Numerous dietary supplements are marketed for weight loss. Reliable evidence of

efficacy for these agents is limited and safety data are lacking. Clinical data do not

support the use of these agents and S.B. should be advised not to use dietary

supplement for weight loss.

CASE 36-1, QUESTION 9: S.B.’s health insurance changed and she was no longer able to continue orlistat

and she slowly regained the lost weight. Two years after discontinuing orlistat, SB has regained 7 kg. Her

current weight is 85 kg and her BMI is 30.1 kg/m

2

. She is frustrated that she has regained weight despite

compliance with comprehensive lifestyle interventions. She asks whether her results are usual and inquires

about additional options for weight loss.

S.B.’s regain after discontinuing orlistat is typical. Trials with a crossover design

have shown that the weight loss achieved with anti-obesity agents is unlikely to be

sustained after discontinuation.

6 Weight regain is to be expected after discontinuing

anti-obesity agents because the underlying pathology of obesity is not changed.

Medical Devices for Obesity Treatment

A device called the vBloc Maestro Rechargeable System has been recently approved

by the FDA as a treatment option for patients with extreme obesity (BMI ≥40 or ≥35

kg/m2 with comorbid conditions) who have failed at least one supervised weight

management program within the past 5 years.

124 The device is surgically implanted

into the abdomen where it emits intermittent electrical pulses to block signaling by

the vagus nerve.

124,125

In a recent randomized, double-blind, sham-controlled clinical

trial, the vBloc system produced weight loss of 9.2% of initial body weight,

compared to weight loss of 6.0% of initial body weight with the sham technology.

126

The most common adverse events were heartburn, dyspepsia, and abdominal pain.

126

S.B.’s current BMI is 30.1 kg/m2 which is below the threshold for use of vBloc;

therefore, she is not a candidate for a medical device at this time. In order to sustain

weight loss, long-term treatment must continue.

CASE 36-1, QUESTION 10: S.B. returns to her physician 3 years later. She has gained an additional 16 kg

and her BMI is now 35.4 kg/m

2

. She reports inability to maintain her weight with diet and exercise therapy after

completion of the behavioral modification program in which she was participating. Laboratory tests provide the

following results:

Blood pressure, 154/92 mm Hg

Fasting blood glucose, 162 mg/dL

TG, 354 mg/dL

Total cholesterol, 227 mg/dL

HDL, 35 mg/dL

LDL, 182 mg/dL

S.B. requests a referral to a bariatric clinic for evaluation for surgical intervention for weight loss. Is S.B. a

candidate for bariatric surgery? How could a bariatric surgical procedure affect medication administration in

S.B. postoperatively?

Surgery

Surgery may be an option for individuals with extreme obesity (BMI ≥40 or ≥35

kg/m2 with comorbid conditions) who have not responded to lifestyle changes with or

without adjunctive pharmacotherapy.

7,127 For severely obese patients (>100% more

than normal weight), the most effective treatment is a surgical procedure to reduce

the size of the stomach. Bariatric surgical procedures either reduce the absorptive

surface of the GI tract resulting in malabsorption, or reduce the stomach volume so

that the person feels full after a smaller meal. Procedures include gastric banding,

vertical banded gastroplasty, Roux-en-Y gastric bypass, and biliopancreatic

diversion; all have demonstrated efficacy, although the degree of weight loss and

complications may differ.

128 Gastric bypass has been shown to produce a greater

weight loss compared with gastroplasty procedures.

129

In addition, laparoscopic (vs.

open surgical) approaches may be preferred for reducing postoperative

complications and hospital stay.

128

The mortality rate from bariatric surgery is estimated to be 0.3% to 1.9% and

literature has shown that centers that perform surgeries at high volume have better

outcomes.

67 Some of the complications of bariatric surgery include nausea, stomach

ulceration, stenosis, anemia, and cholelithiasis. Postsurgical precautions include

careful evaluation of meal sizes and timing along with meal content, especially

immediately after surgery. Patients should be aware that they will not be able to

resume their normal eating habits, and they should be properly educated on lifestyle

modifications for maintenance of weight loss. In addition, medications and adequate

intake of necessary nutrients are important considerations after surgery. Medications

such as nonsteroidal anti-inflammatory drugs, salicylates, and bisphosphonates may

cause ulcerations, and medications that are delayed release or extended release may

not be absorbed owing to changes in gastric size.

130 Medications may need to be

administered using liquid formulation and other dosage routes. Transdermal

formulations need to be carefully dosed to account for changes in body surface area

postsurgically.

130

Although S.B. is a candidate for bariatric surgery based on her BMI of 35.4 kg/m2

and her comorbid conditions (hypertension and sleep apnea), she may also consider

alternative pharmacotherapeutic options. S.B.’s fasting blood glucose indicates that

she may have type 2 diabetes. Liraglutide is an option that will lower her blood

glucose as well as result in clinically significant weight reduction.

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

Key References

Apovian CM et al. Pharmacological management of obesity: an endocrine society clinical practice guideline. J Clin

Endocrinol Metab. 2015;100(2):342–362. (6)

Domecq JP et al. Drugs commonly associated with weight change: a systematic review and meta-analysis. J Clin

Endocrinol Metab. 2015;100(2):363–370. (57)

Garvey WT et al. Two-year sustained weight loss and metabolic benefits with controlled-release

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extension study. Am J Clin Nutr. 2012;95(2):297–308. (93)

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Smith SR et al. Multicenter, placebo-controlled trial of lorcaserin for weight management. N Engl J Med.

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Torgerson JS et al. XENical in the prevention of diabetes in obese subjects (XENDOS) study:A randomized study

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Care. 2004;27(1):155–161. (78)

Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA.

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CDC. http://www.cdc.gov/obesity/.

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