2. OUTLINE
• INTRODUCTION
• DEFINITION AND MEASUREMENT
• HOMEOSTATIC MECHANISMS CONTROLLING ENERGY BALANCE
• ETIO-PATHOGENESIS OF OBESITY
• TREATMENT OF OBESITY
• PHARMACOTHERAPY OF OBESITY
• HISTORICAL ASPECTS
• CONTEMPORARY ANTI-OBESITY DRUGS
• FUTURE DEVELOPMENTS
• CONCLUSION
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3. INTRODUCTION
• Survival is continuous; Food is intermittent.
• “Globesity” on the rise.
• 2.1 billion people – nearly 30% of the world’s
population – either obese or overweight.
(Lancet. 2014 Aug 30;384(9945):766-81)
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4. INDIAN PERSPECTIVE
• 5% morbidly obese.
• rs12970134
• India’s obesity doubled in last 10 years; Urban-
Rural divide. (NFHS-4, 2015-2016)
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5. DEFINITION AND MEASUREMENT
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Obesity is a state of excess adipose tissue mass.
ICMR
♂:102 cm
(90cm)
♀: 88 cm
(80cm)
6. HOMEOSTATIC MECHANISMS
CONTROLLING ENERGY BALANCE
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• Early 20th Century – hypothalamus damage – wt.
gain.
• 1940s – discrete lesions in rodents – obesity.
• 1953 – hormone from adipose tissue –
hypothalamus.
• Genetic studies in mice – ob (obesity), tub (tubby),
fat, db (diabetes).
• 1994 – Conceptual breakthrough – ob gene cloned;
protein product identified as Leptin.
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• Leptin secreted by adipose cells; acts on hypothalamus.
• Level of Leptin production provides an index of adipose
energy stores.
• “Leptin resistance.”
• The mechanism for leptin resistance is not yet established.
• SOCS3 and PTP1b involved in the leptin resistant state.
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Energy Expenditure
• Energy expenditure is required to maintain
metabolism, physical activity and thermogenesis.
• Symp. Nerv. Sys. (sometimes with thyroid hormone)
in regulation of energy expenditure.
• Both ‘white’ and ‘brown’ fat cells have a major role in
thermogenesis.
• Mitochondrial uncoupling proteins (UCP).
• Noradrenaline (β3), increases PPAR-γ, ↑ UCP-1.
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ETIO-PATHOGENESIS OF OBESITY
• Dietary and socio-cultural factors.
• Genetic susceptibility.
• Specific syndromes.
• Deficiencies in synthesis/ action of leptin.
• Defects in hypothalamic neuronal systems.
• Defects in systems controlling energy expenditure.
• Decreased thermogenesis caused by dysfunction of
proteins that uncouple oxidative phosphorylation.
15. TREATMENT OF OBESITY
•GOAL: To improve obesity-related comorbid conditions
and to reduce the risk of developing future comorbidities.
•Treatment approaches-
1) Lifestyle modification (meal plan, physical activity
and behavioral interventions).
2) Pharmacotherapy.
3) Surgery.
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16. PHARMACOTHERAPY OF OBESITY
AACE/ACE Guidelines (2016)
• Pharmacotherapy - adjunct to lifestyle therapy and not alone.
• Adding pharmacotherapy produces greater wt. loss & wt. loss
maintenance.
• Short-term t/t (3-6 mo) with weight loss medications is not
recommended.
• Consider differences in efficacy, adverse effects, warnings, as well as
weight-related complications and medical history.
• An algorithm for medication preferences that would apply to all
patients cannot currently be scientifically justified.
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17. Indication for Pharmacotherapy
•BMI ≥ 30 kg/m².
OR
•BMI ≥ 27 kg/m²- For patients who have concomitant
obesity-related diseases and for whom dietary and
physical activity therapy has not been successful.
•Drug therapy is adjunctive to lifestyle intervention.
18. PHARMACOTHERAPY: HISTORICAL ASPECTS
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•Soranus of Ephesus (second century AD): Laxatives and
Purgatives.
•1920s and 1930s- Thyroid hormone.
•1933 - 2,4-Dinitrophenol (DNP).
•Late 1930s - Benzedrine. “Rainbow pill" regime.
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• Amphetamines - Second World War. Outlawed - Late 1950s.
•Phentermine (1959) and Fenfluramine (1973).
• 1992 - Fen-phen - 10% weight loss.
• Mid-1990s - Dexfenfluramine (1996).
• Valvular Heart Disease in up to 30% patients.
•1997 - Withdrawal of Fen-phen and dexfenfluramine.
21. ORLISTAT
• Lipostatin (Streptomyces toxytricini).
• MOA: Lipase inhibitor (irreversible).
• PK: Virtually all of it excreted in faeces.
• Dose: 120 mg three times a day.
• A/E: Malabsorption of dietary fat, flatus with
discharge, fecal urgency, fatty/oily stool, and
increased defecation. Fat-soluble vit D and E and
β-carotene.
• Interaction – Cyclosporin.
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22. •Orlistat also reported to be effective in patients suffering
from type 2 diabetes. (Curran & Scott, 2004)
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XENDOS
Torgerson, et al. Diabetes Care, 2004.
23. LORCASERIN
•Lorcaserin- selective 5-HT2C receptor agonist.
•MOA: ↓ food intake through pro-opiomelanocortin.
•Dose: 10 mg Two times a day.
•BLOOM trial: Weight loss was 3.6%.
•No difference in the development of valvulopathy between
drug-treated and placebo-treated participants at 1 year.
•A/E: headache, dizziness, and nausea.
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24. PHENTERMINE-TOPIRAMATE (PHEN/TPM)
• Approved by FDA (2012), not by EMA.
• MOA: Not well understood.
• EQUIP and CONQUER trials: Wt loss 9.3% and 8.6%
respectively.
• Dose: 15mg/90 mg (PHEN/TPM) once a day
• A/E: Paresthesias, dry mouth, constipation,
dysgeusia, insomnia.
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25. NALTREXONE-BUPROPION
•MOA: Combined to dampen the motivation that food
brings (dopamine effect) and the pleasure of eating
(opioid effect).
•In a randomized, double-blind, placebo-controlled trial,
1742 enrolled participants - weight loss = 6.1%.
•Dose = 32 mg/ 360 mg (Naltrexone-Bupropion).
•A/E: Nausea, headache, dizziness, vomiting and dry
mouth.
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26. LIRAGLUTIDE
•Liraglutide, GLP-1 receptor agonist.
•MOA: Weight loss effects via hypothalamic neural
activation causing appetite suppression.
•SCALE™ Obesity and Prediabetes trial: 9.2 % weight loss.
•Dose = 3 mg once daily, injected s/c.
•A/E: Nausea, vomiting, change in bowel habits, acute
pancreatitis.
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27. AGENTS WITHDRAWN IN THE LAST DECADE
•Sibutramine (2010) – ↑ Cardiovascular risks.
•Rimonabant (2008) - Serious psychiatric side effects.
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28. FUTURE DEVELOPMENTS
•Cetilistat - inhibits pancreatic lipase, Phase 3 trials.
•GT 389255 - pancreatic lipase inhibitor and fat-binding
hydrogel polymer. Phase-II.
•TM-38837 - antagonist of the CB1 cannabinoid receptor,
phase I.
•Experimental:
•Inhibit anabolic molecules.
•Stimulate catabolic signals.
•Gastric peptides.
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Leptin was approved in the United States in 2014 for use in congenital leptin deficiency and generalized lipodystrophy
Leptin signals through proopiomelanocortin (POMC) neurons in the hypothalamus to induce increased production of α-melanocyte-stimulating hormone (α-MSH),
requiring the processing enzyme PC-1 (proenzyme convertase 1). α-MSH acts as an agonist on melanocortin-4 receptors to inhibit appetite, and the neuropeptide AgRp (Agouti-related peptide) acts as an antagonist of this receptor. Mutations that cause obesity in humans are indicated by the solid green arrows.
Idiopathic cranial hypertension (pseudotumor)
In patients with type 2 diabetes mellitus who are overweight or obese, antidiabetic medications that have additional actions to promote weight loss (such as glucagon-like peptide-1 [GLP-1] analogs or sodium-glucose-linked transporter-2 [SGLT-2] inhibitors) are suggested, in addition to the first-line agent for type 2 diabetes mellitus and obesity, metformin.
In obese patients with type 2 diabetes mellitus who require insulin therapy, at least one of the following is suggested: metformin, pramlintide, or GLP-1 agonists to mitigate associated weight gain due to insulin. The first-line insulin for this type of patient should be basal insulin. This is preferable to using either insulin alone or insulin with sulfonylurea.
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers, rather than beta-adrenergic blockers, should be considered as first-line therapy for hypertension in patients with type 2 diabetes mellitus who are obese.
In women with BMI of more than 27 kg/m 2 with comorbidities or BMI of more than 30 kg/m 2 seeking contraception, oral contraceptives are suggested over injectable medications because of weight gain with injectables, provided that women are well informed about risks and benefits (ie, oral contraceptives are not contraindicated).
Anorexiants affect satiety and hunger (the biologic sensation that prompts eating). By increasing satiety and decreasing hunger, these agents help patients reduce caloric intake without a sense of deprivation. The target site for the actions of anorexiants is the ventromedial and lateral hypothalamic regions in the central nervous system. The biologic effect of these agents on appetite regulation is produced by augmentation of the neurotransmission of three monoamines: norepinephrine; serotonin and, to a lesser degree, dopamine. The classic sympathomimetic adrenergic agents (benzphetamine, phendimetrazine, diethylpropion, mazindol, and phentermine) function by stimulating norepinephrine release or by blocking its reuptake. Among the anorexiants, phentermine has been the most commonly prescribed.
Xenical/ Alli- Brand names
Behavioral Modification and Lorcaserin for Overweight and Obesity Management (BLOOM) and Behavioral Modification and Lorcaserin Second Study for Obesity Management (BLOSSOM). weight loss was 3.6% and 3.0%, respectively, in the BLOOM and BLOSSOM trials.
*Agents withdrawn in past decade : Sibu (2010), Rimonabant (2008)
World Obesity Day is observed globally on 11 October with the view of promoting practical solutions to end the global obesity crisis
27th US President William Howard Taft