Bariatric Times

Insights into Patient Pop with Obesity 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Bariatric Times • December 2016 • Supplement C C7 considered. This is framed by the Endocrine Society as a strong recommendation based on high-quality evidence. Comorbidity introduces a level of complexity into the care of any patient with obesity. Many patients with comorbid conditions take drugs to manage their disorders and this can complicate their care. Patients with obesity with uncontrolled hypertension and/or a history of cardiovascular disease (CVD) should not use sympathomimetic agents. In patients with type 2 diabetes mellitus (T2DM), weight-losing and weight- neutral medications should be employed as first-line and second-line therapy. Whenever patients with overweight or obesity are prescribed any potentially weight-altering medications, this side effect should be discussed in advance with the patient. It can be counterproductive for a patient with overweight or obesity to take a weigh-gaining medication to manage a comorbidity. Fortunately, there are many drugs in the armamentarium and it may be possible to select an alternative with a more weight-neutral or favorable profile. See Table 3. In the past, certain selective serotonin reuptake inhibitors (SSRIs) were prescribed to help patients lose weight, but there is not much evidence to support their use in this population. To the contrary, some SSRIs are associated more with weight gain than others. (See Table 3.) American Association of Clinical endocrinologists (AACe). The American Association of Clinical Endocrinologists (AACE) has published guidelines primarily aimed at practicing endocrinologists and focusing on assessment of complications in patients with obesity. 4,5 The primary goal of these guidelines is to improve the treatment of obesity-associated comorbidities rather than just achieving a specific weight target. This might be described as complications- centric patient assessment, that is, treatment geared to the patient's clinical presentation rather than trying to achieve a target weight. The AACE Advanced Framework and Levels of Treatment and Prevention of Chronic Diseases defines obesity as BMI≥30kg/m 2 (no obesity-related complications). For patients with a BMI in the range of 25 to 29.9kg/m 2 (overweight but not obesity), comorbidities should be a clear indication to intervene for weight loss. Thus, patients who are do not have obesity but who have overweight with comorbidities should be prioritized for treatment over patients who might have a higher BMI but no comorbid conditions. Ethnic considerations are included for patient assessment along with the advice that medications should be used early, even if lifestyle interventions have not been tried or have been attempted and failed. Unique to these guidelines are their ethnicity specific recommendations. For example, waist circumference as a metric for obesity and an indicator of metabolic syndrome is given for U.S. men and women (40 and 35 Table 3. Weight-altering medications commonly taken by patients with overweight and obesity; when possible, weight-neutral or weight-losing medications should be prescribed. CONDITION MEDICATIONS THAT MAY CAUSE WEIGHT GAIN ALTERNATIVE AGENTS (WEIGHT-REDUCING AGENTS IN PARENTHESES) D iabetes i nsulin, sulfonylureas, TZDs, mitglinide, sitagliptin? ( metformin), (acarbose), (miglitol), (pramlintide), (exenatide), (liraglutide), (SLGT2 inhibitors) Hypertension alpha-blocker? Beta-blocker? ACE inhibitors? Calcium channel blockers? Angiotensin-2 RAs Antidepressants and mood stabilizers amitriptyline, doxepin, imipramine, nortriptyline, trimipramine, mirtazapine, fluoxetine?, (bupropion), nefazodone, fluoxetine (short term < 1 year, sertraline) Oral contraceptives progestional steroids barrier methods, intrauterine devices ? indicates uncertainty or that the drug is currently under investigation; TZD: thiazolidinedione Adapted from: Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342–362. Insights into the Patient Population with Obesity: Assessment and Treatment

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