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Semelhante a Management Of The Morbidly Obese
Semelhante a Management Of The Morbidly Obese (20)
Management Of The Morbidly Obese
- 1. Management of the Morbidly Obese Sarah Nelson, Pharm.D. Pharmacy Practice Resident
- 4. Classification of Body Weight Buchwald H, Avidor Y, Braunwald et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA 2004. 292: 1724-1737 Chan L, Downing J. Management of Patients Receiving Bariatric Surgery. Pharmacotherapy Self-Assessment Program, 6 th edition. 63-81. Class III Obesity ≥ 40 Class II Obesity 35.0-39.9 Class I Obesity 30.0-34.9 Overweight 25.0-29.9 Normal weight 18.5-24.9 Underweight <18.5 Weight Category BMI (kg/m 2 )
- 8. In a Decade . . . http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm
- 13. Regulation of Energy Balance Bell C, Walley A, Froguel, P. The genetics of human obesity. Nature Reviews. 2005;6:221-29.
- 19. Treatment Options for Obesity
- 24. STORM Trial James W, Astryp A, Finer N, et al. Effect of sibutramine on weight maintenance after weight loss: a randomised trial. Lancet. 2000;356:2119-25.
- 28. Bupropion Anderson J, Greenway F, Fujioka K, et. al. Bupropion SR enhances weight loss: a 48-week double-blind, placebo-controlled trial. Obesity Research. 2002;10:633-41.
- 31. Orlistat (Alli®, Xenical®) Davidson M, Hauptman J, DiGirolamo M et al. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat. JAMA. 1999;281:235-242.
- 43. Banding vs. Bypass Tice J, Karliner L, Walsh J et al. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. The American Journal of Medicine. 2008;121:885-93. 14 17 Long term complication 3.3 5.2 Short term complication 75 84 Osteoarthritis 48 37 Dyslipidemia 66 56 Hypertension 72 77 Diabetes 64 34 Weight loss Gastric Bypass (n=232) Gastric Banding (n=160) Pt characteristic (%)
- 47. Outcomes in the Bariatric Patient
- 48. Co-morbidities following Treatment Buchwald H, Avidor Y, Braunwald E, et al. JAMA. 2004;292:1724-37. James W, Astryp A, Finer N, et al. Lancet. 2000;356:2119-25. Anderson J, Greenway F, Fujioka K, et. al. Obesity Research. 2002;10:633-41. Davidson M, Hauptman J, DiGirolamo M et al. JAMA. 1999;281:235-242. -46.3 Biliopancreatic diversion -28.6 Gastric banding -43.5 Gastric bypass -8.6 Bupropion -7.6 Orilstat -10.2 Sibutramine Absolute weight change (kg) Treatment
- 49. Co-morbidities following Treatment Buchwald H, Avidor Y, Braunwald E, et al. JAMA. 2004;292:1724-37. James W, Astryp A, Finer N, et al. Lancet. 2000;356:2119-25. Anderson J, Greenway F, Fujioka K, et. al. Obesity Research. 2002;10:633-41. Davidson M, Hauptman J, DiGirolamo M et al. JAMA. 1999;281:235-242. --- Biliopancreatic diversion --- Gastric banding --- Gastric bypass -1.73 Bupropion -0.8 Orilstat 0.1 Sibutramine Systolic BP (mmHg) Treatment
- 50. Co-morbidities following Treatment Buchwald H, Avidor Y, Braunwald E, et al. JAMA. 2004;292:1724-37. James W, Astryp A, Finer N, et al. Lancet. 2000;356:2119-25. Anderson J, Greenway F, Fujioka K, et. al. Obesity Research. 2002;10:633-41. Davidson M, Hauptman J, DiGirolamo M et al. JAMA. 1999;281:235-242. -5.79 Biliopancreatic diversion -3.2 Gastric banding -3.4 Gastric bypass -2.71 Bupropion 1.0 Orilstat -0.8 Sibutramine Fasting glucose (mg/dL) Treatment
- 51. Co-morbidities following Treatment Buchwald H, Avidor Y, Braunwald E, et al. JAMA. 2004;292:1724-37. James W, Astryp A, Finer N, et al. Lancet. 2000;356:2119-25. Anderson J, Greenway F, Fujioka K, et. al. Obesity Research. 2002;10:633-41. Davidson M, Hauptman J, DiGirolamo M et al. JAMA. 1999;281:235-242. Biliopancreatic diversion Gastric banding Gastric bypass -2.95 Bupropion -20 Orilstat -0.8 Sibutramine LDL (mg/dL) Treatment
- 53. In the mean time . . .
Notas do Editor
- BMI is not all encompassing, waist circumference and abdominal obesity have higher prognostic factors for morbidity BMI ranges may change for certain populations . . . Asian Americans have increased risk of DM with BMI around 23. Diet and lifestyle modifications are recommended for pts with BMI of 27 + and concurrent comorbidities or BMI > 30; bariatric surgery is indicated for pts with class II obesity and at least 1 comorbiditiy and class III obesity
- These numbers have doubled in the past decade and are expected to double again by 2015.
- Risk of developing diabetes with a BMI of 35 vs 22 is 40-90 fold higher, greater risk in obese females
- Replacement of leptin via subcutaneous injection in a 9 y/0 with congenital leptin deficiency led to complete reversal of obesity after 1 year of leptin treatment MC4R: melanocortin 4 receptor; autosomal dominant forms of obesity mutates the gene that encodes M4CR
- We examined the contributions of genetic factors and the family environment to human fatness in a sample of 540 adult Danish adoptee who were selected from a population of 3580 and divided into four weight classes: thin, median weight, overweight, and obese. There was a strong relation between the weight class of the adoptee and the body-mass index of their biologic parents - for the mothers, P less than 0.0001; for the fathers, P less than 0.02. There was no relation between the weight class of the adoptee and the body-mass index of their adoptive parents. Cumulative distributions of the body-mass index of parents showed similar results; there was a strong relation between the body-mass index of biologic parents and adoptee weight class and no relation between the index of adoptive parents and adoptee weight class. Furthermore, the relation between biologic parents and adoptee was not confined to the obesity weight class, but was present across the whole range of body fatness - from very thin to very fat. We conclude that genetic influences have an important role in determining human fatness in adults, whereas the family environment alone has no apparent effect.
- Absence of high school education increased female BMI by 1.52 kg/m2 and male BMI by 0.9 kg/m2
- Approved by the FDA in 1997. A beta-phenylethylamine that exhibits monoamine reuptake inhibitor activity for NE and 5ht2 and to a lesser extent, also dopamine Differs from fenfluramine and dexfenfluramine as it does not potentiate the release of NE and 5HT2 Active metabolites cause the hypophagic properties of sibutramine Exerts it’s affects by increasing the activity of other receptors via the increased levels of NE and 5HT2, namely alpha and beta receptors and 5HT2a/2c receptors Sibutramine and cardiovascular effects: Increases HR by 4 bpm Increases SBP by 4 mmHg Increases DBP by 2-4 mmHG Can be tolerated in pts with controlled htn.
- Silbutramine Trial of Obesity Reduction and Maintenance Trial
- 24 week multicenter, randomized, placebo controlled, double blind, parallel group study
- Rates of GI effects decreased over 2 years, 5.5%, 4.4%, 1.8%, 2.8%, 2.1% respectively
- Metformin most likely alters leptin levels
- CB receptors are widely distributed throughout the body, including in the brain and areas related to feeding, fat cell, GI tract. CB2 receptors are expressed in the immune system. Fasting increases levels of cannabinoids to agonist CB1 receptors, Blockade of the agonism leads to decreased stimulation for intake of high fat and sweet foods. Works opposite of marijuana. Received marketing approval from the European Medical Agency in June 2006. RR of psychiatric disorder: 1.9
- RIO= Rimbonabant in Obesity
- Increase in bariatric surgery spurred by obesity epidemic and improved outcomes of bariatric surgery. Most effective for treatment of class II and III obesity that attains long term weight loss In 2006, 177,000 people received bariatric surgery, should be >200,000 for 2007 4925 procedures in 1990, 12541 in 1997, 41000 in 2000, and 63000 in 2002
- Talk about length of Roux limb and risk for dumping syndrome
- Irreversible procedure, take-down can happen if needed.
- Laparoscopic adjustable gastric banding Best for women who wish to bear children as the band can be maximally deflated to allow for adequate nutritional intake with the fluctuating caloric needs of the pregnant woman Bands are usually not removed, even after adequate weight loss has been attained Poor candidates for LAGB are those who have severe obesity (BMI >50), severe abdominal adiposity, chronic dysfunction of the GI tract (GERD). Outpatient procedure!
- Early complications: band failure, slippage, difficulty swallowing
- Bariatric procedure rates have increased exponentially Banding is promoted as a safer, potentially reversible and effective alternative to bypass. Evaluation of what procedure should be standard of care.
- Also called the duodenal switch