Obese patients

Appetite suppressants have been widely used as an adjunct to dietary restriction and sympathomimetic amines have traditionally been used for this purpose. These agents have not proven particularly useful and frequentiy cause unacceptable side effects, hence their popularity has been waning for several years. The most promising newer dmgs work through a serotoninergic mechanism and hold considerable promise at least for certain obese patients. 

Leptin has proved to be an efficient treatment for the rare form of obesity associated with leptin deficiency. By contrast, the results of the fust clinical trial with human leptin in obese patients (without leptin deficiency) were less promising. This may be explained by leptin resistance in a high proportion of these patients. However, the mechanisms involved in the development of leptin resistance could become new drug targets. 

Dose based on actual body weight (even in obese patients)... 

Adjusted nutrition body weight for overweight, obese, or extremely obese patients... 

Use actual body weight for all calculations. Adjusted body weight (ABW) may be used for obese patients (greater than 130% of IBW). ABW = IBW + (actual body weight - IBW) x 0.7. 

In obese patients or those with only small amounts of fluid accumulation, ultrasound evaluation may be necessary to detect ascites with certainty. 

BMI. A reduction in body weight is always recommended in obese patients prior to the transplant procedure to help lower their NODAT risk.74... 

Protein requirements based on ideal body weight (IBW) use AdjBW in obese patients. 

Protein requirements must be based on the patient s nutrition assessment and appropriate amounts provided (based on IBW or AdjBW for obese patients) to facilitate anabolism and wound healing, and avoid adverse effects (e.g., azotemia and uremia). 

Recommend appropriate nonpharmacologic and pharmacologic therapeutic interventions for overweight or obese patients. 

Body mass index (BMI), waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. 

Surgery is warranted when other treatment attempts have failed in severely obese patients (BMI of 40 kg/m2 or greater or 35 kg/m2 or greater with other obesity-related risk factors). 

Phentermine decreases food intake, and hence weight, by increasing norepinephrine and dopamine release in the central nervous system. This drug is indicated for short-term use—no more than a few weeks—in addition to lifestyle modifications in obese patients with a BMI of 30 kg/m2 or greater or a BMI of 27 kg/m2" or greater in the presence of other risk factors.38... 

IBW is the weight expected for a nonobese person of a given height. The IBW formulas below and various life insurance tables can be used to estimate IBW. Dosing methods described in the literature may use IBW as a method in dosing obese patients. 

M.D. Crowell, A.G. Decker, V.A. Schettler, M.M. Moirano, H.J. Kim, and V.K. Sharma, Continuous 48-hr esophageal pH-metry in obese patients with gastroesophageal reflux symptoms compared to non-obese patients. Am. J. Gastroenterol. 100, S9-S23 (2005). 

Obese patients (>120% ideal body weight) without contraindications should be started on metformin initially, titrated to about 2,000 mg/day. A thiazolidinedione (rosiglitazone, pioglitazone) may be used in patients intolerant of or having a contraindication to metformin. 

A reduction in the loading dose is recommended for elderly patients, and a larger loading dose is required in obese patients. 

In order to avoid overdosing, estimated lean body mass should be used in obese patients. 

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