Anti-Obesity Medication

1. Anti-Obesity Medication • NPT VTS Teaching Programme • Bethan Yeoman

2. Anti-Obesity Medication – General Principles • Should not be first-line in treatment of obesity • Should only be used in conjunction with a healthy eating and good exercise programme. • Should not be prescribed to children in General Practice – if all other advice on behavioural changes, exercise and diet is failing – refer to secondary care.

3. Assessment in Adults • Measure BMI • Assess comorbidities – DM, smoking, HTN, CVD, hyperlipidaemia, OA, sleep apnoea. • Benefit in taking BP and blood for fasting glc and lipid profile • NICE talk about waist circumference but actully minimal impact on management • Assess diet & exercise; psychological stresses; enviroment, social & family factors; motivation to change.

4. General Measures • Advice about the health implications of obesity. • Take into account personal circumstances. • Behavioural - goal setting, slow eating, modifying thoughts, assertiveness and problem solving. • Exercise – 30mins of at least mod. intensity on five or more days of the week. Build up levels. • Diet - balanced and nutritious. 600 calory deficit. Reduce snacking. Programmes only if remain healthy (NOT Atkins).

5. Anti-obesity Medication • If BMI >35 and other measures have been started and evaluated and patient not achieving target wt loss. • Monitor regularly, give info on support programmes, discuss limitations and monitoring requirements. • No license for co-prescribing of anti-obesity drugs. • Orlistat (Xenical) - GI Tract • Sibutramine (Reductil) - Central appetite suppressant • Rimonabant (Acomplia)* - Central appetite suppressant *Rimonabant has recently been linked to a two-fold increase in psychiatric problems including suicide and the European Medicines Agency (and UK MHRA) has asked doctors not to prescribe the drug and to review all those who are currently taking it.

6. Orlistat • License – BMI 30+ or BMI 28+ with associated risk factors. • Lipase inhibitor – reduces absorption of dietary fat. • Cont after 3mths only if patient has lost at least 5% of body wt since starting. • Cont for longer than 12mths only after discussing benefits / limitations with pt. • Part of wt loss likely to be result of pts decreasing fat content of diet to avoid GI Ses (incl Steattorhoea). • Vitamin supplementation (esp D) may be considered if concern about absorption of fat soluble vitamins.

7. Orlistat • Contra-indications – chronic malabsorption syndrome, cholestasis, breast-feeding • Cautions – pregnancy • Side Effects – GI – flatulence, faecal urgency and incontinence, oily stools, abdo pain and distension. Tooth and gingival disorders, fatigue, headache, anxiety. • Dose – 120mg during or up to an 1hr after a meal up to TDS. If a meal is missed or contains no fat – omit the dose of orlistat.

8. Sibutramine • License – BMI 30+ or BMI 27+ with associated risk factors. • Inhibits re-uptake of noradrenaline and serotonin. • Cont after 3mths only if patient has lost at least 5% of body wt since starting. Stop if wt loss stabilises at <5%. • Not recommended for use beyond licensed 12mths. • Need to monitor bp and pulse mthly for 3mths and then at least every 3mths. Stop if bp >145/90 or if either S/D rises >10mmHg or if pulse rises >10bpm on 2 consecutive occasions.

9. Sibutramine • Contra-indications – Hx of eating disorder / psychiatric illness, cerebro-/cardio-/peripheral-vascular disease. Uncontrolled HTN. Hyperthyroid. Pregnancy and breast feeding. • Cautions – open-angle glaucoma, risk of raised ocular/pulmonary hypertension, predisposition to/drugs that increase bleeding. • Side effects – constipation, dry mouth, N+V,palpitations, arrhythmias • Dose – 10mg mane, increase to 15mg if wt loss <2kg after 4wks, stop if wt loss remains <2kg after 4wks at 15mg.

10. Rimonobant • Cannabinoid receptor antagonist • Contraindicated in anyone with a history of psychiatric illness and now linked to a possible increased incidence of psychiatric illness and suicide. • Advised not to prescribe at present but await future developments.