Jennifer L. Hofmann, MS, PA-C

This article was updated October 24, 2019.

Clinicians should recommend routine yearly influenza vaccinations for everyone 6 months or older who has no contraindications for the 2019-2020 influenza season starting at the end of October, according to the Advisory Committee on Immunization Practices.

In older adults, vaccinating earlier may result in lower immunity before the season ends.

Children aged 6 months through 8 years who need 2 doses should get their first dose as early as possible so that they can receive the second dose 4 weeks later.

Populations that are considered at risk include

Adults and children with chronic disease, including cardiovascular (excluding isolated hypertension), chronic pulmonary (including asthma), hematologic, hepatic, metabolic disorders (including diabetes mellitus), neurologic, or renal, American Indians or Alaska natives

Children and adolescents aged 6 months through 18 years who have a higher risk for Reye syndrome after influenza virus infection, because they are taking aspirin- or salicylate-containing medications

Individuals who care for or live with high-risk individuals, such as health care workers or those who work in a nonmedical capacity in health care facilities

People who are extremely obese, with a body mass index of ≥40 for adults

Women who are or who expect to be pregnant during influenza season

Individuals with a known egg allergy or previous reaction to eggs may receive any licensed, recommended influenza vaccine. Live vaccines are not recommended for immunocompromised or pregnant patients. Clinicians should use precautions in patients who have a history of Guillain-Barré syndrome within 6 weeks of receiving any type of influenza.

Influenza vaccines are either trivalent, which contain 2 influenza A antigens and 1 influenza B antigen, or quadrivalent which contain 2 influenza A and influenza B antigens. There are several types of influenza vaccines available, including inactivated influenza vaccines (IIVs), one recombinant influenza vaccine, Flublok Quadrivalent (RIV4) and a live attenuated vaccine (LAIV). There are several standard-dose IIV products, which are all quadrivalent and many of which are licensed for those as young 6 months of age. There is 1 high-dose trivalent IIV and 1 adjuvanted trivalent IIV, both of which are recommended for those aged ≥65 years.

Although the CDC recommends annual influenza vaccination for everyone 6 months and older with any age-appropriate, licensed flu vaccine there are certain conditions where specific vaccines types may be preferable.

Most vaccines are administered intramuscularly in the deltoid muscle, with the exception of the quadrivalent egg-grown live-attenuated influenza vaccine, which is administered via intranasal spray.

For most patients 1 dose of the intramuscular quadrivalent inactivated vaccine is preferred and should be administered annually before the onset of flu season. Needle-phobic adult patients can receive either trivalent inactivated influenza vaccine (Afluria) using a jet injector device, or healthy, nonpregnant adults up to 50 years of age can receive LAIV. Patients who are 65 or older should receive the intramuscular high-dose trivalent inactivated influenza vaccine (Fluzone High-Dose).

The high-dose influenza vaccine is more effective than standard-dose vaccines but is more expensive and has an increased rate of adverse effects. Additionally, the standard-dose influenza vaccines may be less effective in older patients taking statin medications.

Influenza vaccines are generally well-tolerated. The most common adverse effect is temporary arm soreness at the injection site. The high-dose influenza vaccine is associated with a higher incidence of mild-to-moderate local reactions compared with the standard-dose vaccine. The most common adverse effects of the intranasal LAIV are nasal congestion and rhinorrhea.

Contraindications to influenza vaccination depend on the type of vaccine administered. Any history of severe allergic reaction, such as anaphylaxis, to an influenza vaccine is a contraindication to all types of vaccines.

The effectiveness of flu vaccines varies significantly from season to season and depends on several host and viral factors. Studies from flu seasons 2017-2018 and 2018-2019 demonstrate vaccine efficacy of about 38% and 29%, respectively.

In addition to reducing the risk of influenza illness, vaccination can protect children, patients with chronic illness, and pregnant women from hospitalization and serious illness.

Antiviral drugs can lessen symptoms and shorten the time of sickness by 1 or 2 days. They also can prevent serious flu complications, such as pneumonia. The CDC recommends prompt treatment for people who have influenza infection or suspected influenza infection and who are at high risk of serious flu complications.

There are 4 FDA-approved medications approved for the 2019-2020 flu season

is a new antiviral drug approved in 2018 for the treatment of seasonal influenza in patients who have been symptomatic for 48 hours or less. Patients 12 years and older who weigh 40-79.9 kg dose 40 mg PO x1. Patients > 80 kg dose 80 mg PO x1. This drug is contraindicated in pregnancy and breastfeeding. October 2019 Xofluza became the first and only FDA-approved treatment option indicated specifically for those at high risk of flu complications. This includes patients with conditions such as asthma, COPD, diabetes, heart disease, morbidly obese and 65 years or older. Side effects occur in < 1% of patients and include diarrhea, bronchitis, nausea, sinusitis and headache.

2. Oseltamivir phosphate (generic version or trade name Tamiflu) is available as a liquid suspension or pill and is FDA-approved for early treatment of flu in people 14 days and older.

3. Peramivir (Rapivab), is given intravenously by a health care provider and is approved for early treatment of flu in people 2 years and older.

4. Zanamivir (Relenza) is a powder that is inhaled and approved for early treatment of flu in people 7 years and older. It is administered using an inhaler device and is not recommended for those with breathing problems, such as asthma or chronic obstructive pulmonary disorder.

Clinicians must keep in mind that the best treatment for flu is prevention. It is the health care provider’s responsibility to recommend the flu vaccine to all patients 6 months or older and especially those considered high risk for flu complications.

, is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional PA program clinical pharmacology seminar adjunct professor in New York.

, is a clinical professor at Pace University’s College of Health Professions in New York.

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Articles

What Are the Latest Influenza Vaccine Recommendations?

Gestational diabetes (GD) is defined as diabetes that is diagnosed during the second or third trimester of pregnancy. The prevalence of GD is increasing, with the incidence at about 7% of all pregnancies. The etiology of GD is most commonly related to insulin resistance and several placental factors, including human placental lactogen, progesterone, and prolactin, leading to maternal hyperglycemia. Maternal hyperglycemia can cause increased fetal insulin levels and excessive fetal growth, or macrosomia.

Risk factors for GD include obesity, previous history of glucose monitoring (GM), and strong family history of type 2 diabetes (T2D). Certain ethnic groups are at increased risk for GD, including African Americans, Asian Americans, Latinos, Native Americans., and Pacific Islanders. Advanced maternal age, exessive early-pregnancy weight gain, and pregnancy with twins are other associated risk factors. Complications of GD include an increased risk of cesarean delivery, preeclampsia, and spontaneous preterm birth. Fetal and neonatal complications include an increased risk of macrosomia, neonatal respiratory problems, shoulder dystocia, and metabolic complications, such as hypoglycemia and polycythemia.

In addition to antenatal and fetal complications, other long-term consequences exist. Women with GD are more likely to have the condition in subsequent pregnancies. A large population-based, retrospective study demonstrated that women with GD during their first pregnancies have a 41.0% risk of having the condition during their second pregnancies compared with just a 4.2% risk in women without previous GD.

Women with GD are also at increased risk of developing diabetes, and the risk increases over time. A large population-based study demonstrated that the rate of developing of diabetes after GD was almost 19% by 9 years. The risk for T2D was much higher in women with GD who were obese and had a large waist circumference.

Women with GD have a higher risk for cardiovascular disease (CVD) and at a younger age than women without a history of GD. A cross-sectional study concluded that women with GD, especially those with a family history of diabetes, were at a significantly increased risk of coronary artery disease and stroke at a younger age. Another large longitudinal prospective cohort study followed for 25.7 years demonstrated an elevated risk of myocardial infarction in women, particularly in women with GD that progressed to T2D.

GD is generally asymptomatic, and 90% of pregnant women have at least 1 risk factor for glucose impairment during pregnancy. This supports the rationale for universal GD screening.

Screening for GD is performed for all pregnant women in the United States at between 24 and 28 weeks gestation. The American College of Obstetricians and Gynecologists recommends screening with a 1-hour oral 50-g glucose tolerance test. A 50-g oral glucose load is given, and venous plasma is assessed an hour later. If the 1-hour glucose screening test shows blood glucose levels of 130 mg/dL, a 3-hour, 100-g glucose tolerance test is ordered to confirm the diagnosis of GD.

GD diagnosis is based on at least 2 diagnostic 3-hour oral glucose thresholds met or exceeded using either of the following criteria:

Carpenter and Coustan plasma or serum glucose levels fasting ≥95 mg/dL (5.3 mmol/L)

National Diabetes Data Group plasma glucose levels

After confirming the diagnosis of GD, clinicians should initiate treatment to achieve glycemic control and improve pregnancy outcomes and possibly future health-related outcomes. A combination of exercise, medical nutritional therapy, and blood glucose monitoring is often successful in achieving glycemic goals. When glucose levels are consistently elevated despite nutritional therapy, pharmacologic interventions with either insulin or alternatively glyburide or metformin is indicated. Clinicians should monitor women with GD for recurrence in subsequent pregnancies and the development of T2D. Lifestyle interventions, such as achieving and maintaining a health weight, healthy eating, not smoking, and regularly exercising, are beneficial in reducing the risk of diabetes mellitus and related CVDs.

ACOG Committee on Practice Bulletins. ACOG practice bulletin, Number 60, March 2005. Pregestational diabetes mellitus: Clinical management guidelines for obstetrician-gynecologists.

Dodd JM, Crowther CA, Antoniou G, Baghurst P, Robinson JS. Screening for gestational diabetes: the effect of varying blood glucose definitions in the prediction of adverse maternal and infant health outcomes.

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Carr DB, Utzschneider KM, Hull RL, et al. Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes.

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Tobias DK, Stuart JJ, Li S, et al. Association of history of gestational diabetes with long-term cardiovascular disease risk in large prospective cohort of US women.

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Danilenko-Dixon DR, Van Winter JT, Nelson RL, Ogburn PR Jr. Universal versus selective gestational diabetes screening: application of 1997 American Diabetes Association recommendations.

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2018;131(2):e49-e64. doi: 10.1097/AOG.0000000000002501.

Zhang C, Tobias DK, Chavarro JE, et al. Adherence to health lifestyle and risk of gestational diabetes mellitus: prospective cohort study.

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is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional clinical pharmacology seminar adjunct professor in New York.

practices with an obstetrician-gynecologist in private practice in West Islip, New York.

Gestational diabetes (GD) is defined as diabetes that is diagnosed during the second or third trimester of pregnancy.

There Is No Sugar-Coating Gestational Diabetes

Immunizations are an important part of preventive care for adults 65 and older.

Specific recommendations from the Advisory Committee on Immunization Practices (ACIP) and CDC include the following vaccinations; herpes zoster; influenza; pneumococcal; and tetanus or pertussis with tetanus.

Clinical tetanus is rare but is more common in older adults who are not vaccinated. Adults can serve as a reservoir to transmit pertussis to unvaccinated infants and young children. Older adults are less likely to have received vaccinations for or may have diminished immunity to tetanus, diphtheria, and pertussis.

Vaccination against pertussis is important for close contacts of infants less than 1 year, such as caregivers or grandparents. Although the efficacy of a complete series of diphtheria toxoid and tetanus toxoid vaccines is excellent, acellular pertussis does not offer as effective long-term immunity. The only available adult vaccine against pertussis is the Tdap vaccine. The ACIP recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap; Adacel or Boostrix) 0.5 mL intramuscularly for all adults 19 years and older who have not received Tdap previously.

The most common adverse reactions with both tetanus and diphtheria and Tdap vaccines were injection site redness, pain, and erythema, with less common systemic reactions, such as fever and myalgias.

Older adults experience significantly increased mortality and morbidity from influenza illness. Annual influenza vaccination is recommended for all adults. There are 2 types of influenza vaccine are available: inactivated influenza vaccines (IIVs) and a live attenuated vaccine. Two vaccines specifically approved for adults 65 and older are the high-dose inactivated influenza virus (60 mcg hemagglutinin per strain) vaccine and the adjuvanted (standard dose of 15 mcg of hemagglutinin per strain) trivalent IIV. Both are administered intramuscularly on an annual basis, ideally before the onset of influenza season. High-dose IIV is more effective and immunogenic than standard-dose IIV and may confer a mortality benefit.

Adverse effects of the influenza vaccines are generally localized, mild, and most commonly arm soreness at the injection site. The high0dose flu vaccine is associated with more local reactions and possibly increased vomiting.  The IIVs are contraindicated in patients who have had a severe allergic reaction (eg, anaphylaxis) to any influenza vaccine.

Pneumococcal diseases, such as bacteremia, meningitis, and pneumonia, cause significant morbidity and mortality in older adults. Two types of pneumococcal vaccines are approved for use: the 23-valent polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13). The ACIP recommends both pneumococcal vaccines for adults 65 and older. The PCV13 should be given first, followed by the PPSV23, given at least 1 year later. Both vaccines are administered intramuscularly and can be given concomitantly with other vaccines in different anatomic sites. Extensive data supports the effectiveness of PPSV in preventing invasive pneumococcal disease.

The most common adverse effects of both pneumococcal vaccines were local redness, pain, and swelling at the injection site and less commonly fever and myalgias. Contraindication to vaccination is any allergy to any component of either vaccine.

Herpes zoster vaccination is  recommended to prevent herpes zoster or shingles, which is caused by the reactivation of the latent varicella zoster virus. Older people are more likely to experience sequelae of herpes zoster, such as encephalitis, post-herpetic neuralgia, and nerve palsies. All individuals 50 years and older should receive the herpes zoster vaccination. There are 2 types of zoster vaccines: live attenuated zoster vaccine live (ZVL), sold as Zostavax, and non-live recombinant zoster vaccine (RZV), sold as Shingrix. Data suggest that RZV has greater efficacy and prolonged immunity and is preferable in most cases to ZVL.

RZV is administered intramuscularly in 2 doses, with the second dose 2 to 6 months after the first. RZV can be administered with other vaccines at a different anatomic site. Adverse effects are more common with RZV then ZVL and include injection site reactions (78%) and systemic reactions, including fatigue, fever, headache, and myalgia, (ranging from about 20% to 45%). Reactions that prevented normal activities were also more common with RZV but only lasted 1 to 3 days.

Contraindication to RZV administration is allergy to any vaccine component. ZVL is administered as 1 subcutaneous dose. ZVL is well tolerated with fewer adverse effects than RZV. The most common adverse effects were injection site reactions. Contraindications to ZVL include allergy to vaccine components, immunocompromise, and pregnancy. Rare cases of eye disorders including acute retinal necrosis have been reported in associated with ZVL.

Routine preventive care for older adults includes appropriate immunizations, according to updated ACIP and CDC guidelines. Herpes zoster, influenza, pneumococcal, and Tdap vaccines are safe and generally effective in older adults.

CDC. Immunization schedules. cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated February 5, 2019. Accessed March 25, 2019.

CDC. Tetanus surveillance --- United States, 2001-2008.

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CDC. About diphtheria, tetanus, and pertussis vaccines. cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/about-vaccine.html. Updated December 17, 2018. Accessed May 7, 2019.

CDC. People 65 years and older & influenza. cdc.gov/flu/about/disease/65over.htm.  Updated February 12, 2019. Accessed March 21, 2019.

Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults.

2013;(1):CD000422. doi: 10.1002/14651858.CD000422.pub3.

Bonten MJ, Huijts SM, Bolkenbaas M, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults.

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Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines.

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Cunningham AL, Lal H, Kovac M, et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older.

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Charkoudian LD, Kaiser GM, Steinmetz RL, Srivastava SK. Acute retinal necrosis after herpes zoster vaccination.

2011;129(11):1495-1497. doi: 10.1001/archophthalmol.2011.320.

Jennifer L. Hofmann, MS, PA-C, is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA Program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional clinical pharmacology seminar adjunct professor in New York.

Routine preventive care for seniors includes appropriate vaccinations according to updated ACIP and CDC guidelines.

Immunizations for Older Adults Are Vital

Asthma is a chronic disease that is commonly diagnosed and managed in primary-care settings. Yet, health care providers can develop partnerships with patients to provide education and skills for asthma self-management. This education includes an asthma action plan; monitoring of asthma symptoms and peak flow; a regular review of asthma control, medication use, and symptoms and skills training on the use of inhalers.

Patients can learn to self-monitor asthma symptoms, such as cough, nocturnal awakenings, shortness of breath, wheezing, and triggers for asthma exacerbations. Asthma self-management can improve asthma control and reduce morbidity, hospitalizations, and unscheduled health care visits.

It also can provide patients with a better understanding of their asthma and empower them to control the disease.

Common asthma triggers include cold weather, dust mites, high humidity, indoor allergens, tobacco smoke, and viral infections.

Daily asthma diaries can help patients identify and record core symptoms, limitations in activities because of asthma symptoms, peak flow measurements, triggers, and the use of asthma medications. The American Lung Association provides a brief description and video on how to use a peak flow meter.

Patients who use peak flow meters should compare all readings with their personal bests to help determine the severity of an asthma attack and the plan for management.

A written asthma action plan shows patients how to manage worsening asthma symptoms and diminished peak flow measurements. These plans also include how and when to access medical care, such as in a hospital or office setting. Many asthma action plans are color coded using green, red, and yellow, based on the level of symptom severity, peak flow, and response to relief medications. Several asthma action plan templates are available for patients with varying levels of health literacy. The CDC, for example, provides options for electronic, interactive, and printable versions of asthma action plans.

An action plan for patients with exacerbations should include increasing the use of acute relief medications, such as short-acting beta

agonists, or daily controller medications, such as inhaled corticosteroids, as well as self-assessing response to relief medications. For patients with more severe attacks and symptoms that persist after the use of acute relief medications, the asthma action plan should include the addition of oral corticosteroids (ie, amount, duration, frequency) and immediate contact with their health care providers. In general, patients should follow up with their health care providers within 1 to 2 weeks after an asthma exacerbation.

Another component of asthma self-management is regular review with a health care provider. The reviews should address patient concerns and questions about inhaler techniques, medication use, and frequency. Identifying issues with medication costs and clarification to distinguish relief medications from controller medication use are essential. Adherence may be enhanced by simplifying the medication regimen (combination inhalers, oncedaily dosing), using cost-effective medications, and correcting or teaching inhaler techniques.

Patients can demonstrate how they use their inhalers to providers, which may identify and correct potential issues with techniques. The CDC provides written instructions and videos that demonstrate correct inhaler technique.

Health care providers also can review a patient’s self-assessment of the frequency and severity of asthma symptoms and peak flow measurements and help identify triggers that may be avoidable. Patients’ reports of the frequency of relief medication use can identify a lack of asthma control and the need forcontroller medications. Review consultations should include updates of asthma action plans, including additions or changes to current medications.

Three core components of asthma self-management center on patient education and engagement. Patients can self-monitor asthma using daily symptom diaries to assess the level of asthma control. Asthma self-monitoring action plans provide guidance for patients to assess and respond to exacerbations. These plans are reviewed at regular health care provider visits. Medication use, including adherence, increasing use of relief medications, and technique, are also core components of follow-up visits. Effective and guided asthma self-management improves asthma control and reduces asthma-related morbidity.

, is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA Program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional clinical pharmacology seminar adjunct professor in New York.

Global Initiative for Asthma. ginasthma.org. Accessed January 28, 2019.

CDC. Tools for asthma control. cdc.gov/asthma/tools_for_control.htm. Updated June 13, 2018. Accessed January 25, 2019.

American Lung Association. How to use a peak flow meter. lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/patient-resources-and-videos/videos/how-to-use-a-peak-flow-meter.html. Updated May 16, 2018. Accessed January 25, 2019.

CDC. Asthma action plan. cdc.gov/asthma/actionplan.html. Updated April 24, 2009. Accessed January 25, 2019.

Weinstein AG. Improving adherence to asthma therapies.

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CDC. Know how to use your inhaler. cdc.gov/asthma/inhaler_video/default.htm. Updated March 7, 2018. Accessed January 25, 2019.

Providing them with advice can improve control of the disease and reduce hospitalizations, morbidity, and unscheduled health care visits.

Help Patients Manage Asthma

The prevalence of obesity was 39.8% among US adults in 2015-2016.

Many common medical problems, such as cardiovascular and pulmonary diseases and diabetes, are related to obesity and can improve with weight loss.

Obesity-related conditions also include certain types of cancer, heart disease, stroke, and type 2 diabetes (T2D), all leading causes of prevent- able death.

Behavioral modifications, exercise, and nutrition, are the cornerstones of obesity man- agement, but physiologic adaptations can occur with weight loss.

Weight loss through lifestyle modifications alone can be limited and difficult to maintain.

Medication can address appetite and energy levels and improve adherence to lifestyle changes. These can be considered if patients have a body mass index (BMI) of 30 kg/m

or greater with comorbidities, such as dyslipidemia, hypertension, obstructive sleep apnea, and T2D, according to the 2013 American College of Cardiology/American Heart Association/The Obesity Society guideline for the management of overweight and obesity in adults and the Endocrine Society’s clinical practice guidelines on the pharma- cologic management of obesity.

Phentermine (Adipex-P) was the first drug approved by the FDA for obesity. It is indicated for short-term use of about 3 months and is a sympathomimetic amine drug, which increases satiety. Phentermine is available in doses from 8 to 37.5 mg in capsule or tablet formulations. A 28-week randomized clinical trial (RCT) demonstrated a 5- to 6-kg weight loss in patients taking phentermine compared with a 1.5- kg weight loss with placebo.

The most common adverse effects (AEs) include dizziness, dry mouth, insomnia, and irritability. Phentermine should be avoided in patients with anxiety, coronary artery disease, glaucoma, hyperthyroidism, uncontrolled hypertension, and a history of drug abuse and in women who are pregnant.

Orlistat (Xenical) inhibits lipases, decreases the breakdown and absorption of dietary fat (calories), and increases fecal fat loss. Dosage is either 60- or 120-mg capsules orally 3 times a day with a fat-containing meal. The results of a large long-term study comparing orlistat plus lifestyle changes with placebo with lifestyle changes demonstrated a modest weight loss after 4 years: 5.8 and 3 kg, respectively. Fifty-three percent of patients lost 5% or more of their initial body weight with orlistat.

A meta-analysis of several trials confirmed the moderate efficacy of orlistat, with a mean placebo-subtracted difference of 3 kg at 12 months.

Orlistat may improve lipid panel (total cholesterol and low-density lipoprotein) and lower both blood pressure and blood glucose, all conditions correlated with obesity.

Primary AEs of orlistat relate to fat malabsorption and include fecal urgency, oily stool, and fecal incontinence reduction in absorption of fat-soluble vitamins. Other possible AEs are increased risk of cholelithiasis and urinary oxalate excretion. Patients should take vitamins A,D,E,andKhalfanhourbeforeor2to3hours after taking orlistat. Avoid orlistat in patients with malabsorption syndromes.

Phentermine/topiramate (Qsymia) is a combination sympathomimetic amine and antiepileptic medication that is thought to suppress appetite by affecting gamma-aminobutyric acid, glutamate, and carbonic anhydrase. Doses range from an initial dose of 3.75/23 mg orally to a maximum dose of 15/92 mg, and the dosage can be escalated based on weight response. Data from a large, controlled, 56-week trial demonstrated dose-dependent weight loss of 7.8 to 9.8 kg with phentermine/ topiramate compared with 1.2 kg with the placebo. Between 62% and 70% of patients lost 5% or more of their body weight compared with 21% taking the placebo.

an ongoing weight loss 52 weeks after the initial 56-week trial of 9.3% to 10.5% compared with the placebo (1.8%) and a significant reduction in the progression to diabetes in patients taking phentermine/topiramate.

Dry mouth, constipation, and paresthesia are the most common AEs. Discontinue phentermine/topiramate gradually if there is inadequate weight loss by 12 weeks, and avoid use in pregnant women, as topiramate can cause an orofacial cleft in a developing fetus, and in patients with glaucoma or hyperthyroidism who take monoamine oxidase inhibitors. Topiramate use has been associated with increased risk of developing kidney stones, so it may be prudent to encourage patients to increase water intake.

Lorcaserin (Belviq) is a schedule IV selective agonist of the serotonin 2C receptor that reduces food intake and increases satiety. The dosage is 10 mg orally twice daily. Data from large randomized trials show a modest effect on weight loss, with a mean difference in weight loss between active and placebo-treated groups of about 3 to 4 kg.

AEs were mild, most commonly including headache, nausea, back pain, and nasopharyngitis. Lorcaserin should not be used during pregnancy, in patients with creatinine clearance of less than 30 ml/min, and among those taking serotonergic drugs, such as most antidepressants.

Naltrexone/bupropion sustained release (SR) (Contrave) is a dopa- mine reuptake inhibitor and an opioid receptor antagonist that works by reducing appetite and food cravings. The initial dose is 8 mg of naltrexone and 90 mg of bupropion orally once daily, increased to a therapeutic dosage of 32 mg/360 mg. The results of multiple long- term controlled trials demonstrated moderate weight loss averaging 4% to 5%.

Naltrexone/bupropion SR may be useful for smoking cessation and weight loss.

Naltrexone/bupropion SR can increase blood pressure and heart rate, and long-term cardiovascular safety is unknown. The most common AEs are constipation, dizziness, dry mouth, insomnia, and nausea. Naltrexone/bupropion SR should not be used in patients with eating or seizure disorders or conditions that predispose them to seizures or by chronic opioid users. Bupropion is an antidepressant and has a black box warning about increased suicidality in patients younger than 24 years; it can also cause a false-positive urine test for amphetamines.

Liraglutide (Saxenda) is a once-daily subcutaneous injection of a glucagonlike peptide agonist and was initially approved for T2D. It is associated with decreased food intake and increased satiety, related to delayed gastric emptying. Dosage titration ranges from 0.6

to 3.0 mg per day. Efficacy data from 2 large RCTs in those with and without diabetes demonstrated a mean weight loss of 6% to 8% body weight at 56 weeks with liraglutide 3 mg compared with 2% to 2.6% with placebo.

Liraglutide was also superior to the placebo for weight maintenance (6.2% vs 0.2%) in a 56-week RCT in patients on a low-calorie diet.

The most common AEs of liraglutide were gastrointestinal in nature, including abdominal pain, diarrhea, nausea, and vomiting. Patients using insulin or other hypoglycemic medications may require a dose adjustment to avoid hypoglycemia. Pancreatitis can be a rare but serious complication, and patients must discontinue liraglutide if this occurs. Avoid using liraglutide in patients who are pregnant or have a family or personal history of medullary thyroid carcinoma and/or multiple endocrine neoplasia type 2.

The choice for obesity pharmacotherapy depends on drug AEs, contraindications, and patient comorbidities. For example, patients with seizure disorders and/or cardiac conditions should not use bupropion, while patients with migraines might benefit from topi- ramate and smokers from bupropion. Liraglutide and orlistatmay be good choices for patients with diabetes.

Patients should be monitored frequently, and if the medication is ineffective by 12 weeks, defined as weight loss of less than 5% at 3 months, discontinue and switch to an alternative therapy.

Primary care providers should be familiar with the pharmacotherapy available to patients with obesity as an adjunct to behavioral, nutritional, and physical therapies. The objective of antiobesity therapy is to treat the metabolic biomechanical and psychosocial health consequences of obesity. Pharmacotherapy should be instituted to treat obesity only after careful analyses of patients’ behaviors and comorbidities. Close monitoring of efficacy, safety, and tolerability is imperative. If a patient’s response to a weight loss medication is effective (weight loss ≥5% of body weight at 3 months) and safe, continue the medication. If the medication is ineffective (weight loss <5% at 3 months) or if there are safe- ty or tolerability issues at any time, discontinue the medication and consider alternative medications or a referral for a new treatment approach.

, is a clinical associate professor and full-time faculty and pharmacology courses instructor at Pace University-Lenox Hill Hospital PA Program in New York, New York. She is also a PA program adjunct professor for the Touro College School of Health Sciences in Bayshore, New York, and Nassau University Medical Center

in East Meadow, New York. In addition, she is a Stony Brook University PA Program postprofessional PA program clinical pharmacology seminar adjunct professor in New York.

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