7, 2008).
Comorbidities of Obesity
 Obstructive sleep
PULMONOLOGY
apnea (OSA)

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

Adult asthma
Cor pulmonale
Hypoventilation
(CO2 retention)
Respiratory
failure
2° Pulmonary
hypertension
Complications
during general
anesthesia
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Comorbidities of Obesity
GASTROENTEROLOGY


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



Gastro-Esophageal Reflux Disease (GERD)
Non-Alcoholic Steato-Hepatitis (NASH)
Non-Alcoholic Fatty Liver Disease (NAFLD)
Gall bladder disease (stones,
cholestasis, cholecystitis)
Increased incidence and earlier
age of cholecystectomy
Gallstone-induced pancreatitis
Gastrointestinal cancers:
Liver, gall bladder,
colon and anorectal
Comorbidities of Obesity
RHEUMATOLOGY





Marked increase in gout and osteoarthritis in general
Earlier onset DJD in weight-bearing joints
(feet, ankles, knees, hips, sacroiliac joints)
Lumbar degenerative discs
Low back pain:
protuberant abdomen

results in forward shift
of the center of gravity

with compensatory

lumbar muscle strain
Myofascial pain syndrome
(formerly fibromyalgia)


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Comorbidities of Obesity
ORTHOPÆDICS
 Total hip replacement:
Increased need, earlier intervention
(up to 10 years sooner if BMI ≥ 35)
Longer surgery/rehab, or worse outcome
 Total knee replacement:
Increased need, earlier intervention
(risk ratio of 6.6 if the BMI ≥35)
Longer surgery, 2x infections, longer rehab
 Impaired mobility and falls
Devices (cane, walker, wheelchair, scooter)
 Obese pediatric population:
Malalignment in legs, increased fracture risk
Comorbidities of Obesity
GENITOUROLOGY

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Chronic renal failure (CRF)
Renal stones (♀ > ♂)
Urinary incontinence
Renal cell carcinoma
Diseases of the prostate
(prostatitis and pain)
Prostate cancer (57%
increase in incidence, more aggressive tumors,
increased morbidity, earlier mortality when BMI>35)
Secondary male hypogonadism / hypotestosteronism,
erectile and/or ejaculatory dysfunctions
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Comorbidities of Obesity
PSYCHIATRY

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Altered self-image  low self-esteem, shame
Embarrassment  social isolation/seclusion
Anxiety related to body size/image may
paradoxically lead to binge-eating
Depression is more common among the obese
…but suicide attempts are less common
Adverse effects on relationships (marital, family,
work, social) and academic achievement
Obesity stigma (present at any age, but often
most severe in obese children)
Teasing, name-calling, bullying (and retribution)
Comorbidities of Obesity
ONCOLOGY
(Relative risks, as compared with persons with BMI <25)
Solid Cancers
Liver
Endometrium
Esophagus
Renal cell
Colorectal
Gallbladder
Stomach
Pancreas
Prostate
Breast (post-menopausal)
BMI >25
BMI >30
1.5
2.0
2.0
1.5
1.5
1.5
1.5
1.3
1.3
1.3
4.0
3.5
3.0
2.5
2.0
2.0
2.0
1.7
1.6
1.5
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Comorbidities of Obesity
DERMATOLOGY
Striae
Psoriasis
Cellulitis Lymphedema
Hirsutism
Intertrigo
Acanthosis
Hyperkeratosis
Consequences of Obesity
HEALTH CARE BIAS

Obese patients who experience stigma in health-care
settings may forego or delay essential preventive care,
including age-appropriate screenings for breast, cervical
and colorectal cancer. Wee CC, et.al. Screening for cervical and breast
cancer: Is obesity a barrier to preventive care? Ann Intern Med 2000; 132: 699–704.

When asked about specific reasons for delay of care,
women reported disrespectful treatment and negative
attitudes from providers, embarrassment about being
weighed, receiving unsolicited advice to lose weight,
and chairs, gowns and exam tables, etc., too small to be
functional. These concerns increased as BMI increased.
Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer
screening for White and African-American obese women. Int J Obes 2006; 30: 147–155.

NOTE! Providers, please increase your awareness of
the complex nature of obesity, and be more supportive.
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VII.
OBESITY
MORTALITY
All passengers
and crew on
both planes
are killed !
Total dead:
1,000
This is what OBESITY is
doing in America every day.
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435
365
98
75
60
52
42
26
24
Relative Risk
Relative
Risk
of Mortality
ofbyMortality
BMI
by BMI
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Years of Life Lost (YLL)
as a Function of BMI
Weight Class
BMI
Years Lost
________________________________________________________
__________________
______________________________________________
<19
19-25
>27
>30
>35
>40
>50
Variable
Reference
2-3 years
4-5 years
6-7 years
8-9 years
12-16 years
Underweight
Normal
Overweight
Obese I
Obese II
Obese III
Extreme Obesity
VIII.
OBESITY
EVALUATIONS
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Medical History Items of
Importance in Obesity

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

Weight Gain History, Onset, Pattern
Previous Weight Loss History and How?
Dietary History (what & how much)
Exercise History (how active & how often)
Past Medical / Psychiatric History
Pregnancies (and weight gain during…)
Habits, Addictions, Bulimia, Anorexia
Current and Previous Medications
Family (Obesity and Comorbidities)
Evaluation of Obesity
PHYSICAL EXAM




WEIGHT, BMI, BODY FAT % (for classification)
VITAL SIGNS (hypertension, tachycardia)
HEENT
 Facial redness/puffiness  Cushing’s disease
 Hirsutism  PCOS, Cushing’s
 Periorbital edema, thinning of lateral eyebrows,
scalloped tongue  hypothyroidism
 Erosion of dental enamel, swollen parotid glands
 consider bulimia nervosa
 Vertical nystagmus  low magnesium
NECK
 Circumference > 17”M, > 16” F (sleep apnea)
 Enlarged thyroid/masses/nodules
 Buffalo hump  Cushing’s disease, steroids
39
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Evaluation of Obesity
PHYSICAL EXAM




HEART
 Rhythm abnormalities, murmurs
ABDOMEN
 Girth measurement (abnormal > 40” M, > 35” F
 Waist:Hip ratio (high risk: > 1.0 M, > 0.85 F
 Tenderness, ascites, umbilical hernia
EXTREMITIES AND SKIN
 Edema from CHF, renal insufficiency, liver disease
 Muscle weakness  myasthenia gravis, Cushing’s
 Dry, cracked heels  diabetes, hypothyroidism,
essential fatty acid deficiency (linoleic, α-linoleic)
Deep Tendon Reflexes
 Delayed relaxation phase  hypothyroidism
 Hyperactive  low magnesium
Evaluation of Obesity
LABORATORY TESTING
Basic Laboratory Work-Up
Metabolic panel
Lipid profile
CBC w auto diff
Vitamin D level
T3, T4, TSH
Urinalysis
Other Tests when Indicated
EKG/Cardiac testing
Polysomnography
Hormone levels
Hgb A1c, GTT
Uric acid
Serum Mg++
Other Considerations of Relevance in Obesity
Insulin resistance
Pre-diabetes
Diabetes type II
Metabolic syndrome
Hyperlipidemia
Hypothyroidism
Vitamin D def.
Cushing’s synd.
Fatty liver
Cancers
PCOS
Low Mg++
40
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IX.
OBESITY
TREATMENTS
41
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Dietary Guidelines



RCD (reduced calorie diets) – Most of the successful
weight loss diets include a reduction in calories, a
marked reduction in carbohydrates (SugarBusters,
Atkins, Weight Watchers, South Beach, The Zone,
Mediterranean, American Diabetic Association, etc.),
elimination of saturated fats, modest reduction in
unsaturated fats; maintain adequate intake of protein,
fiber, water, antioxidants, and essential vitamins.
LCD (low calorie diets, ≤ 1200 Cal/day) include
meal replacements (shakes, cookies, chips, soups)
plus one limited-calorie, low carb meal per day.
VLCD (very low calorie diets, ≤ 600 Cal/day) include
meal replacements (protein shakes). VLCD requires
weekly visits / labs; vitamin / electrolyte supplements.
These are best left to physicians with VLCD training.
Activity Guidelines





Weight maintenance in an adult requires at least
150 minutes of cardiovascular (aerobic) exercise per
week ( = 22 minutes/day, 30 minutes 5 days/wk, or
50 minutes 3 days/week. EASY: While watching an
hour of TV, stand and “march-in-place” only during
commercials. Equals 22 minutes of cardio exercise.
For faster loss, increase to 225-300 min/week.
Moderate weight-lifting limits muscle loss.
Gym memberships and group classes, although
not required, often aid in exercise compliance.
In order to avoid injury in the markedly obese,
concentrate first on dietary change (with or without
medications), add exercise later as tolerated.
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Activity Guidelines
Calories Used in 22 Minutes








Running
Swimming
Bicycling
Aerobics
Stairs
Weights
Walking
Sitting
250
220
200
225
200
165
150
20
Lifestyle Guidelines








Set a realistic weight loss goal for each interval:
-4% @ week 5, -7% @ week 10, -10% @ week 15…
Adhere to a grocery list and snack list. Pay close
attention to ingredients and food preparation.
Use smaller plates, bowls, spoons, glasses, bites.
Keep a diary of intake and exercise (phone app’s).
Limit meals that are consumed away from home.
Ensure adequate sleep (at least 7 hours per 24).
Commercial weight-loss programs (Weight Watchers,
NutriSystem, Jenny Craig, Slim-Fast, Biggest Loser).
Formal behavioral modification therapy may be
useful for binge eating disorder, nocturnal eating
syndrome, or prior history of anorexia or bulimia.
43
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NIH. www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
Common Obesity Surgeries
44
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X.
OBESITY
ANOREXIANTS
GENERIC
Methamphetamine
Phenmetrazine
Phendimetrazine
Phentermine
Diethylproprion
Benzphetamine
Phenylpropanolamine
Fenfluramine
Mazindol
Chlorphentermine
Dexfenfluramine
Sibutramine
Orlistat
Phentermine-topiramate
Lorcaserin
Naltrexone-buproprion
Liraglutide
BRAND(s)
DEA YR
Desoxyn®, Hydrin®
Preludin®
Bontril®, Anorex®
Adipex®, Ionamin®
Tenuate®, Tepanol®
Didrex®, Regimex®
Dexatrim®, Accutrim®
Pondimin®
Sanorex®, Mazanor®
Presate®
Redux®
Meridia®
Xenical®, Alli®
Qsymia®
Belviq®
Contrave®
Saxenda®
II
II
III
IV
IV
III
OTC
IV
IV
IV
IV
IV
Rx
IV
IV
Rx
Rx
1947
1954
1959
1959
1959
1960
1960
1973
1973
1973
1996
1996
1999
2012
2012
2014
2014
P
W
W
W
W
W
W
W
45
6/21/2016
Anorexiants approved by FDA
and ABME for use in Alabama
Medication
DEA
Year
Phentermine
Diethylproprion
Phendimetrazine
Benzphetamine
Qsymia®
Belviq®
Contrave®
Saxenda ®
Class IV
Class IV
Class III
Class III
Class IV
Class IV
Rx only
Rx only
1959
1959
1959
1960
2012
2012
2014
2014
Phentermine ©IV
2-methyl-1-phenylpropan-2-amine
The most frequently
prescribed anorexiant
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CLINICAL PROPERTIES:
1) Anorexiant - Primary Noradrenergic effect:
stimulates receptors in the hypothalamus to
produce and release norepinephrine, leading
to a catecholamine-induced “fight or flight”
phenomenon that includes hunger reduction.
2) Metabolic – An Adrenergic effect: binds to
β3 receptors (ADRβ3) on adipose cells to
stimulate lipolysis (metabolism of stored fat).
3) Satiation - Weakly Serotonergic which leads
to a sense of fullness with less food intake.
4) Thermogenic – Also an Adrenergic effect,
stimulates peripheral receptors to produce
increased calorie usage in skeletal muscle.
Brands available:
Adipex-P®
37.5 mg scored tab
often dosed as
1/2 tab BID
37.5 mg capsule
Ionamin®
phentermine resin
30 mg, 15 mg cap
Suprenza®
oral-disintegrating
unscored tablets
15, 30, 37.5 mg
Several generics:
 Scored tab 37.5 mg
(often dosed ½ tab BID)
 Capsule 37.5 mg
 Capsule 30 mg
 Capsule 15 mg
Adult dosing
(≥ 16 yrs of age).
Lowest dose is 15 mg/
day. Frequent starting
dose of 18.75 mg BID.
Advance as needed to
30 mg AM, 15 mg
afternoon, 30 mg BID
(rarely 37.5 mg BID)
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Phendimetrazine ©III
(Five decades as Bontril-SR® 105 mg capsules
and Bontril-PDM® 35 mg tablets)
 The first non-Class II drug (1959)
 Mixed CNS effects (NE, 5HT, DA)
O
 Now available in generics only.
 105 mg sustained-release capsule to be taken
once daily after first meal (acid-sensitive)
 35 mg scored tablet, take TID before meals
 Sometimes SR 105 mg AM, 35 mg afternoon
NOTE: The SR capsule is usually ineffective
in persons after gastric bypass surgery
due to poor absorption of the capsule.
Benzphetamine ©III
Highest anorexiant potency
Noradrenergic (stimulates release
of hypothalamic norepinephrine)
Never a first-line anorexiant
Available in brands:
 Didrex® 50 mg scored tablet
Also available in generic:
 50 mg scored tablet
 Regimex® 25 mg scored tab
Always begin with 25 mg BID, titrate
upward to a maximum 50 mg TID,
taken 30 min prior to meals
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Diethylproprion ©IV
(Tenuate Dospan® 75 mg, Tenuate® 25 mg
Structurally similar to the antidepressant Buproprion
Di-ethyl
group
Butyl
group
Tenuate
©IV
diethylproprion
Primary effect: dopamine release
Blocks reuptake of norepinephrine
Increases brain leptin (satiety)
Reduces brain neuropeptide-Y
levels (reduces hunger)
Brands and quality generics available:
 Tenuate® 25 mg (immediate
release tabs, TID before meals)

Tenuate Dospan® 75 mg
sustained-release tablet, taken
once daily after the first meal
Unique: Fully renal excretion
Avoid: Using with buproprion
Okay: With SSRI’s (no crossover)
Okay: ≥12 years age (2002 PDR)
Safest: With HTN - CAD - CVD
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Potential Adverse Effects
of Older Anorexiants
 Tachycardia (1% ≥ 110 bpm)
 BP increase (avg ≤ 5 mm)
 Chest pain (rare)
 Dysuria, hesitation, frequency
 Low libido, anorgasmia (<2%)
 IOP (closed-angle glaucoma)
 Dry eyes (common)
 Dry mouth (common)
 Dry gut (constipation)
 Metallic aftertaste
 Sleeplessness
 Nervousness
 Tremulousness
 Irritability
 Mood changes
 Depression
 Pain/headache
 Body aches
 Sweating
 Thinning hair
Long-Term Pharmacotherapy
in the Management of Obesity
National Task Force on the Prevention and Treatment of Obesity.
JAMA 276(23): 1907-15 (Dec 1996).
 60’s: FDA approved anorexiants for “short-term” use.
 70’s: FDA requirements for longer-term therapy.
 Obesity is a chronic condition with long-term effects.
 Obesity responds poorly to short-term therapy.
 Anorexiant treatment for ≥ 24 weeks is more likely to



produce a weight loss of ≥ 10% from baseline.
Medication-induced weight loss plateaus ~6 months.
Weight remains below baseline during active
treatment with anorexiants for ≥ 2 years.
Reported adverse effects, if any, are mild and
self-limited; serious adverse events are rare.
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Long-Term Pharmacotherapy
in the Management of Obesity
Position Statement:
“Pharmacotherapy, when combined
with appropriate dietary change and
physical activity, helps some obese
and overweight patients lose more
weight and maintain the weight loss
better than with dietary, activity and
behavioral modifications alone.”
National Task Force on the Prevention and Treatment of Obesity.
JAMA 276(23): 1907-15 (Dec 1996).
Qsymia® ©IV
(Low-dose Phentermine + Topiramate ER)
FDA-approved in 2012 for chronic therapy as
an adjunct to diet and exercise in patients with:
 Obesity: BMI over 30 kg/m²
 Overweight: BMI over 27 kg/m² plus at least
one weight-related co-morbidity (hypertension,
diabetes type II, hyperlipidemia, etc)
______________________________________________________________________________
Qsymia is available in 4 fixed-ratio combinations:
Phentermine (mg) 3.75
Topiramate ER (mg) 23
7.5
46
11.25
69
15
92
 Can be Rx’ed by PA’s / CRNP’s in Alabama (2015).
51
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Phentermine/Topiramate ER
combination (SEQUEL trial)
Mean (95% CI) percentage weight loss from baseline to week 108.
©2012 by American Society for Nutrition
Garvey W T et al. Am J Clin Nutr 2011;95:297-308
Qsymia® Adverse Effects

Pregnancy category X (cleft lip, palate, et.al.).
Both phentermine and topiramate cross blood-milk
barrier, so do not take if breast-feeding.
 Topiramate causes metabolic acidosis:
 Paresthesias in the face, lips, hands and feet
 Increases the risk of forming renal stones
 Impaired memory, concentration, speech
 Phentermine may cause anxiety, panic, aggression
 Most common were anticholinergic effects (dry mouth,
dry eyes, constipation), sinus infections, and URI’s.
 REMS is available from the manufacturer, VIVUS.

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Belviq® (lorcaserin)
Belviq® FDA-approved in 2012 for chronic therapy
► Obesity: BMI over 30 kg/m²
► Overweight: BMI over 27 kg/m² plus at least one
weight-related co-morbidity (eg, HTN, DM, Lipids)
_________________________________________________________________________________________________________
Available as 10 mg film-coated tablet. Recommended
to begin with 10 mg once daily for up to 2 weeks. An
increase to 10 mg BID yields better weight reduction
and maintenance at one year. Eisai provides REMS.
_________________________________________________________________________________________________________
Potential adverse effects (mostly serotonergic):
Headache, dizziness, fatigue, nausea, constipation, dry mouth
Low blood sugar
Bradycardia
Hallucinations
Inattention, memory impairment
Serotonin syndrome
Neuroleptic malignant syndrome
Painful erections
Reduction in RBC or WBC counts
Belviq® (lorcaserin)
► Selectively
activates 5-HT2C receptors in the brain
► Increases the production of Hypothalamic POMC
(pro-opiomelanocortin), leads to earlier satiety
► Has both serotonergic and anorectic properties
Arena: Patients must lose 5% of TBW in 12 weeks to continue.
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Contrave®
(naltrexone/buproprion)
Contrave® FDA-approved in 2014 chronic therapy:
► Obesity: BMI over 30 kg/m²
► Overweight: BMI over 27 kg/m² plus 1+ weightrelated co-morbidity (eg, HTN, DM-2, hyperlipidemia)
► Available as a single fixed-dose combination:
Naltrexone (mg)
8 mg In bottles of
Buproprion ER (mg) 90 mg
120 tablets
Sites of action: hypothalamus and mesial limbic system,
leading to regulation of appetite, intake and satiety.
Contrave® clinical studies used two tablets BID.
Risks include seizure, nausea, headache, constipation,
hepatotoxicity, hypertension, tachycardia, suicidal
thoughts and behaviors, mania, or opiate withdrawal.
 Prescription only, non-controlled, no DEA scheduling.
Saxenda® (liraglutide injection)
Saxenda® FDA-approved in 2014 chronic therapy:
► Obesity: BMI over 30 kg/m²
► Overweight: BMI over 27 kg/m² plus at least one
weight-related co-morbidity (eg, HTN, DM, Lipids)
Weekly subcutaneous injection,
with dosing determined by
an escalating schedule:
Mode of action: Agonist of the
Glucagon-like-peptide-1 receptor:
Stimulates insulin secretion and
sensitivity in α-cells and β-cells;
inhibits gastric acid secretion and
gastric motility; decreases food intake by aiding brain satiety.
Adverse effects and risks include nausea, tachycardia at rest,
pancreatitis, gallstones, hypertriglyceridemia, thyroid tumors
and medullary cancer, hypoglycemia, renal failure, depression.
 Non-controlled, no DEA regulation. Tread very carefully.
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XI.
Alabama Board of Medical Examiners
RULES FOR
PRESCRIBING
ANOREXIANTS
Alabama Board of
Medical Examiners
Rules for the Prescribing
of Anorexiants 540-X-17
written by an ad hoc committee
of two ABME Members and
several weight-loss physicians
In Effect since January, 2012
55
6/21/2016
The evaluation before prescribing:
1) The prescribing physician (MD,DO) will take
and document an appropriate medical history
(illnesses, medications, surgeries, dietary,
exercise) and perform a physical examination;
2) Obtain ancillary testing (labs, cardiac, urine)
based on the history and physical, when
medically indicated for weight management;
3) Discuss with the patient the risks, benefits and
relative contraindications to anorexiants;
4) Assess freedom from drug or alcohol abuse;
5) Make medical referrals when indicated.
DEA Scheduled Class II medications are
NOT to be prescribed or dispensed in
Alabama for the treatment of obesity,
weight reduction or weight control.
Such drugs include d-amphetamine (Dexedrine®),
methamphetamine (Desoxyn®, Hydrin®),
and any other Schedule II sympathomimetics
(Adderall®, Ritalin®, Concerta®, ProCentra®), or
any preparations that are equivalent to Class II
stimulants. [ This position on Class II drugs is
endorsed by the Obesity Medicine Association. ]
Vyvanse® ©II, is FDA-approved for binge-eating disorder,
a diagnosis distinctly different from exogenous obesity.
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 In Alabama, prescribing or dispensing of the older
Class III-IV anorexiants that are not FDA-approved
for chronic use (phentermine, phendimetrazine,
benzphetamine, diethylproprion) is limited to:
 Doctors of Medicine (MD’s) and
 Doctors of Osteopathy (DO’s), that hold:
 A valid medical license (Medical Licensure Commission);
 An Alabama Controlled Substances Certificate (ABME).
 Prescribing of the newer Class IV drugs that are
FDA-approved for chronic use (Qsymia® and Belviq®)
is open to all prescribers: PA’s, CRNP’s, MD’s, DO’s.
These two drugs are FDA-approved for long-term use,
unlike the older drugs that are prescribed off-label.
 Contrave® and Saxenda® are not Scheduled by DEA.
Patient criteria to qualify for treatment with
Scheduled Class III, IV, V anorexiants:
 Obesity (BMI of 30 or above)
- OR  Overweight (BMI of 25.0-29.9) with at least
one weight-related comorbidity factor
- OR FEMALES MALES
 Abdominal girth ≥ 35 inches ≥ 40 inches
- OR  Body fat content ≥ 30 %
≥ 25 %
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6/21/2016










A prescribing physician (MD/DO) must be present
in the clinic at the time any Class III, IV, or V
anorexiant is prescribed or dispensed.
A written prescription for any of the older (1959-60)
Schedule III or IV anorexiants for the purpose
of weight reduction or weight maintenance
must be signed by a doctor (MD or DO) on the
date the prescription is provided to a patient,
or that a medication is dispensed in a clinic.
Prescribing or dispensing an anorexiant is limited
to a maximum supply of 35 days at a time.
Each patient must be re-evaluated in person every
35 days by an MD/DO, or a PA/CRNP working
in collaboration with an on-premises physician.
Maintain appropriate medical records (weight, BMI,
BP, HR, labs / tests) during anorexiant therapy.
Carefully document the presence or absence of any
adverse effects of anorexiant therapy.
PA’s and CRNP’s may write and sign prescriptions
for Qsymia® or Belviq®, if their collaborative
doctor is physically present in the clinic.
PA’s and CRNP’s may write and sign prescriptions
for Contrave® or Saxenda® with or without the
presence of a doctor, as these drugs are not
scheduled by the DEA or the ABME.
Physicians will follow all the applicable laws and
rules for transmission of electronic prescriptions.
NO phone, fax or email prescriptions are allowed.
Refills are allowed ONLY for Qsymia®, Belviq®,
Contrave® or Saxenda®, up to 6 months per visit.
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
Within the first 70 days of Schedule III-IV anorexiant
therapy, the treated patient should show progress
toward established medical goals*
(* loss of weight, body fat reduction, lower W:H ratio,
smaller abdominal girth, improved diabetes control,
hypertension control, or improvement in serum lipids,
gastric reflux, LBP, musculoskeletal symptoms, etc.)
Once the established medical goals* have been met,
the MD/DO should prescribe reduced dosing
and/or utilize drug holidays for those patients
needing to continue on maintenance medication.
 Longer-term therapy is permissible by ABME Rules
… but is still considered off-label by FDA/DEA.
 All patients should be appropriately advised of the
off-label nature of longer-term anorexiant therapy,
with signed informed consent.

SITUATIONS LEADING TO
TERMINATION OF ANOREXIANT






Pregnancy - or breast-feeding
Substance abuse - history of drug or alcohol abuse
or a propensity toward such abuse
Dishonesty - making false or misleading statements
to the prescribing doctor, PA, CRNP or office staff
Diversion - selling or improper consumption
Noncompliance - repeatedly failing to comply with
the prescriber’s treatment recommendations,
including dietary and exercise instructions
Lack of progress - development of tolerance to the
clinical effects of the medication being used
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ABME Rule Related to hCG
hCG (human chorionic gonadotrophin)
Injectable hCG is FDA-approved for female infertility.
NO products (shots, pellets, drops, sprays) alleging hCG
content are FDA-approved for weight loss. Persons who
purchase these products are given a 500-calorie ketotic diet.
NO evidence exists that oral hCG products aid weight loss,
beyond that of the ketosis from the very low calorie diet.
The FDA and FTC (on 12-06-11) issued warnings to seven
companies marketing over-the-counter hCG products labeled
as “homeopathic” for weight loss, warning those companies
that they are in violation of federal laws by selling drugs
that have not been FDA-approved and that their actions are
fraudulent and illegal in the USA.
The ABME Rules prohibit all Alabama practitioners from
selling or promoting any oral “hCG” products for weight loss.
ABME Rules Related to the
Prescribing of Anorexiants
Practice evidence-based medicine!
One example of evidence-based medicine in
reference to obesity management is the set of
“Practice Guidelines” published by the
Obesity Medicine Association
(and referenced in the ABME Rules)
www.obesitymedicine.org
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XII.
ANOREXIANTS
LIMITATIONS
TO TREATMENT
Anorexiant Concerns
 Obese/Overweight Type II Diabetes Patients
 Obese/Overweight Hypertension Patients
 Obese/Overweight Coronary Artery Disease Patients
 Obese/Overweight Cardiac Dysrhythmia Patients
 Obese/Overweight Migraine/Headache Patients
 Obese/Overweight Depressed Patients
 Obese/Overweight Anxiety Disorder Patients
 Obese/Overweight Bipolar Disorders Patients
 Obese/Overweight Adult Patients Treated with

Medications for Attention Deficit Disorder
Obese/Overweight Patients of Advancing Age
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
Obese/Overweight Diabetic-II Patients
Anorexiants are very useful in aiding obese or overweight
adults with type II diabetes lose weight more readily.
Once a type II diabetic patient begins an anorexiant, the
serum glucose drops rapidly within the first few days.
To help prevent inadvertent hypoglycemia, and because
all insulins cause weight gain, I instruct patients to
reduce the insulin dose by 1/3 on day one of anorexiant
therapy. Weight, waist and glucose all decrease more
rapidly with the reduced insulin dose. Patients on oral
agents should check glucose BID for a couple of weeks.
Metformin (Glucophage®, etc.) and all the SGLT-2 inhibitors often result in
weight loss in type II diabetic patients. These may be preferable over other
oral agents associated with weight gain. Also, some of the newer noninsulin injectable drugs (Byetta®, etc.) may be associated with weight loss.

Patients with Hypertension
If initial blood pressure > 140/90:
Initiate antihypertensive therapy at the same time as
prescribing an anorexiant, and stress the importance of
taking them together. I generally start with a potassiumsparing diuretic (Maxzide or Dyazide) esp if edema is
present; lisinopril 5-20 mg if heart rate is normal; or
atenolol or metoprolol 25-50 mg if both the blood
pressure and heart rate are elevated.
If initial blood pressure > 152/96:
Treat with antihypertensive therapy for 1-2 weeks,
then recheck BP prior to prescribing an anorexiant.
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
Patients with Coronary Artery Disease
Although unpublished and somewhat arbitrary, I tend to
use a “2-year rule” when treating cardiac patients
with any of the adrenergic/noradrenergic anorexiants:

2 years since CABG

2 years since insertion of a stent

2 years since cardiac catheterization (if abnormal)
Among the “older” anorexiants, Tenuate (diethylproprion)
has a primarily dopaminergic effect and is safest among
patients with coronary, cardiac or hypertensive disease.
Weight reduction (in particular, abdominal fat reduction)
helps cardiac patients live longer and healthier, and
anorexiant benefit may outweigh risks within parameters.
 Patients with a Cardiac Dysrhythmia
 Cardiac risks clearly exceed weight loss
benefits in certain situations, therefore
Do Not Use Anorexiants in:
•
•
•
•
•
Wolff-Parkinson-White Syndrome
Left Bundle Branch Block (LBBB), new
Recent onset Atrial Fibrillation
Chronic A-Fibrillation with RVR (>95 bpm)
QTc prolongation > 0.44 sec
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
Obese/Overweight Migraine Patients
Both headache and obesity are common in the population, and
often occur together. Although headache is listed in PDR as
a potential adverse effect of anorexiants (and patients should
be so warned), they rarely report a significant increase in
headache frequency, severity or duration with anorexiant Rx.
Topamax® (topiramate) is FDA-approved for migraine
prevention, and is commonly associated with weight loss.
Zonegran® (zonisamide) is used off-label for migraine
prevention and is sometimes associated with weight loss.
Keppra® (levetiracetam) is used off-label for migraine prevention
and is weight-neutral or with small weight loss.
Depakote® (valproate) is FDA-approved for prevention of
migraine. Significant weight gain is very common problem
with this drug, among numerous other adverse effects.

Obese/Overweight Depressed Patients
Phentermine when taken in conjunction with:
Total
<3 mo
3-6 mo
>6 mo
Prozac
581
209
109
263
Zoloft
111
21
28
62
Celexa
73
20
15
38
Lexapro
69
17
15
37
Paxil
13
2
5
6
Tricyclics 159
25
39
95
~ CASES OF SEROTONIN SYNDROME: ZERO (0) ~
Tricyclic (TCA) antidepressants are virtually always associated
with weight gain, dry mouth, dry eyes and constipation. Also,
TCA’s bear a risk for arrhythmias. Concomitant use of a TCA
with an anorexiant is an open invitation for adverse effects.
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
Patients with Anxiety Disorders
Persons with anxiety disorders commonly overeat, or choose
fattening foods, as “treatment” during periods of anxiety.
SSRI’s are widely prescribed for treatment of anxiety and panic
disorder. Weight gain may be significant with these drugs,
with Paxil (paroxetine) and Zoloft (sertraline) at the top of the
list and Luvox (fluvoxamine) and Lexapro (escitalopram) being
less associated with weight gain. Prozac (fluoxetine) is more
commonly associated with weight loss than weight gain.
The NRI Wellbutrin (buproprion) often aids weight loss.
The SNRI’s Effexor (venlafaxine) and Pristiq (desvenlafaxine)
may cause weight gain at lower doses, but are weight-neutral
at higher doses due to increased norepinephrine effect.
For anorexiant-induced anxiety in otherwise responding patients,
a low dose of a mild anxiolytic aids tolerability of the drug.

Patients with Bipolar Disorders
Unfortunately, most of the medications used
in the treatment of bipolar disorders are
associated with or cause weight gain,
Depakote® (valproate) and Lithium in
particular. Avoid anorexiants in bipolar
patients due to the high risks of CNS
excitability, and the high potential for
production of mania/hypomania.
The risks far exceed any potential benefit
of anorexiants in this group (!).
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
Obese/Overweight Persons Treated
with Medications for Attention Deficit
Disorder or Other Schedule II Drugs
Do Not Prescribe an Anorexiant
until a person has been off a Schedule II
ADD or ADHD medication for a period of
at least six (6) weeks. Use the PDMP
and appropriate drug testing to confirm
the absence of other amphetamine-like
drugs prior to prescribing.

Obese/Overweight in Advancing Age
Most individuals actually lose, not gain, weight as they age.
Patients over 65 years of age presenting to a weight
loss specialist usually do so in order to improve control
of diabetes type II. Be aware that older individuals:
1) are usually already taking several daily medications;
2) have a greater potential for adverse effects of
anorexiants (dry mouth, dry eyes, constipation,
hypertension, glaucoma, arrhythmias, insomnia, etc.);
3) have a greater risk of drug-drug interactions between
their daily medications and anorexiants.
Always weigh the potential risks vs. benefits of any drug
(anorexiants included) and discuss these potential risks
and benefits in detail prior to prescribing. Best to have
a recent EKG on the chart, and “go low and go slow.”
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Robert F. Allen, MD
Weight Management Clinic
105 N. Pontiac Ave, Suite 1
Dothan, AL 36303-3959
rfa7255 @ hotmail.com
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