Therapeutics 4 - Health Promotion and Prevention

tylerwise's version from 2015-05-03 18:55

Obesity Facts

Question Answer
Overweight/obese prevalence68%
"New" consequence of obesityCryptogenic cirrhosis
Percentage of weight loss/gain for significant metabolic activity5-10%
Six tips for weight loss1) Start with small steps
>Start by eliminating sugar-sweetened drinks

2) Make realistic goals

3) Seek support from those who can relate to the struggle

4) Keep portions under control

5) Keep careful track of caloric intake

6) Always make physical activity a part of your life
Set pointMetabolic balance point of caloric intake and expenditure to maintain current weight
>A higher set point requires FEWER calories to maintain body weight
>A set point will never reset to a lower level after losing weight
Single best lifestyle changeStop drinking sugar-sweetened beverages
Three recommendations for exercise1) At least 150 minutes of moderate-intensity aerobic activity every week
2) Some form of muscle-strengthening exercise at least twice a week
3) 60 minutes of moderate-to-vigorous physical activity every day for children
Seven factors of ideal cardiovascular health1) Optimal cholesterol
2) Normal blood pressure
3) No diabetes
4) Lean BMI
5) No smoking
6) Physical activity
7) Healthy diet
Treatment goals
Caloric intake
Decrease 500-1000 calories/day
>Difficulty in adjusting to decrease of >1000 calories/day
Treatment goals
Weekly weight loss goal
1-2 pounds per week
Treatment goals
Long-term weight loss goal
10% loss in 6 months
When is pharmacologic treatment approved?BMI > 30
BMI > 27 with risk factors (HTN, dyslipidemia, heart disease, T2DM, sleep apnea)

Key Recommendations of the Obesity Management Guidelines

Question Answer
1.1Lifestyle modifications (diet, exercise, behavioral) are key to all obesity management approaches
Pharmacotherapy may be used as adjuncts to behavioral modification
Drugs may increase adherence to behavioral changes
1.2Use approved pharmacotherapy to promote long-term weight maintenance
Losing weight is often easier than maintaining weight
1.3Do not use sympathomimetics in patients with uncontrolled HTN or heart disease
1.4Assess efficacy and safety of pharmacotherapy monthly for first 3 months
Assess every 3 months thereafter while on therapy
1.5Continue treatment if response is effective (>5% loss in 3 months) and safe
Discontinue and try alternate therapy if ineffective (<5% loss in 3 months)
1.6Initiate pharmacotherapy with dose escalation based on efficacy and tolerability

Weight Loss Drugs (Dosing)

Question Answer
Phentermine15-37.5 mg daily
8 mg TID with food
**For short-term use only**
OrlistatXenical (Rx): 120 mg TID with food
Alli (OTC): 60 mg TID with food
**Long-term use**
Phentermine/topiramate SRInitial: 3.75/23 mg daily x 14 days
Then 7.5/46 mg daily

May be increased to 11.25/69 mg or 15/92 mg daily after 14-day intervals
Lorcaserin10 mg BID
Bupropion/naltrexone SR90/8 mg tablets
Initial: 1 tab QD x 1 week
Then 1 tab BID x 1 week
Then 2 tabs QAM and 1 tab QPM x 1 week
Then 2 tabs BID
LiraglutideInitial: 0.6 mg SQ QD x 1 week
Then 1.2 mg SQ QD x 1 week
Then 1.8 mg SQ QD x 1 week
Then 2.4 mg SQ QD x 1 week
Then 3 mg SQ QD

Weight Loss Drugs (Side Effects, Contraindications, and Cautions)

Question Answer
PhentermineSEs: insomnia, increased BP and HR, palpitations, arrhythmias
CIs: CVD, HTN, glaucoma, concomitant MAOI
OrlistatSEs: headache, GI shit (:-P)
CIs: chronic malabsorption syndrome, cholestasis
Cautions: fat-soluble vitamin deficiency, associated with severe liver injury
Phentermine/topiramate SRSEs: Paresthesia, dry mouth, constipation, headache, insomnia, altered taste
CIs: pregnancy, glaucoma, hyperthyroidism
Cautions: topiramate has been linked to risk of cleft lip/palate during 1st trimester, increased HR
LorcaserinSEs: headache, dizziness, fatigue, back pain, hypoglycemia
CIs: pregnancy
Cautions: Risk of serotonin syndrome when taking other serotonergic agents
Bupropion/naltrexone SRSEs: nausea, constipation, headache, dizziness
CIs: seizure disorders, history of bulimia or anorexia, uncontrolled HTN, abrupt discontinuation of alcohol, opioids, or MOAI within 14 days
Cautions: increased risk of suicidal ideation
LiraglutideSEs: nausea, hypoglycemia, GI stuff
CIs: personal/family history of medullary thyroid carcinoma (very rare)

Weight Loss Drugs (Counseling Points)

Question Answer
Phentermine1) Only approved for short-term treatment
2) May increase BP and HR
3) Must be combined with lifestyle modifications
Orlistat1) Take a multivitamin containing fat-soluble vitamins two hours before or after the dose
2) Avoid high-fat diet to decrease GI events
3) Don't take a dose if the meal doesn't contain fat
4) Most GI effects last only 1-4 weeks
5) Must be combined with lifestyle changes
Phentermine/topiramate SR1) Increase dose if weight loss is <3% of body weight in 12 weeks
2) Women of child-bearing age must have negative pregnancy tests every month
3) May increase breakthrough bleeding of women on OCs
4) Don't discontinue abruptly
5) May cause worsening of depression and/or suicidal ideation
6) May cause disturbances in attention, concentration, and memory
7) Must be combined with lifestyle changes
8) Only dispensed through specially certified pharmacies
Lorcaserin1) Associated with disturbances in attention and memory
2) May be associated with worsening of depression and/or suicidal ideation
3) May increase risk of priapism
4) Associated with feelings of euphoria
5) Patients with T2DM have experienced increases in hypoglycemic events
6) Must be combined with lifestyle modifications
Bupropion/naltrexone SR1) BP and HR should be monitored
2) Do not take if you have a history of seizures
3) Do not take opioids with this medication
4) Tablets must be swallowed whole
5) Avoid taking with high-fat meal
6) Must be combined with lifestyle modifications
Liraglutide1) Discontinue if loss <4% at 16 weeks
2) Decrease doses of insulin secretagogues by 50%
3) To decrease risk of nausea and dyspepsia, decrease meal sizes by half
4) Store in refrigerator prior to use; store at room temp for 30 days after first use
5) Must be combined with lifestyle modifications

Immunization Facts

Question Answer
Reasons a parent must tell healthcare providers their child is unvaccinated1) Physician can consider the possibility the child has a vaccine-preventable disease
2) Initiation of isolation precautions to prevent the spread of vaccine-preventable disease to others
Rationale to discharging unvaccinated patientsProtecting other patients who cannot receive or have failed to become protected by vaccinations
Advantages to keeping patients who refuse to vaccinateContinuing education that could possibly change their opinions/views
Are vaccinations necessary?Yes
>For common diseases, choosing to not get the vaccine is choosing to get the disease
>Vaccines keep uncommon diseases uncommon
>Some diseases eliminated in the US persist in other countries
Risks associated with vaccines?Pain, redness, tenderness at injection site
Some cause persistent, uncontrollable crying; lethargy
Why so many vaccines?11 different vaccines exist
More vaccinations means fewer diseases
Can an infant handle vaccines?Yes
Infants are born with fairly robust immune systems.
Is it better to be naturally infected?No
Consider the "price" of vaccination vs. "natural" infection
>Both will give you immunity
>Having the disease can still cause death
Does MMR cause autism and should it be separated?Evidence concludes that MMR does not cause autism
Thus, there is no reason to separate the vaccinations
Also, separating them would require to additional injections for the child
Can you prove vaccines do not cause chronic illness?Studies have proven that vaccines do not cause chronic illness

Prescription Drug Abuse Facts

Question Answer
Age group with above-average rate of prescription drug abuseYoung adults (18-25 years old)
% increase in opioid prescriptions dispensed between 2000 and 200948%
Prescription painkillers responsible for more deaths thanCocaine and heroin combined
Six indicators of fraudulent prescriptions1) Physician writes significantly more prescriptions
2) Patient returns far too early for refills
3) Prescriptions for stimulants and depressants at the same time
4) Patient presents prescriptions with other people's names
5) Numerous people present with similar scripts from the same physician during a short window of time
6) Numerous new patients present with scripts from the same physician
Purpose of MAPSReports controlled substance prescriptions dispensed from pharmacies and providers
What is SBIRTScreening (assessment for a problem)
Brief Intervention (encourage personal insight)
Referral to Treatment (specialized care)
How can pharmacists help? (6 ways)1) Talk with patient about safety in using/storing/disposing of controlled substances
2) Use MAPS reports on unknown patients or when filling a controlled substance
3) Call physicians with inappropriate behavior
4) Refuse to fill prescriptions of patients with inappropriate behavior
5) Call physicians regarding excessive quantities
6) Check ID at time of dispensing