Obesity and phentermine soap notes examples

phentermine examples and obesity soap notes

Either your web browser doesn't support Javascript or it is currently turned off. In the soap phentermine case, please turn on Javascript support in your web browser and reload this page. Obesity is now a major public health concern worldwide with increasing prevalence and a growing list of comorbidities and complications. The morbidity, mortality and reduced productivity associated with obesity and its complications result in a major burden to health care costs.

Obesity is a complex chronic medical syndrome often with multiple different etiologic factors in individual patients. The long term successful management of obesity remains particularly challenging and invariably requires a multifaceted approach including lifestyle and behavioral modification, increased physical activity, and adjunctive pharmacotherapy. Bariatric surgery remains a last resort though at present it has the best results for achieving sustained robust weight loss. Obesity pharmacotherapy has been very limited in its role for long term obesity management because of the past history of several failed agents as well as the fact that presently available agents are few, and generally utilized as monotherapy.

This review details the history and clinical trial basis for the use of both phentermine and topiramate in obesity therapeutics as well as the results of clinical trials of their combination for obesity treatment in humans. It is anticipated that this agent will be the first in a new trend of multi-agent combination therapy for the chronic adjunctive management of obesity. Obesity is a highly prevalent, complex condition that now appears to best fit the chronic "examples" model well known to apply to other clinical conditions like type 2 diabetes and essential hypertension.

There is also evidence that obesity is now becoming a global pandemic that requires the serious attention of clinicians all over the world. Obesity has a complicated, often multifactorial etiology that often makes its effective management difficult. The place of pharmacotherapy in the management of obesity is a long and checkered one. Obesity pharmacotherapy is new does xanax cause pinpoint pupils using fixed drug combinations but promises examples potential.

Table 1 details the major oral agent options currently available as well as some that recently became soap notes phentermine for clinical use. A central premise for the role of combination therapy in the examples of obesity is the potential of synergism between the component medications resulting in weight loss that exceeds the weight loss associated with the component medications.

While the two prime examples of combination pharmacotherapy for obesity valium and vicodin for back pain no longer available for clinical prescription because of long term safety concerns, the combinations of ephedrine and caffeine as well as of phentermine and fenfluramine did provide important historical examples of the clinical potential of combination therapy in long term obesity management.

Orexigen Therapeutics La Jolla, CA, USA holds the patent and license for a fixed drug combination of sustained release naltrexone and sustained release bupropion that is in review by the FDA pending the results examples ongoing cardiovascular safety studies for clinical use in the management of obesity. Vivus Mountain View, CA, USA patented and licensed the fixed drug combination of phentermine and an extended release formulation of topiramate which will be discussed in more detail later in this review and was recently FDA examples for marketing under the trade name Qsymia previously known as Qnexa.

Phentermine is administered orally as a tablet or capsule one to two times daily. The most common side effects experienced include dry mouth and insomnia. However, data suggest that phentermine may not be associated with serious adverse events and that use may actually cause blood pressure lowering associated with the resultant examples loss. Other contraindications for phentermine therapy include use with monoamine oxidase inhibitors, hyperthyroidism, glaucoma, agitation states, pregnancy, and use in patients with known history of drug abuse.

The potential for abuse with phentermine and obesity a major concern among providers which may preclude prescribing this agent for weight loss. The validity of this concern has been investigated examples notes a recently published study. Each of the patients evaluated was being treated with phentermine and stopped therapy on their own. None of these patients zofran interaction with azithromycin 250 cravings for phentermine or typical withdrawal symptoms that would be will wellbutrin help stop smoking in a patient abruptly stopping therapy with an amphetamine related medication.

Also, this may not be the case for a patient with a history of dependency issues so caution and appropriate clinical judgment is still warranted. Most of the Clinical research studies on phentermine use for obesity management were relatively short duration, involving small cohorts and completed between the s and 80s. According to a pooled analysis of several placebo-controlled randomized controlled trials lasting 2 to 24 weeks, patients that were treated with phentermine had a 3.

One of the longest studies conducted using phentermine was examples in Sixty-four patients completed the trial with a mean weight loss of These results demonstrated that intermittent therapy and obesity be as effective as daily phentermine treatment. Of note, the patients receiving intermittent therapy experienced some weight regain or lost weight more slowly during the 4 weeks on placebo. Weight loss reccurred when the phentermine was restarted indicating that the drug is really only effective during the time that it is being taken.

Phentermine has a long history of effectiveness for weight loss, albeit with a clinically modest effect. The clinical response to phentermine as with virtually all obesity pharmaceuticals can be quite variable ranging obesity and very modest to profound 35383960 with associated salutary effects on obesity associated comorbidities including blood obesity and, glycemic and lipid profiles.

A persistent challenge continues to be correctly identifying initially those patients who will respond best to this medication as an adjunctive intervention in their chronic weight management. Also, in spite of the presumed risks, is ultram good for toothache data shows that it is generally well tolerated with relatively minor symptoms associated with its use even in the longterm.

Because of this, it is not a surprise that phentermine is commonly examples clinically for longer than the examples weeks recommended in its package insert. Examples should also be counseled regarding the appropriate timing of the phentermine dose since the potential for insomnia is greater if phentermine soap notes dose is taken too late in the day. Despite examples of the potential issues with this medication however, phentermine remains the most commonly prescribed anti-obesity agent in the United States and much of the world and has remained so for several decades.

Topiramate is adderall with food or without sulfamate-substituted monosaccharide marketed sinceand initially approved by the FDA for management examples seizure disorders. It was first investigated as a antidiabetic medication; as a fructose-1,6-diphosphate analog sulfamate-substituted monosaccharide that inhibits fructose 1,6-bisphosphatase and soap notes inhibit gluconeogenesis.

As its usefulness in migraine prophylaxis was discovered incidentally, so was topiramate found to have potential as a weight loss medication during its trials as an antiepileptic drug published in andand then later was found to have diabetes-fighting qualities independent of the amount of weight that patients lost. Topiramate was also found to have effects on neuropeptide-Y as well as its Y1 and Y5 receptors, corticotrophin-releasing hormone and type-II glucocorticoid receptors in rats in whom its weight loss characteristics were being examined.

Table 2 details some of the observed, reported and putative modes of action of topiramate based on in vitro, as well as in vivo animal based trials. The product development profile of topiramate has included forays into its potential as an antidiabetic, and antiepileptic, a neuroprotective agent and a migraine prophylactic amongst others. Identified and putative modes of action of topiramate peripherally and centrally 65 Several of the "phentermine soap notes" effects of topiramate may be related to its inhibitory effect of carbonic anhydrase.

Adverse effects of tramadol hydrochloride addition to paresthesias, the carbonic anhydrase inhibitor activity of topiramate can contribute to a metabolic acidosis and type 3 renal tubular acidosis. The acidosis can usually be resolved by reducing the dose of topiramate and administration of sodium bicarbonate if needed.

Nephrolithiasis is also more common among patients taking topiramate and the incidence can be decreased with potassium citrate supplementation. Central nervous system side effects including cognitive decline, memory deficits, dizziness, word finding difficulty etc are usually the major consideration and limitation to maximizing the dose of topiramate that patients can tolerate. Oligo- or hypohidrosis which is "examples" decreased ability to cool the body by sweating is thought to also occur due to carbonic anhydrase inhibitory activity or by inhibition of aquaporin 5 in sweat glands.

Vision disturbances including diplopia, blurred vision, myopia, as well as the more severe acute myopia and secondary angle-closure glaucoma have been reported. Topiramates use in children older than 2-years is well-established in the treatment of epilepsy and usually well tolerated, although there is a higher incidence of metabolic acidosis in younger patients.

In addition, use of the medication in women of reproductive age should be done with adequate counseling of the patient and appropriate examples contraception The effects of metabolic acidosis may be more dire in pregnant women and may cause harm to the patient or result in fetal death. Weight loss was noted as a side effect as topiramate was being investigated for other uses such as migraine prevention, seizures and bipolar disorder.

InChengappa et al added topiramate to the medical treatment of 18 patients with bipolar I and schizoaffective disorder — bipolar type. Patients in this study who were noted to have higher BMIs at the study start had slightly more weight loss than their thinner counterparts. InBen-Menachem et al published the first prospective study of the weight loss effects of topiramate as well as investigating the major predictors of weight loss. They found that obese patients lost a higher percentage of body examples than did their normal or overweight counterparts.

Calories examples were noted to decrease in the beginning of topiramate use, but by 1 year patients were eating almost the same amount of calories as they had in pre-treatment. In general, "examples" composed a greater portion of the weight loss than lean mass how much lexapro is an overdose body composition was measured.

Ultimately they found that while caloric intake correlated with weight loss with most patients at the 3 month mark, as the study progressed initial BMI was more strongly correlated with weight loss. Johnson and Johnson New Brunswick, NJ, USA sponsored a series of large randomized, double-blind, placebo-controlled trials that were ultimately cut short in order for the company to focus on production of a controlled release formulation.

Systolic BP also decreased but not significantly. A randomized, double-blind, placebo-controlled, dose-ranging trial was conducted by Bray et al and reported in BMIs of 27—30 were also allowed if the patients had well controlled comorbidities of hypertension or take tramadol with ibuprofen. Results showed that all the topiramate groups showed an increased amount of weight loss and all were significant when compared to placebo.

Blood pressures were also monitored in this trial at each treatment visit, and significant decreases were found in all treatment groups versus placebo. The report mentioned four cases of patients who had serious adverse effects that were felt to be related to the topiramate: This study too was cut short to one year when Johnson and Johnson discontinued trials in order to pursue development of a timed-release version. This was one of the larger studies with a safety examples of patients and a modified intent to treat population of There was no significant improvement in blood lipids.

Five of the six cases resolved with cessation of topiramate and one patient continued to have depressed mood after stopping the drug. Vivus Mountain View, CA, USA have spearheaded the clinical development of a combination of phentermine and topiramate for the clinical management phentermine soap notes obesity. Unlike regular topiramate which has a half-life of 19—23 hours, the extended release form has a half-life of greater than 24 hours with a significantly slower onset of action and longer time to establishment of steady state compared to regular topiramate.

The combination of topiramate and phentermine has been approved by the FDA for use along with reduced dietary caloric intake for the management of obese subjects or overweight subjects with at least one weight related comorbidity. Furthermore there remains an intent to perform further studies to obtain additional therapeutic indications for its use as an adjunctive antidiabetic, for management of obstructive sleep apnea examples for potential obesity and in pediatric obesity.

Preliminary phase 1 trials using these formulations in small cohorts of subjects with varying degrees of renal and hepatic compromise helped establish the now recommended dosing schedule. The following paragraphs discuss the major findings from these studies while Table 3 details the major features of these studies. Further analyses of other cardiometabolic surrogates including blood pressure, lipid profiles and fasting glucose showed no statistically significant benefits though the trends observed suggested minimal improvements.

The primary end points of the study were similar to those of the EQUIP trial and the intent to treat, last observation carried forward findings showed that while the 7. Examples additional benefit of improvement in glycemic profiles was also reported. The study design was essentially similar as were the treatment arms and this study demonstrated the durability of the findings from the CONQUER study over a 2 year period.

The current dosing schedule for Qsymia included in the product insert 80 recommends starting with two prescriptions; a 14 day prescription of the 3. After 12 weeks on the maintenance dose based on clinical response a decision can be made as to the need for further dose titration. The dose escalation is again suggested to be a two how much lexapro can i take process with a 14 examples prescription of the titration dose of The stepwise approach to dosing and dose escalation does xanax have antidepressant properties designed to optimize clinical response while keeping adverse events to the minimum.

The observed side effects from the various certification clinical trials of Qsymia are as examples be anticipated based on the individual component medications in the combination. The majority of them resolved spontaneously without resolution and did not spur stopping the medication. Every potential side effect identified with the individual component medications have been described and noted with the combination preparation and special attention needs to be paid to potential teratogenicity, potential for acute closed angle glaucoma and myriad neuropsychiatric symptomatology including mood disorders and suicidal ideations.

Overall the clinical results of the trials thus far completed for the fixed drug combination of phentermine and topiramate-ER give reason for measured optimism. The degree of weight loss achieved, the percentage of subjects overall achieving this degree of weight loss and it robustness based on the thus far 2 year follow up data suggest that this combination therapy has an important place to occupy in the armamentarium for chronic obesity management.

Beyond the significant improvement in weight, the findings from various trials of associated improvements in relevant surrogates such as blood pressure, glycemic control examples burden as well as waist circumference specifically suggest the potential added utility of the agent in cardiovascular risk modification. Azithromycin ip 250 mg results of planned clinical trials to investigate the effect of the combination on actual atherosclerotic vascular event risks is anticipated as are the results of other planned clinical trials in special populations such as pediatrics as well as for other distinct clinical end points such obesity and phentermine obstructive sleep apnea.

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