Pediatric Healthy Lifestyles & Nutrition Toolkit | Page 51

Obesity Pharmacotherapy a. To Start Metformin: i. Check basic metabolic panel, ALT, and HbA1c ii. If suspect type 1 DM, check auto-antibodies( GAD antibody, IA- 2 antibody, insulin antibody, islet cell antibody, zinc transporter antibody) iii. Review side effects with patient and family. GI symptoms are most common – diarrhea, nausea, vomiting, flatulence. Diarrhea usually is the dose limiting factor. iv. Rare cobalamin( B12) deficiency v. Start metformin ER 500 mg QD with dinner for 2 weeks, then increase to 1000 mg ER with dinner( or 500 mg BID; if < 10 yo, consider starting at 250 mg QD) vi. Suggest daily multivitamin containing B12 vitamin b. Follow-up: i. Consider increasing to maximum of 2000 mg ER with dinner( or divided BID) as tolerated, especially if also taking atypical antipsychotics ii. Monitor HbA1c every 3-6 months, basic metabolic panel and CBC annually iii. Hold metformin during an illness with vomiting or diarrhea. Also, stop at time of IV contrast for

CT studies and resume 48 hours after the procedure c. Discontinue: i. If unable to tolerate ii. If BMI continues to increase and no improvement in HbA1c
11. Orlistat( Xenical)( mean change in BMI: 4 %)
a.
Patient Selection:
i.
FDA approval:
1.
Youth ≥12 years old with BMI ≥95th percentile
2.
Adults with BMI ≥30 kg / m2 or ≥27 kg / m2 with weight-related comorbidities
3.
Other Consideration
a.
Consider for the following patients:
i.
want a medication that is not systemically absorbed or without central
activity
ii.
prefer to purchase medication over the counter
ii.
USE CAUTION in the following patients:
1.
taking levothyroxine
2.
taking cyclosporine
3.
taking seizure medications
4.
liver disease
5.
renal impairment
iii. CONTRAINDICATIONS
1.
chronic malabsorption
2.
cholestasis
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