Diagnostic Tests

A.Thyroid function.

B.Lipid panel.

C.Triglycerides.

D.Pregnancy test.

E.Fasting blood sugar/3-hour glucose tolerance test (GTT).

F.Sleep study (if indicated).

G.Nocturnal hypoxemia study.

Differential Diagnoses

A.Obesity.

B.Pseudotumor cerebri.

C.Binge eating.

D.Genetic syndrome (e.g., Prader–Willi syndrome).

E.Cushing syndrome.

F.Diabetes mellitus (DM).

G.Insulin resistance syndrome.

H.Primary pulmonary HTN.

PLAN

Manage obesity as a chronic relapsing disease, including the comanagement of other diseases secondary to obesity (i.e., diabetes, HTN):

A.General interventions:

1.Reinforce the positive impact that weight-loss measures (diet, exercise) can have and the overall health benefits of weight loss.

2.Identify and monitor any cardiovascular complications.

3.Behavior modification: Intensive behavioral therapy has been shown to increase weight loss success and to help achieve sustainable weight loss for longer periods of time. Behavioral therapy includes weekly meeting with healthcare professionals for at least 6 to 8 weeks:

a.Dietary plan:

i.Low-calorie diet.

ii.Increase in fruits and vegetables.

iii.Eliminate alcohol and beverages containing sugar.

iv.Reduction of high-glycemic foods such as candy.

v.Reduction in high-caloric foods and drinks.

vi.Reduction of fat intake.

vii.Reduction of portion sizes.

viii.Reduction of the amount of processed foods in the diet.

ix.Increase in water intake.

b.Exercise: HHS (2018) physical activity guidelines recommend that adults must achieve at least 150 minutes (2½ hours) of moderate-intensity aerobic physical activity per week. Suggested intervals of a minimum of 10 minutes should yield the highest health benefits. At least two times a week strengthening exercises (push-ups, sit-ups, lifting weights) are also recommended.

c.Wide range of benefits:

i.Helps lower BP.

ii.Improves cholesterol.

iii.Helps lower hemoglobin A1C in diabetes.

iv.Helps strengthen bones.

v.Weight loss.

vi.Improves depression.

vii.Boosts immune system.

viii.Reduces stress.

ix.Improves sense of well-being.

x.Believed to be a major driving force in lifestyle change.

d.Obtain counseling on stimulus control, goal setting, self-monitoring, and contracts that reward behaviors:

e.Contraindication to exercise:

i.There are several contraindications for beginning exercise: Individuals with recent myocardial infarction (2 weeks), unstable angina, severe aortic stenosis, decompensated congestive heart failure (low ejection fraction), left ventricular outflow obstruction, uncontrolled dysrhythmias, uncontrolled diabetes or diabetic complications, and uncontrolled HTN.

B.Patient teaching:

1.Keep a food diary to identify food triggers.

2.Counsel about pharmaceutical therapy drug side effects and the lack of long-term safety data. Stress to the patient the temporary nature of the weight-loss medication. Typical weight loss is modest, less than 5 kg (10–11 lbs) at 1 year.

C.Pharmaceutical therapy:

1.After an adequate trial (minimum of 6 months) of diet and exercise therapy, consider pharmaceutical therapy. Pharmacologic intervention is not allowed in some states. State statutes should be considered prior to prescribing weight control products.

2.Studies lack evidence to support whether one drug is more efficacious than another; nor does the literature support use of combination therapy for increased weight loss.

3.The choice of a pharmaceutical agent depends on the side effect profile of the drug and tolerance of the side effects.

4.The Food and Drug Administration (FDA) has not approved any weight-loss medication for use beyond 2 years in adults. Appetite suppressants that are FDA approved:

a.Qsymia, phentermine, diethylpropion, benzphetamine, and phendimetrazine are approved for short-term (12 weeks) use.

b.Sibutramine (Reductil) is FDA approved for 1-year use.

c.Orlistat (Xenical) is FDA approved for 2-year use.

d.Naltrexone HCl/bupropion HCl (Contrave) is FDA approved for 1-year use.

e.Liraglutide injection (Saxenda). A glucagon-like-peptide FDA approved for weight loss.

f.Lorcaserin HCl (Belviq) is FDA-approved for 12 weeks use. Lorcaserin HCl is a serotonin 2C (5-HT2C) receptor agonist.

5.Appetite suppressants:

a.Qsymia (phentermine and topiramate extended release). Start with 3.75/23 mg extended release per day for initial BMI greater than 30 kg/m², or BMI greater than 27 kg/m² in the presence of risk factors. May gradually increase dose to 15/92 mg:

i.Avoid evening dose.

ii.Monitor for hypersensitivity to phentermine and topamax

iii.These drugs are not recommended in the presence of HTN, hyperthyroidism, cardiovascular disease (CVD) and drug or alcohol abuse.

iv.Do not use if history of glaucoma, hyperthyroidism, or within 14 days of monoamine oxidase inhibitors (MAOIs).

b.Phentermine (Adipex-P) 37.5 mg orally once daily before or 1 to 2 hours after breakfast, or 18.75 mg one to two times per day for initial BMI greater than 30 kg/m², or BMI greater than 27 kg/m² in the presence of risk factors:

i.Avoid late-evening dosing.

ii.Not recommended in the presence of HTN, hyperthyroidism, CVD, and drug or alcohol abuse.

iii.Do not prescribe during or within 14 days of MAOIs.

c.Benzphetamine (Didrex) 25 to 50 mg orally initially in the midmorning or midafternoon. Increase if needed to 25 to 50 mg one to three times a day:

i.Not recommended in the presence of HTN, hyperthyroidism, CVD, and drug or alcohol abuse.

ii.Not to be prescribed during or within 14 days of MAOIs.

iii.Pregnancy category X: Known to cause fetal abnormalities or toxicity in animal and human studies.

d.Diethylpropion (Tenuate) 25 mg 1 tablet every 8 hours, 1 hour before meals. May add one additional dose for night hunger. Half-life of 4 to 6 hours:

i.Avoid late evening dosing.

ii.Not recommended in the presence of hypertension, hyperthyroidism, CVD, and drug or alcohol abuse.

iii.Do not prescribe during or within 14 days of MAOIs.

e.Phendimetrazine (Bontril PDM) 35 mg orally two or three times daily 1 hour before meals. May reduce to 17.5 mg/dose. Maximum dose 210 mg/d in three evenly divided doses. Also available in slow-release 105 mg in the morning 30 to 60 minutes before breakfast:

i.Not recommended in the presence of HTN, hyperthyroidism, CVD, and drug or alcohol abuse.

ii.Not to be prescribed during or within 14 days of MAOIs.

f.Naltrexone HCl/bupropion HCl (Contrave) is a combination of an opiate antagonist and antidepressant. The synergistic effect reduces appetite:

i.Opioids should not be used 7 to 10 days before starting Contrave.

ii.Take medication with low-fat meal twice daily.

iii.Do not take close to bedtime to avoid insomnia side effect.

iv.Do not crush because a quick release would increase risk of seizure side effect.

g.Liraglutide (Saxenda) is FDA approved for adults with a BMI ≥27 who also have weight-related medical problems:

i.Saxenda comes in a prefilled pen.

ii.It is not treatment for type 2 diabetes.

iii.Should not be used with Victoza, insulin, or other GLP-1 receptor agonist medicines.

iv.Should not be prescribed to patients with thyroid tumors/cancer.

v.Monitor for potential hypoglycemia in type 2 diabetics.

vi.Recommended dose: Initiate at 0.6 mg daily and increase in increment of 0.6 mg every week until 3 mg daily is reached. Administer at any time without regard to meals.

h.Lorcaserine HCl (Bleviq) is an FDA approved (CIV) agonist of serotonin 2C (5-HT2C) receptor for adults with a BMI 27 >27 kg/m² with comorbidities:

i.Recommended: 10 mg tablet twice a day or 20 mg extended-release tablet daily.

ii.Monitor for adverse effects; serotonin syndrome, cognitive impairment, dysrhythmias, valvular heart disease, prolactin elevation, HTN, psychiatric disorders, potential hypoglycemia in type 2 diabetics

iii.Risk for drug dependence.

6.Lipase inhibitor:

a.Orlistat (Xenical) for use with a low-fat diet. Recommend 30% of calories spread over three main meals:

i.Take one 120 mg capsule orally during or up to 1 hour after main meals up to three times per day.

ii.If a meal is missed or had no fat, skip dosage.

iii.May decrease absorption of fat-soluble vitamins and beta-carotene.

iv.Supplement diet with a multivitamin.

v.FDA approved for up to 2 years use in adults.

vi.GI side effects include fatty/oily stools, oily spotting, flatus with discharge, fecal urgency, and fecal incontinence.

vii.Contraindicated in chronic malabsorption syndrome and cholestasis.

viii.May affect doses for antidiabetic medications.

ix.Monitor warfarin and cyclosporine levels.

b.Alli, a lipase inhibitor, is the only FDA-available OTC weight-loss product.

7.Off-labeled medications used for obesity:

a.Metformin (Glucophage) is used to decrease central adiposity in weight loss, lower insulin levels, and slow down the process of gluconeogenesis:

i.Start Metformin 500 mg at the evening meal. The dosage can be increased by 500 mg per week in divided doses up to the maximum of 2,000 mg/d.

ii.Titrate slowly due to the GI side effects.

iii.Check a metabolic panel before and every 3 to 6 months to evaluate for lactic acidosis.

iv.Metformin is contraindicated in patients with renal impairment; assess renal function prior to instituting metformin and monitor regularly.

v.Metformin must be stopped prior to any procedure with radiographic dye.

vi.Start on a patient with a waist-to-hip ratio greater than 0.8%.

b.Topiramate (Topamax) is used to treat seizures and several types of headache. In small doses, it can be used alone or adjunct with phentermine to suppress appetite longer. Be familiar with the risks associated with the use of Topamax:

i.If used alone, may start at 25 mg every day in the morning. Increase up to two or three times a day. Topamax has a longer half-life of 19 to 25 hours.

ii.May be used as adjunct with phentermine. Start patient at 18.75 mg of phentermine and 12.5 mg of Topamax. Then gradually increase the dose to 37.5 mg of phentermine and 25 mg of Topamax.

iii.Always give the phentermine in the morning, preferably 30 minutes before meals. Topamax should be dosed in the afternoon or evening.

iv.Phentermine (Adipex-P) 37.5 mg orally once daily before or 1 to 2 hours after breakfast, or 18.75 mg one to two times per day for initial BMI greater than 30 kg/m², or BMI greater than 27 kg/m² in the presence of risk factors.

v.Avoid late-evening dosing.

vi.Not recommended in the presence of HTN, hyperthyroidism, CVD, and drug or alcohol abuse.

vii.Do not prescribe during or within 14 days of MAOIs.

Follow-Up

A.Reevaluate the patient every week for 6 to 8 weeks; then monthly either with or without pharmaceutical therapy until goal is achieved.

B.Maintain the recommended schedule for comorbid conditions.

C.If patient is a candidate for bariatric surgery, follow recommended pretreatment/reauthorization guidelines required by the payer and bariatric center.

Consultation/Referral

A.Refer to a nutrition/registered dietitian consultation.

B.Consider a referral to a bariatric center/surgical consultation and evaluation of bariatric surgery.

C.Consider a psychology consultation (may be required prior to bariatric surgery).

D.If the family is eligible, refer to the Women, Infant, and Children (WIC) Program.

Individual Considerations

A.Pregnancy: