Obesity (and Medications)

Courtesy of Dr. Bartlett! (Summary of some lecture points and potential pharmacologic plan step up below - Brad 6/25/2023)

Obesity Focused Eval (over 24 hours): 

1. Eating habits/time/portions 

2. Cravings, hunger

3. Emotional eating

4. ETOH and sugar beverages

5. Times eating out per week? 

Associated Conditions: OSA (STOP-BANG), anxiety (stress), FMH

Labs: Fasting Lipid, CMP (CBC if NAFLD, NASH concern), TSH, Vit. D, A1C

Correlate clinically: Sex hormones and Cortisol if concern for PCOS vs Hypogonadism  vs Cushings

Plan: 

1. Nutrition referral

2. Goal 500 kcal deficit per day to lose 1lb/week

3. Drink glass of water before meals to increase fullness

4. Veggies first, then protein, then carbs

5. Adress stress: BH specialist f/u and pharmacologic optimizations

6. Sleep: Goal 7-9 hours per night

Pharmacologic intervention: 

Candidates: 

1. BMI > 25: Hydrogels (ie Gelesis) - FDA device

2. BMI > 30: AOM Pharmacotherapy

3. BMI > 27 + Comorbidity (ie HTN, OSA, GERD, DM, NAFLD): AOM Pharmacotherapy

Tricare AOM Pharmacotherapy options: (THESE WILL NEED PRIOR AUTHS!!!! GO on Tricare formulary website and search the medication you want to see forms)  

1. Start with Phentermine: 1/2 tab of 30mg or 37.5mg in AM. (Approved for short term use (<12 weeks) but off label for longer if working. Pt should sign a waiver. 

CAUTION with Amphetamine use (UDS?), females (pregnancy; should be on contraception), anxiety or "agitated state". Monitor HR and BP (M-W-F and check q 4-6 weeks in clinic). Goal is to lose >5% TBW in 12 weeks.

2. If fails, next you can try Qsymia (Phentermine/topiramate): 3.75/23 for 14 days, then increase to 7.5/46mg. 12 week reassessment. If patient did not lose >3% TBW, taper off or escalate to 11.25/69 for 14 days then increase to 15/92mg. Reassess at next 12 weeks. If patient did not lose >5% TBW taper off. 

CAUTION with GFR 30-49 (limit use to 7.5/46mg daily), anxiety or "agitated state", females (pregnancy; should be on contraception and should get pregnancy prior to starting and monthly). Monitor HR and BP (M-W-F and check q4-6 weeks in clinic). 

3. If fails, next you can try Contrave (Naltrexone SR/ Bupropion SR). See Lecture for dosing/scheduling and monitoring. 

4. If fails, next you can try Semaglutide (Weegovy): See Lecture for dosing/scheduling and monitoring. 

Courtesy of Dr. Herring!