Pediatric Healthy Lifestyles & Nutrition Toolkit | Seite 47

Obesity Pharmacotherapy a. Follow-up: i. See patient every month x 3 initially ii. b.

Recheck electrolytes at 3-6 months to monitor bicarbonate and regularly thereafter( serum CO2
> 17 is acceptable). iii. Review side effects, risks / benefits, and off-label use iv. Expect BMI stabilization at a minimum; may need to split dose or increase dose( up to 75-200 mg BID) if patient not responding( increased risk of side effects like cognitive slowing); consider adding phentermine if BMI stabilizes but not yet decreasing
Discontinue i. If BMI continues to increase at full dose( 50-100 mg BID) after 3-4 months or with side effects ii. To stop topiramate, wean off slowly. Abrupt discontinuation may precipitate seizures( e. g., halve dose weekly until on 25 mg daily)
7. Phentermine / Topiramate Combination Agent( Qsymia)( mean change in BMI: 8-10 %) a.
Patient Selection i. FDA-approval: 1. Youth ≥12 years old with BMI ≥95th percentile 2. Adults ≥18 years old with BMI ≥30 kg / m2 or BMI ≥27 kg / m2 in presence of at least 1 weight- related comorbidity ii.
Consider for patients with
1.
Strong hunger
2.
Binge eating symptoms
3.
Migraine headaches
iii. CONTRAINDICATIONS
1.
Pregnancy
2.
Glaucoma
3.
Hyperthyroidism
4.
Within 14 days or current use of monoamine oxidase inhibitor
5.
History of substance abuse
iv. USE CAUTION
1.
History of coronary artery disease, arrhythmia, including family history of arrhythmia,
stroke, congestive heart failure, uncontrolled hypertension
2.
Agitated state, like mania
3.
High blood pressure
4.
Congenital heart disease
5.
Use of carbonic anhydrase inhibitors as concomitant use with topiramate may increase
the risk of metabolic acidosis
6.
Use of SSRIs( e. g. fluoxetine, sertraline, citalopram) and SNRIs( e. g. duloxetine,
mirtazapine, venlafaxine) may increase risk of serotonin syndrome
7.
Renal impairment, metabolic acidosis( as from ketogenic diet or use of carbonic
anhydrase inhibitors)
8.
History of kidney stones
9.
suicidal ideation
10. Patients at high risk for pregnancy
b.
Start Phentermine / Topiramate ER:
.
i.
Dosage forms: 3.75 / 23 mg, 7.5 / 46 mg, 11.25 / 69 mg, 15 / 92 mg
ii.
Preferred administration time: AM. Need to swallow the capsule whole
iii. Review contraindications and situations for caution
iv. Prescribe phentermine / topiramate ER:
1.
phentermine / topiramate ER 3.75mg / 23mg capsule QAM x 14 days,
2.
phentermine / topiramate ER 7.5mg / 46mg QAM
3.
Phentermine is a controlled substance( Class IV); follow local prescribing regulations
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