Tools in the Toolbox: Obesity Treatment Pyramid

Transcription

1 Tools in the Toolbox: Finding the Weight-loss Option that is Best for You Domenica M. Rubino, MD Obesity Treatment Pyramid Individual Circumstances & BMI and Co-morbid conditions 1

2 Weight Loss Tools Obesity Medicine Comprehensive programs Medications Bariatric Surgery Self- Assessment-What help do I need? Support-Nutrition/Activity/Psychological/Behavioral Individual providers, groups, online, commercial programs Meal Replacements/prescribed diet Mindfulness-self monitoring/awareness Pedometers/accelerometers Records/app Weighing-minimally weekly Obesity Medicine American Board of Obesity Medicine Treats obesity with the understanding of the genetic, biologic, environmental, social, and behavioral factors that contribute to an individual s management. Comprehensive, team-based approach targeting nutrition, activity, behavioral change and pharmacotherapy. May work with nutritionists, exercise physiologists, psychologists, neurologist/pulmonologist, bariatric surgeons as needed as well as integrating care with your primary care physician. Competent in providing pre- peri- and post-surgical care of bariatric surgery patients, promotes the prevention of obesity, and advocates for those who suffer from obesity. 2

3 Medical Management Model/Comprehensive Lifestyle Intervention Weight loss intervention: ~6 + months with weekly groups and/or individual sessions; diet/activity change Maintenance: ~ 1 year + support ; regular bi-monthly or monthly contact; Face-face or telephone optimal; high level of activity. Team approach supporting development of various skills Cognitive behavioral therapy and other therapeutic approaches as needed; self-monitoring, stimulus control, and trigger/cue management. Obesity Medication-if needed Obesity Medications Why consider taking them? How do they work? New FDA-approved medications How do I chose? What should I expect? 3

4 Why take medication? Supports weight loss improve co-morbidities & quality of life Helps make behavioral changes (hunger, impulsiveness; satiety/portion, etc.) Lose more weight when used with behavioral change Long term- control Target mechanisms involved in protecting against weight loss How do they work?* * Warning: The following graphic depiction of physiological systems involved in the regulation of weight may be visually disturbing, annoying and downright frustrating for some viewers, but are presented with the intention of improving understanding as to why weight loss and maintenance can be annoying and downright frustrating. 4

5 Sensory/palatability Family/Social Thoughts/Beliefs/Ads? Eat Not Eat Brain Muscle Fat Cells Gut Sensory/palatability Family/Social Thoughts/Beliefs/Media Obesity Medications Eat? Not Eat Brain Muscle Fat Cells Obesity Medications Gut 5

6 Sensory/palatability Family/Social Thoughts/Beliefs/Media Obesity Medications Eat Not Eat Brain Muscle Fat Cells Obesity Medications Gut Goals/Expectations Goal to lose 5-10% of initial body weight Medications can help support behavioral changes Intensify weight loss with dietary and exercise interventions Supports maintenance of weight loss Individual responsiveness/sensitivity 6

7 What patients say: I don t have multiple helpings I actually feel full. I just don t obsess about food any more. I say Eh not interested and close the pantry door. I am aware of driving by the take-out but I don t stop. I feel like a normal person must feel. The volume has been turned down I can make better decisions. Newly approved (FDA) Obesity Medications-Basics BMI>30 or 27 with DM, HTN, sleep apnea, etc. Use with changes in diet and physical activity Average weight loss 5-9% * Individual response/sensitivity Assess weight at 12 weeks-? 5% ; if not discontinue Improved blood sugar in those with type 2 diabetes 7

8 Newly approved (FDA) Obesity Medications-Basics Drugs that target the brain have the potential to affect concentration, memory or mood. Combination therapies idea to target multiple sites and use lower doses of each drug Not to be taken during pregnancy or planning pregnancy Ongoing additional 5 year studies in those at highest riskcardiovascular disease or diabetes. Newly approved (FDA) Obesity Medications-Basics Online support programs; 2 wk free trial; discount cards May need prior authorization for insurance coverage 8

9 FDA-Approved Obesity Medications lorcaserin (Belviq ) phentermine/topiramate extended release (Qsymia ) bupropion/naltrexone (Contrave ) orlistat (Xenical ; Alli ) liraglutide 3mg (Saxenda ) * FDA decision pending October 20 [EMDAC recommended] Lorcaserin (Belviq ) FDA-approved prescription medication for weight loss Thought to target hunger receptors in the brain (5 HT2c serotonin agonist) 10 mg tablet taken twice a day, with or without food. 47.1% taking lorcaserin lost 5% compared to 22.6% (placebo). 22.4% lost 10% compared to 8.7% taking placebo. Improved blood sugar in men and women with type 2 diabetes. 37.5% lost 5% compared to 16.1% (placebo). 9

10 Lorcaserin (Belviq ) FDA-approved prescription medication for weight loss Most common side effects in patients without diabetes: Headache, dizziness, fatigue, nausea, dry mouth, and constipation. Most common side effects in patients with diabetes: Low blood sugar, headache, back pain, cough, and fatigue. Phentermine/topiramate extended release (Qsymia ) FDA-approved prescription medication for weight loss Combination of two drugs efficacious for weight loss. Use is associated with decreased appetite/food consumption and increased feeling full but precise mechanism of action of the 2 ingredients is unknown. 4 different dose combinations- first effective dose 7.5 mg phentermine/46 mg topiramate ER 15mg/92 mg. Take once daily 10

11 Phentermine/topiramate extended release (Qsymia ) FDA-approved prescription medication for weight loss Average weight loss pounds in one year Average weight loss of 7.8% (7.5/46mg) compared to 1.2% (placebo) 62 % (7.5/46 mg) achieved 5% weight loss compared to 21% (placebo) 48% (15/92 mg)/37% (7.5/46mg) achieved 10% weight loss compared to 7% (placebo) Phentermine/topiramate extended release (Qsymia ) FDA-approved prescription medication for weight loss Most common side effects include: Numbness or tingling in the hands, arms, feet, or face; dizziness; changes in the way foods taste or loss of taste; trouble sleeping; constipation; mood changes, concentration, and dry mouth. Women who are pregnant must not take Qsymia. Women who can become pregnant should have a negative pregnancy test before taking Qsymia and every month while taking Qsymia and use effective birth control consistently while taking Qsymia 11

12 Bupropion SR/naltrexone SR (Contrave ) FDA-approved prescription medication for weight loss Combination drug combining the anti-depressant bupropion (a dopamine and norepinephrine reuptake inhibitor ) with an opioid receptor antagonist, naltrexone. It is thought that the bupropion SR decreases appetite leading to weight loss and the naltrexone increases this effect. This drug may affect two centers of the brain: one that affects appetite and one that affects reward centers in the brain though the exact mechanism is not known. Bupropion SR/naltrexone SR (Contrave ) FDA-approved prescription medication for weight loss Take twice daily A one year study showed that the patients treated with medication lost 9.3% of their initial weight, compared with 5.1% in participants who received placebo. 53% taking drug lost 5% compared to 21% (placebo) over one year. Those who made the most intensive lifestyle changes lost the most weight. 12

13 Bupropion SR/naltrexone SR (Contrave ) FDA-approved prescription medication for weight loss Common adverse effects included nausea, headache, dizziness, insomnia, dry mouth, constipation and can raise BP/HR. Contraindicated in those with seizure disorders or concussion/loss of consciousness; history of bulimia. Label carries the warning that bupropion (antidepressant) regarding potential for worsening depression and increase in suicidal thoughts. CVOT is still ongoing and may be an additional study. How do I choose which medication? Discuss with your physician Read about the medications Side effect profile and potential interactions with current medications Cost; Insurance 2-week free trial Individual responsiveness 13

14 Assessing your needs Identify vulnerabilities Seek out the tools (the help) you need Stress/Anxiety/Depression? Nutrition? Eating-pre and post weight loss Social pressure? Inactive? Addiction? Inadequate sleep? Relationships? Illness? Ambivalent? 14

15 Stress/Anxiety/Depression? treatment past trauma coping family/work/economic Social pressure? work family friends bullying economic Addiction? alcohol drugs smoking gambling Relationships? lonely conflicts early experience Nutrition? Cook vs eat out Processed Sugar/fat/salt High density Habit Illness? worry treatment/meds discomfort Eating-pre and post weight loss emotional hunger foodie deprivation habit Ambivalent? Fear of change Deprived? Inactive? Pain Fear Habit Dislike Job Inadequate sleep? night person sleep apnea restless legs menopause stress/anxiety shift work travel habit *Stress/Anxiety/Depression? counseling, medication self-care self-efficacy/ control coping skills exercise/nutrition Social pressure/relationships? Counseling peer support change social structure explore new opportunities self care new job Nutrition? Fruits/vegetables Fiber Lean protein/grains Cook Breakfast/patterns Habit-records *Eating coping skills cognitive behavior obesity medications habit Active? Movement-daily Exercise (WT/aerobic) Physical therapy/rehab Pain management Habit-reinforcement Least detestable Small amounts Illness? optimize Rx Support *Addiction? exercise/nutrition treatment-meds/groups sleep change social structure habits Acceptance Work with change Fears, deprivation Inadequate sleep? diagnose/treat regular bedtime decrease media exercise/nutrition modify stress habit 15

16 Summary Medications target pathways in the brain affecting eating behavior Individual responsiveness to the medication plus behavioral changes determine the degree of weight loss. Patient-physician decision regarding the use of medication. Focus on where you need the most support and seek out that help to optimize behavioral change. Thank you Enjoy the Conference (and the Sunshine) 16

17 Liraglutide (Saxenda ) GLP-1 agonist (97% similar to glucagon-like peptide 1 produced in the gut) slows gastric emptying, increases satiety/fullness through signals to the brain. Dose: 3 mg injection daily Lowers blood glucose by releasing insulin only when glucose is too high AE GI side effects, diarrhea, nausea, vomiting constipation, hypoglycemia, dehydration which may lead to kidney failure. CI in patients who have had pancreatitis, MEN2, medullary thyroid cancer Liraglutide (Saxenda ) 63.5% lost more than 5% weight compared to 26.6% (placebo) 32.8% lost more than 10% compared to 10.1% (placebo) Improved blood sugar in T2DM (change in A1C of -1.3 compared to -0.4 in placebo) T2DM: 49.9% lost more than 5% compared to 12.7% (placebo) and 22.1% lost more than 10% compared to 3.8% (placebo) 17

18 Orlistat (Xenical ) Prescription and over the counter; 3 x a day dosing. It works by decreasing the amount of fat your body absorbs. Weight loss of 3-4% Approved for several years. Should take with a MVI Common side effects are cramps, gas, stool leakage, oily spotting and gas Improve cholesterol levels and reduce risk of type 2 diabetes. Phentermine (Adipex or Suprenza ) Phentermine is only approved for short-term use; its administration for a period >12 weeks is considered offlabel in the US, whereas it is no longer a licensed drug in Europe. Once daily; dose range 15 mg-37.5 mg Dry mouth, insomnia, constipation common side effects Caution regarding HTN, cardiac disease, stroke, thyroid dx, glaucoma Works on the brain to decrease appetite Weight loss of 5% at one year 18

19 Off-label medications Other medications that have been used off-label to achieve modest weight loss include fluoxetine, topiramate, diethylpropion, buproprion and zonisamide. 19