a. |
Start Bupropion / Naltrexone ER: |
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i. |
Review contraindications and situations for caution |
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ii. |
Review side effects and warnings |
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1. |
Suicidal thoughts and behaviors |
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2. |
Cardiovascular: hypertension, tachycardia, palpitations, |
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3. |
Neuropsychiatric: seizure, headache, depression, anxiety, agitation, panic attacks, |
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insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia( psychomotor | |||
restlessness), hypomania, and mania, | |||
4. |
Allergic Reactions |
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5. |
Hepatotoxicity |
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6. |
Increased serum creatinine |
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7. |
Gastrointestinal: nausea, vomiting, dry mouth, diarrhea, constipation; encourage |
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hydration | |||
8. |
Eye: angle closure glaucoma. acute onset of decreased visual acuity and / or ocular pain |
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may suggest glaucoma | |||
9. |
Hypoglycemia in patients taking insulin or insulin secretagogues; decrease insulin dose |
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by 10 %, counsel on symptoms of hypoglycemia, monitor BG closely | |||
iii. Check for heart murmur, BP, HR, creatinine, liver function, pregnancy test | |||
b. |
Follow-up |
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i. |
See patient monthly x 3 initially |
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ii. |
Review BP, HR, cardiac exam, side effects, pregnancy risk at each visit |
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iii. If BMI is not stabilized or does not decrease by ≥5 % in 3 months, consider adding a second | |||
AOM such as a GLP1RA | |||
iv. If patient has side effects, such as high blood pressure or neurological symptoms, consider | |||
decreasing dose | |||
c. |
Discontinue: |
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i. |
If BMI continues to increase at full dose after 3-4 months or with side effects. |
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a. |
Patient Selection: |
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i. |
FDA approval: |
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1. |
≥10 years old with type 2 diabetes |
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2. |
Studied in children ≥ 6 years old with obesity |
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3. |
Other Considerations |
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a. |
Consider for patients: |
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i. |
taking second generation atypical antipsychotics( in order of most to least |
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obesogenic: olanzapine / Zyprexa, quetiapine / Seroquel, | |||||
risperidone / Risperdal, ziprasidone / Geodon, aripiprazole / Abilify | |||||
ii. |
polycystic ovary syndrome |
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iii. pre-diabetes [ HbA1c 5.7-6.4 or IFG( 100-125) or IGT( 2 hour- OGTT 140- | |||||
199)] | |||||
ii. |
CONTRAINDICATIONS- metabolic acidosis, including DKA |
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iii. USE CAUTION | |||||
1. |
renal or liver disease |
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