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Obesity: Medications and Bariatric Surgery

by Charles Vega, MD
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    00:01 Failing that, failing diet and beyond exercise, of course, those are always going to be foundational.

    00:06 We’re going to recommend those throughout.

    00:08 There are four new medication introduced in the United States for the treatment of obesity.

    00:13 And they do work.

    00:16 In clinical trials, more than half of individuals treated with these medications lost at least 5% of their body weight.

    00:22 So, again, these are significant weight loss.

    00:25 We’re talking along the lines of 6 kg, 8 kg, 9 kg.

    00:30 Phentermine topiramate generally has been associated with the largest amounts of weight loss in these clinical trials.

    00:39 It appears to be safe right now.

    00:44 All these drugs are being monitored for their safety profile over time, given the history of weight loss drugs, but it does appear to be safe to take.

    00:53 One thing with taking any drug with topiramate in it is it can make patients feel a little bit hazy or foggy, with some difficulty in concentration.

    01:02 So, that's one thing to watch and can be managed by cutting the dose.

    01:06 Liraglutide is a glucagon-like peptide-1 antagonist and that drug is used to treat diabetes, but it's also associated with weight loss.

    01:17 It doesn't promote low sugar.

    01:19 So, therefore, that's not a worry.

    01:21 And it can be effective.

    01:22 The main side effects with liraglutide are gastrointestinal upset.

    01:27 So that's something.

    01:28 But, usually, if patients can make it through the first week or two of treatment and tolerate the drug okay and see-through a little bit of nausea, they’re going to be fine in taking over the long-term.

    01:38 Naltrexone bupropion also is effective, another combination agent.

    01:43 Bupropion, we have to watch out for its effects in patients with seizures because it lowers the seizure threshold, can have some effects on sleep as well, but generally pretty well tolerated.

    01:57 All right.

    01:57 But say the patient is failing their diet, exercise, medications and still has some indications for bariatric surgery, that's the time to think about maybe doing surgery for these patients.

    02:10 So, bariatric surgery, the general indications, the things you should know for the exam, body mass index of 40 kg/m² or more or at least 35 kg/m² with complications of obesity, primarily hypertension, diabetes.

    02:27 Now, these treatments really do work.

    02:30 It's possible to lose 50% of the body weight or more.

    02:35 So, the improvements can be dramatic.

    02:37 It's really the only thing that cures diabetes, for example.

    02:42 And one thing we do understand is that now gastric volume procedures, either the Roux-en-Y gastric bypass or the gastric sleeve have become more popular than the banding procedure or laparoscopic band because those procedures, the gastric volume procedures definitely promote greater weight loss.

    03:04 So, if you want to lose a few pounds, the band procedures are okay.

    03:07 But if you really want to make a difference in disease outcomes, like hypertension and diabetes, gastric volume procedures are definitely more effective.

    03:16 And now the gastric sleeve is the most popular form of bariatric surgery in the United States.

    03:21 As I mentioned, it can be highly effective in reducing the risk of diabetes, it can reduce the risk of incident hypertension and it also greatly improves pre-existing diabetes and hypertension as well.

    03:35 It’s associated – there is an associated risk of complications.

    03:39 3 to 5% of these gastric volume procedures, whether we’re talking about the Roux-en-Y bypass or the other sleeve can have leaks after surgery.

    03:50 There is about a 1% perioperative risk of serious adverse events, which isn’t different than some other procedures like an open cholecystectomy, but still something to consider as patients elect to have these procedures.

    04:07 However, in the long term, and particularly as patients get good counseling and good follow-up, so they understand what the procedure entails and what their life will be like after the procedure in terms of early satiety and having to be evaluated for potential nutritional deficiencies and having to titrate their diet accordingly, those patients I think who are prepped appropriately and followed appropriately have a lifestyle that’s actually improved after surgery versus not.

    04:36 And I can say from personal experience, those patients who have unreasonable expectations and don't get the kinds of follow-up that they need have oftentimes more side effects, more symptoms and a worse lifestyle afterwards.

    04:51 So, we discussed the epidemiology of obesity.

    04:54 Diet and exercise are the cornerstone.

    04:57 Really try to focus on those lower carbohydrate diets.

    05:00 Those seem to be the ones that work best.

    05:03 And you can work to that goal gradually with the patients’ values in mind.

    05:08 It is perfectly reasonable.

    05:10 Medications can certainly help and they might stimulate patients to lose a little bit more weight.

    05:15 How long you continue those drugs is a matter of controversy.

    05:19 And for patients who fail diet and exercise conservative therapy and really are suffering with obesity and its complications, bariatric surgery is an option.

    05:31 Hope you found that helpful.

    05:32 Thanks very much for your attention.


    About the Lecture

    The lecture Obesity: Medications and Bariatric Surgery by Charles Vega, MD is from the course Chronic Care.


    Included Quiz Questions

    1. 5%
    2. 50%
    3. 25%
    4. 0.5%
    5. 2%
    1. Difficulty concentrating
    2. Nausea
    3. Fatty diarrhea
    4. Hypoglycemia
    5. Skin rashes
    1. Team based approach to diet and exercise therapy
    2. Gastric banding procedure
    3. Gastric sleeve procedure
    4. Phentermine/topiramate
    5. Naltrexone/bupropion
    1. It can lower the seizure threshold
    2. It can cause impaired cognition and drowsiness
    3. It is associated with hypoglycemia
    4. It is associated with malabsorptive diarrhea and vitamin/mineral supplements should be offered
    5. It is associated with a risk of sudden dangerous massive weight loss
    1. A patient with a BMI of 41 without any co-morbid conditions
    2. A patient with a BMI of 34 and hypertension and diabetes who has not lost any weight with a team based approach to diet and exercise and trial on phentaermine/topiramate and naltrexone/bupropion.
    3. A patient with a BMI of 38 and no other medical problems who has difficulty committing to a regular diet and exercise program and did not tolerate any oral weight loss medication therapies
    4. A patient with a BMI of 35 with diabetes who is struggling with diet and exercise
    5. A patient with a BMI of 35.4 with type 2 diabetes who has lost 1 kg with diet, exercise, and trial of Liraglutide

    Author of lecture Obesity: Medications and Bariatric Surgery

     Charles Vega, MD

    Charles Vega, MD


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