Case Studies (August 2015)

CASE 1

MG is a 42-year-old woman who comes to your pharmacy asking for advice. Her primary care physician recommended that she lose weight (her current body mass index [BMI] is 34 kg/m²). MG is concerned she will be given a diagnosis of diabetes, which runs in her family, so for the past 6 months, she has taken daily walks and decreased the portion sizes of her meals; however, she has not lost much weight. MG has taken phentermine in the past, but it made her heart race. Her medical history includes irritable bowel syndrome and depression (she takes bupropion XL 300 mg orally daily), and she has no known drug allergies.

What pharmacologic options could you recommend for MG?

CASE 2

DT is a 64-year-old man who comes to your pharmacy with a prescription for varenicline (Chantix) 0.5 mg orally for 1 week to be followed by 1 mg twice daily, for a total duration of 12 weeks. He tells you that he smokes 1 pack of cigarettes per day. After looking at his profile, you see that DT is currently taking phenytoin 400 mg/day for seizures and has previously been on disulfiram 250 mg/day for alcoholism. Upon questioning, he admits to consuming about 4 alcoholic drinks almost every night, with no desire to reduce consumption. He has never taken any medications to assist in smoking cession.

Is varenicline a reasonable choice for DT? What else could you recommend?

ANSWERS

Case 1: According to the Endocrine Society’s 2015 Pharmacologic Management of Obesity Guidelines, pharmacotherapy can be considered for patients with a BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 with a weightrelated comorbidity. Diet, exercise, and behavioral modification are still first-line treatment and should be included in all obesity-management approaches. Since MG has taken phentermine in the past and experienced a racing heart rate, it is not advisable to recommend another product that contains phentermine, such as Qsymia (phentermine/topiramate ER). In 2014, 2 medications were approved by the FDA for long-term weight management: Contrave (naltrexone/bupropion ER) and Saxenda (liraglutide). Patients on naltrexone/bupropion should expect to see at least a 5% reduction in their body weight by 12 weeks or the medication should be discontinued. In MG’s case, due to the fact that she is already taking another bupropion medication for her depression, Contrave should not be recommended. Saxenda is a reasonable choice for MG, but it is important to note that it is dosed differently for the weight-loss indication than when used to treat type 2 diabetes. The correct dosing for weight loss is 0.6 mg once daily by subcutaneous injection, which will increase weekly in increments of 0.6 mg/day until the maintenance dose of 3 mg once daily is reached. Per the FDA, patients using Saxenda should be evaluated after 16-weeks to determine if the treatment is working; if at least 4% of body weight has not been lost, discontinue use.

Case 2: Based on the FDA’s 2015 update of the Chantix label, there are 2 reasons not to start DT on varenicline. First, some patients on varenicline experience a decrease in alcohol tolerance, including increased drunkenness or aggressive behavior and amnesia. Patients should be counseled to reduce the amount of alcohol they drink until they know how varenicline affects them. Second, there are rare cases of seizures with varenicline in patients with no previous history of seizure or in patients with a seizure disorder that had been well controlled. Typically, the small increased risk of seizures occurs within the first month of starting therapy. Since DT has a history of alcoholism and a seizure disorder, varenicline may not be the best choice of a smoking cessation aid. For an alternative, DT might try the transdermal nicotine patch, with a nicotine gum or lozenge as needed. Combination nicotine replacement therapy has been shown to be as effective as varenicline. Since DT smokes more than 10 cigarettes each day, he should use the following, in order: (1) one 21-mg patch per day for 4 to 6 weeks, (2) one 14-mg patch per day for 2 weeks, and (3) one 7-mg patch per day for 2 weeks.

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Dr. Kohn is an assistant professor at the University of Saint Joseph School of Pharmacy, Hartford, Connecticut. Dr. Coleman is professor of pharmacy practice, as well as co-director and methods chief, at Hartford Hospital Evidence- Based Practice Center at the University of Connecticut School of Pharmacy.

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