Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 49-year-old woman with obesity, hypertension, and type 2 diabetes mellitus

mksap
Conditions
September 1, 2018
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 49-year-old woman is evaluated during a follow-up visit. She is overweight and has hypertension and type 2 diabetes mellitus, both of which are well controlled. For several years, she has attempted to lose weight through various commercial diets; dietician-monitored, calorie-restricted diets; and physical activity. She has worked with a behavioral therapist, and although she has not achieved weight loss, her weight has remained stable. She exercises 30 minutes daily. Medical history is also remarkable for glaucoma, generalized anxiety disorder, and chronic constipation. Medications are lisinopril, metformin, timolol eye drops, and sertraline.

On physical examination, temperature is normal, blood pressure is 128/74 mm Hg, pulse rate is 70/min, and respiration rate is 12/min. BMI is 29. Waist circumference is 92 cm (36 in). Head, neck, lung, and heart examinations are normal. The abdomen is obese without striae.

In addition to continuing calorie restriction and exercise, which of the following is the most appropriate management to help this patient achieve weight loss?

A. Lorcaserin
B. Orlistat
C. Phentermine-topiramate
D. Roux-en-Y gastric bypass

MKSAP Answer and Critique

The correct answer is B. Orlistat.

The most appropriate management is to treat this overweight patient with orlistat. Pharmacologic therapy may be used as an adjunct to diet, physical activity, and behavioral treatments in patients with a BMI of 30 or higher or in patients with a BMI of 27 or higher with overweight- or obesity-associated comorbidities. In light of this patient’s dieting attempts (including with dietician-monitored diets), physical activity, and behavioral therapy without sustained weight loss, she should be considered for pharmacologic treatment, and the most appropriate pharmacologic agent for this patient is orlistat. Orlistat is an inhibitor of gastric and pancreatic lipases. Taken three times per day (during or up to 1 hour after meals), orlistat results in malabsorption of approximately 30% of ingested fat. Twelve months of orlistat treatment at doses of 120 mg three times per day or 60 mg (available over the counter) three times per day results in a mean weight loss of 3.4 kg or 2.5 kg (7.5 lb or 5.5 lb), respectively, compared with placebo. Orlistat also reduces BMI, waist circumference, blood pressure, blood cholesterol level, and risk for type 2 diabetes mellitus. Loose stool is a common side effect of orlistat; however, this may not be a major concern for this patient given her chronic constipation.

Lorcaserin, a brain serotonin 2C receptor agonist, acts as an appetite suppressant. It should be used with caution in patients taking medications that increase serotonin levels, such as sertraline. Therefore, this patient should not be prescribed lorcaserin.

Combination low-dose phentermine (a sympathomimetic drug) and low-dose topiramate (an antiepileptic drug) has demonstrated efficacy in reducing weight, possibly by suppressing appetite, altering taste, and increasing metabolism. However, phentermine-topiramate is contraindicated in patients with glaucoma; thus, it should not be prescribed in this patient.

Referral for bariatric surgery is indicated in all patients with a BMI of 40 or higher and in patients with a BMI of 35 or higher with obesity-related comorbid conditions. This patient does not meet the criteria for bariatric surgery.

Key Point

  • Pharmacologic therapy may be used as an adjunct to diet, physical activity, and behavioral treatments in patients with a BMI of 30 or higher or in patients with a BMI of 27 or higher with overweight- or obesity-associated comorbidities.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

The demise of medicine: A neurologist advocates for patients and is silenced

August 31, 2018 Kevin 12
…
Next

Sometimes what patients really need can be surprising

September 1, 2018 Kevin 1
…

Tagged as: Obesity, Primary Care

Post navigation

< Previous Post
The demise of medicine: A neurologist advocates for patients and is silenced
Next Post >
Sometimes what patients really need can be surprising

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • Type 1 diabetes is no fun

    Ryan Ritchie
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • Who’s really to blame for the obesity epidemic?

    Peter Ubel, MD
  • Why do we think obesity is caused by lack of exercise and not junk food?

    Martha Rosenberg

More in Conditions

  • Venous leak syndrome: a silent challenge faced by all men

    Elliot Justin, MD
  • Make cognitive testing as routine as a blood pressure check

    Joshua Baker and James Jackson, PsyD
  • Reimagining diabetes care with nutrition, not prescriptions

    William Hsu, MD
  • A speech pathologist’s key to better, safer patient care

    Adena Dacy, CCC-SLP
  • How collaboration saved my life from a rare disease doctors couldn’t diagnose

    Tami Burdick
  • Why your emotions are your greatest compass in therapy and life

    Maire Daugharty, MD
  • Most Popular

  • Past Week

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • A world without antidepressants: What could possibly go wrong?

      Tomi Mitchell, MD | Meds
    • Expert Q&A: Dr. Jared Pelo, ambient clinical pioneer, explains how Dragon Copilot helps clinicians deliver better care

      Jared Pelo, MD & Microsoft & Nuance Communications | Sponsored
    • Why the words doctors use matter more than they think

      Erin Paterson | Conditions
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • Internal Medicine 2025: inspiration at the annual meeting

      American College of Physicians | Physician
    • The silent crisis hurting pain patients and their doctors

      Kayvan Haddadan, MD | Physician
    • What happened to real care in health care?

      Christopher H. Foster, PhD, MPA | Policy
    • How the CDC’s opioid rules created a crisis for chronic pain patients

      Charles LeBaron, MD | Conditions
    • Are quotas a solution to physician shortages?

      Jacob Murphy | Education
  • Recent Posts

    • Expert Q&A: Dr. Jared Pelo, ambient clinical pioneer, explains how Dragon Copilot helps clinicians deliver better care

      Jared Pelo, MD & Microsoft & Nuance Communications | Sponsored
    • The lab behind the lens: Equity begins with diagnosis

      Michael Misialek, MD | Policy
    • Venous leak syndrome: a silent challenge faced by all men

      Elliot Justin, MD | Conditions
    • Rethinking patient payments: Why billing is the new frontline of patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The dreaded question: Do you have boys or girls?

      Pamela Adelstein, MD | Physician
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 2 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions
    • A world without antidepressants: What could possibly go wrong?

      Tomi Mitchell, MD | Meds
    • Expert Q&A: Dr. Jared Pelo, ambient clinical pioneer, explains how Dragon Copilot helps clinicians deliver better care

      Jared Pelo, MD & Microsoft & Nuance Communications | Sponsored
    • Why the words doctors use matter more than they think

      Erin Paterson | Conditions
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • Internal Medicine 2025: inspiration at the annual meeting

      American College of Physicians | Physician
    • The silent crisis hurting pain patients and their doctors

      Kayvan Haddadan, MD | Physician
    • What happened to real care in health care?

      Christopher H. Foster, PhD, MPA | Policy
    • How the CDC’s opioid rules created a crisis for chronic pain patients

      Charles LeBaron, MD | Conditions
    • Are quotas a solution to physician shortages?

      Jacob Murphy | Education
  • Recent Posts

    • Expert Q&A: Dr. Jared Pelo, ambient clinical pioneer, explains how Dragon Copilot helps clinicians deliver better care

      Jared Pelo, MD & Microsoft & Nuance Communications | Sponsored
    • The lab behind the lens: Equity begins with diagnosis

      Michael Misialek, MD | Policy
    • Venous leak syndrome: a silent challenge faced by all men

      Elliot Justin, MD | Conditions
    • Rethinking patient payments: Why billing is the new frontline of patient care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The dreaded question: Do you have boys or girls?

      Pamela Adelstein, MD | Physician
    • Make cognitive testing as routine as a blood pressure check

      Joshua Baker and James Jackson, PsyD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MKSAP: 49-year-old woman with obesity, hypertension, and type 2 diabetes mellitus
2 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...