CASE STUDY: STRATEGIES FOR OVERWEIGHT INDIVIDUALS Mickey and Jim are brothers. T
ID: 80835 • Letter: C
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CASE STUDY: STRATEGIES FOR OVERWEIGHT INDIVIDUALS Mickey and Jim are brothers. Their parents, along with most other members of their family, are overweight and have hypertension. Mickey is the youngest of the family and at age 24 is overweight. He is 5’10” tall and weighs 188 lbs. Mickey is active, although not as active as he should be. He works at an advertising agency and is on the company softball team. They have been practicing every Saturday for the last three months. From 11am – 2pm Mickey is running bases, hitting balls, and playing the outfield. Afterwards, he and his friends go to the local pub for a few beers and a bite to eat. This “bite” is usually a burger and fries. Mickey’s brother, Jim is not active at all. He is 6’0” tall and weighs 338 pounds. Jim is a middle school history teacher. Most of his time is spent behind a desk or sitting at the table grading papers. When he needs a break, he usually goes to the fridge for a snack. Having grown up in the same household, Mickey and Jim have similar food preferences. Both love “old-fashioned” eating: bacon and eggs, ham and cheese, steak and potatoes. As kids, neither brother wanted to eat his vegetables, although they do eat some vegetables now. One habit they fully enjoy, and never grew out of is snacking on milk and cookies. To this day, they both have milk and cookies before bed. They were pudgy children, although they did not seem to eat much differently from the other kids in the neighborhood, they just gained more weight. Mickey loves food just as much as his brother, but he knows his weight is not healthy and that his brother’s is even worse. He asks Jim to go on a diet with him. At first, Jim seemed reluctant, but now he has turned Mickey’s weight loss challenge into a brotherly competition. Both are determined to lose at least 45 pounds in the next 10 weeks. Mickey decides that he needs to exercise more to lose weight. In addition to his Saturday softball practice, he plans to jog for 15 minutes twice a week. This does not produce results quickly enough, so Mickey tries using diet pills, but only “natural” ones. Mickey tries St. John’s Wort, but has tremendous difficulty sleeping at night. He also takes dieter’s tea, but he cannot deal with the nausea and cramping. Finally, he decides to go to his doctor and get prescription drugs. The doctor tells him that Sibutramin and Orlistat are the most common drugs on the market, but he feels Orlistat is the better choice for Mickey. Jim also goes to his doctor, but does so before attempting to change his activity level or trying natural diet products. He asks his physician if he would be a good candidate for bariatric surgery. Jim schedules an appoint for a consultation with the surgeon, but never sees it through. The brothers have a long talk and decide they should change their diets and eating habits to obtain healthier more long tem goals.
Mickey is substantially overweight to the point that his doctor was willing to prescribe medicine. Why did the doctor recommend Orlistat but not Sibutramine?
Explanation / Answer
Orlistat and Sibutramine work by very different mechanisms of action - orlistat prevents fat absorption whereas sibutramine enhances satiety.
Weight loss efficacy
Orlistat may be slightly less effective than sibutramine in reducing body weight5. Although orlistat and sibutramine undoubtedly produce weight loss, the effect is modest. Neither orlistat, nor sibutramine is able to induce large weight reduction in a majority of obese people2.
Extra health benefits
Orlistat may be more powerful in improving blood glucose control.
Orlistat promotes a significant reduction of total cholesterol levels6.
Orlistat therapy is associated to a mild reduction in blood pressure1. Weight loss >/=5% of initial body-weight during orlistat therapy is associated with reductions in blood pressure in obese patients with or without hypertension.
Sibutramine can increase blood pressure and heart rate4 In obese patients with hypertension, sibutramine appears to increase blood pressure only if patients do not reduce caloric intake.
Side effects
Two drugs have disparate tolerability profiles. Sibutramine is generically better tolerated than orlistat1. However, sibutramine is contraindicated in people with coronary artery disease, congestive heart failure, arrhythmias, stroke, or inadequately controlled hypertension or those receiving psychiatric drugs.
The most common side effects with orlistat are oily stools, flatus and fecal urgency. And with sibutramine side effetcs are headache, dry mouth and anorexia. Sibutramine can also increase blood pressure and heart rate.
What to Choose?
Both sibutramine (Meridia) and orlistat (Xenical) promote and maintain weight loss. Orlistat does not cause cardiovascular side effects and may be particularly useful for obese people with pre-existing cardiovascular disease.
On the other hand, the time frame for deciding if drug therapy is effective is 12 weeks for orlistat but only 4 weeks for sibutramine. This shorter time frame for evaluation with sibutramine allows more rapid treatment reconsideration.
The possibility of oily stools and discharge, the need for vitamin supplementation and a 3 times daily dosage schedule with orlistat can be bothersome or inconvenient. The once-daily dosage regimen with sibutramine is attractive but the potential for drug interactions or increased blood pressure, and contraindicatins in patients with
Feature Orlistat (Xenical) Sibutramine (Meridia) Drug class Gastric and pancreatic lipase inhibitor Noradrenaline (norepinephrine) and serotonin reuptake inhibitor (via active metabolites M1 and M2) Mechanism of action Locally: prevents absorption of approximately 30% of dietary fat Centrally: enhances satiety (decreases food intake) Target population Initial BMI of >/=30 kg/m2, or >/=27 kg/m2 (US) or >/=28 kg/m2 (UK) with risk factors (hypertension, diabetes mellitus, dyslipidaemia) Initial BMI of >/=30 kg/m2, or >/=27 kg/m2 with risk factors (hypertension, diabetes mellitus, dyslipidaemia.) Usual dosage 120mg orally 3 times daily with each main meal 10-15mg orally once daily with or without food Special instructions Patients must take a multivitamin supplement (2h before a dose). No dose should be taken if a meal is missed or contains no fat Blood pressure monitoring is required before and during therapy Contraindications Chronic malabsorption syndrome, cholestasis, pregnant/nursing women, hypersensitivity CAD, CHF, arrhythmias, stroke, severe renal or hepatic impairment, poorly controlled or uncontrolled hypertension, anorexia nervosa, patients taking MAOIsc or other serotonergic drugs Use with caution History of hyperoxaluria or calcium oxalate nephrolithiasis History of hypertension, seizures, narrow angle glaucoma Use in children Safety and efficacy have not been established Safety and efficacy in pediatric patients (<16 years of age) have not been established Abuse potential As with any weight-loss agent, the potential exists for misuse in inappropriate patient populations (e.g. with anorexia nervosa or bulimia) Physicians should evaluate patients for history of abuse and observe closely for signs of misuse or abuse Most common side effects Gastrointestinal (oily spotting or stool, flatus, increased fecal urgency) Headache, dry mouth, anorexia, insomnia, constipation Cardiovascular side effects None Increased blood pressure and heart rate Potential drug interactions Decreased absorption of fat-soluble vitamins May potentiate action of MAOIs and drugs that increase BP or HR; metabolism may be inhibited by CYP3A1 inhibitors "Differential features: Comparison of various features of the antiobesity drugs orlistat and sibutramine"from http://www.medscape.com/content/2000/00/40/64/406413/406413_tab.html3
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