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Peak Development for ...

Medication Administration

Vol. 16 Issue 7
July 2015

Obesity: Pharmacologic Implications


Peak Development Resources
P.O. Box 13267
Richmond, VA 23225
Phone: (804) 233-3707
Fax: (804) 233-3705
Email: editor@peakdev.com

Peak Development for Medication


Administration and Competency
Assessment Tool for Medication
Administration are components of
a site license for the Peak
Development Resources
Competency Assessment System
for Medication Administration
and may be reproduced for this
individual facility only. Sharing
of these components with any
other freestanding facility within
or outside the licensees corporate
entity is expressly prohibited.

The information contained in


Peak Development for Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patients physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the readers
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.
Copyright 2015

After completion the learner should be able to:


1. Identify population trends, body mass index,
and health issues related to obesity.
2. Describe physiologic changes associated
with obesity that impact drug therapy.
3. Discuss pharmacologic & nursing implications
of drug therapy in obese patients.
The Issue of Obesity
Obesity in the US is a significant public
health issue that has increased dramatically
over the last three decades. Currently, the
majority of adult Americans, over 65%, are
overweight or obese. More than one-third of
Americans, almost 35%, are obese. This is a
significant increase from just 30 years ago,
when 15% of the US adult population was
obese. Childhood obesity has also increased at
an alarming rate, doubling in the last 30 years
for children and quadrupling for adolescents.
Americans spend an estimated $60 billion
annually on attempts to lose weight. Of those
who lose weight, however, the vast majority
regain the lost weight, plus more. If these
trends are not reversed, healthcare providers
will be working with millions more obese
patients in the next 1020 years.
To determine whether someone is
overweight or obese, the body mass index
(BMI) is used. This is a ratio calculated on a
persons height and weight, and can be read
from a BMI chart. A BMI of 2529.9 is
considered overweight, while a BMI of 30 and
above is defined as obese (BMI of 18 to less
than 25 is normal). A BMI of 40 and above is
considered morbid obesity. For example, an
adult who is 56 tall is of normal weight at
118154 lbs, overweight at 155 lbs, obese at
186 lbs, and morbidly obese at 248 lbs.
Nutritional factors in the obesity epidemic
include poor nutrition, an increase in fast food
intake, and oversized portions of food. Other
factors include lack of physical activity, and a
possible genetic role. Medical conditions and
some drugs can also cause weight gain.

Obese patients are at high risk for disorders


such as diabetes, heart attack, heart failure,
high blood pressure, stroke, arthritis, respiratory
problems, gallstones, and certain types of
cancer. Risk for mobility-related conditions,
such as deep vein thrombosis and pressure
ulcers, is also increased. Obesity-related
healthcare costs are estimated to total over
$147 billion per year, and can double or triple
the cost of prescription drugs for these patients,
compared to patients of normal weight.
Physiologic Changes with Obesity
Obesity results in a number of physiologic
changes throughout the body. In addition to an
excessive amount of adipose tissue, an obese
persons lean body mass is also increased.
This excess tissue results in higher metabolic
demands and oxygen consumption, which are
met by increased cardiac output, blood volume
and red blood cell production. These demands
can cause ventricular hypertrophy, cardiac
enlargement, heart failure, hypertension and
pulmonary hypertension. Even though blood
volume is generally increased, the ratio of blood
volume to body mass remains much lower than
in a person of normal weight, with risk for
decreased perfusion and lower tissue
oxygenation. Despite the obese persons need
for increased oxygen consumption, the
respiratory system is compromised by pressure
from excess adipose tissue in the abdomen,
reducing expansion of the lungs and chest wall
compliance. Also, the neck and throat tissues
are commonly enlarged with fat, and may
collapse during sleep. This results in
obstructive sleep apnea, causing temporary
blockage of the airway.
Body composition of obese persons reflects
a lower percentage of total body water and
higher percentage of adipose tissue. Liver
function may be reduced by nonalcoholic fatty
liver disease (NAFLD), caused by build-up of
fatty deposits in the liver. Renal function is

altered by increased renal perfusion, glomerular filtration rate


and renal plasma flow.
Pharmacologic Considerations of Obesity
The management of drug therapy for obese patients
presents a number of significant challenges. Data regarding
appropriate drug dosages for these individuals simply does not
exist for many drugs. Obese persons have often been underrepresented or excluded from clinical trials for development of
new drugs, therefore data regarding drug pharmacokinetics
are often not collected on this population. The physiological
changes associated with obesity can cause wide variations in
pharmacokinetics, including drug distribution and excretion.
Also, obese persons are at increased risk for many other
conditions, such as diabetes, lipid abnormalities and
hypertension, and are likely to be taking a number of
medications concurrently.
A drugs pharmacokinetic properties affect how it moves
through the body, acted on by the various organ systems.
These determine how the drug is absorbed, distributed,
metabolized, and excreted. These important processes are
responsible for such characteristics as when the drugs effects
begin, how long the drug lasts in the body, the intensity of its
effects, the dosing schedule, and the appropriate route of
administration. Effects of obesity on pharmacokinetics include:
AbsorptIon: Most studies have shown little to no effect on
oral drug absorption caused by obesity. Subcutaneous drug
absorption may be delayed or less effective, due to poor
perfusion of large amounts of adipose tissue. This is a
concern for obese patients receiving insulin or other
hypoglycemic agents by sub-q injection. Intramuscular drug
absorption may be reduced if a needle of insufficient length
is used, not fully depositing the drug into muscle tissue.
Distribution: The volume of distribution (Vd) can be
significantly affected in obese patients. This is a general
measure of a drugs concentration and spread throughout
the body. A drug that remains primarily in the blood stream,
such as heparin, has a low Vd, while one that distributes
readily into body tissues, such as morphine, has a higher
Vd. In general, lipid-soluble drugs tend to accumulate in
body fat, increasing the Vd for these drugs in obese
patients, although not all lipid-soluble drugs have this effect.
Increased loading doses of some lipid-soluble drugs, such
as phenytoin, may be necessary for obese patients.
Metabolism: Fatty deposits in the liver (NAFLD) and the
resulting poor circulation to liver cells can affect the livers
ability to metabolize various drugs. Drugs metabolized by
the cytochrome P-450 enzymes may be metabolized more
rapidly or more slowly than usual, depending on the specific
enzymes involved. Some drugs progress to phase II
metabolism and are joined with glucuronic acid or sulfate to

make them water-soluble, such as lorazepam, oxazepam,


and acetaminophen. These are likely to be metabolized and
cleared more quickly than usual. If liver function is very poor,
drug metabolism and clearance are generally decreased.
Excretion: The increased glomerular filtration rate and renal
plasma flow may result in faster clearance of water-soluble
drugs and those eliminated primarily by the kidneys. This
may cause therapeutic drug levels to decrease sooner than
desired, and increased frequency of administration may be
indicated.
There are several approaches that prescribers may use to
determine drug dosage for obese patients, and this depends
on the selected drug. The patients ideal body weight may be
used, which may result in an insufficient dosage of some
drugs. The patients total body weight (current total weight)
may be used, which may result in administration of too much
medication. To determine a dosage in between these, the
prescriber may base the dosage on the patients adjusted body
weight, such as by using a formula that adjusts the patients
weight to account for 40% of the excess body weight. Or, the
calculated lean body weight may be used, if the drug is not
lipid-soluble and does not accumulate in fat. Some groups
have addressed this issue in their guidelines. For example, the
American Society of Clinical Oncology has issued guidelines
recommending that the total body weight of obese patients be
used in determining dosage for chemotherapy drugs.
Special caution is required when administering drugs with
a narrow therapeutic index. Therapeutic levels of these drugs,
such as digoxin, warfarin, lithium, phenytoin and theophylline,
are fairly close to levels that may produce toxicity. Drugs with a
narrow therapeutic index have an increased risk for adverse
effects and toxicity, and must be used cautiously with obese
patients, since serum drug levels can be unpredictable in this
group. Close monitoring of patient response and serum drug
levels helps to avoid toxicity and promotes therapeutic effects.
Caution must also be used when administering drugs to
obese patients that may exacerbate their existing conditions or
risk factors. For example, use of opioids or sedatives may
increase the risk of respiratory depression and/or airway
obstruction, due to restricted respiratory function and enlarged
oral tissues associated with obesity.
Because most drugs do not have clear guidelines for
adapting the dosage and frequency in obese patients, monitor
these individuals carefully for therapeutic and adverse effects
of any prescribed drug. Antibiotics may be of particular
concern, since an ineffective dosage that does not adequately
control the infection in a timely manner can result in lifethreatening sepsis or the development of antibiotic resistance.
An understanding of how medication use may need to be
adapted to the physiologic needs of the obese patient
promotes patient safety and effective drug therapy.

Peak Development for Medication Administration


Obesity: Pharmacologic Implications

Page 2

Peak Development for ...


Medication Administration
Competency Assessment Tool

Vol. 16 Issue 7
July 2015

Obesity: Pharmacologic Implications


NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. The majority of adult Americans are overweight or obese.
A. True
B. False
_____2. A person with a body mass index (BMI) of 36 is considered to be:
A. of normal weight
B. overweight
C. obese
D. morbidly obese
_____3. Obesity increases the risk of developing conditions such as:
A. deep vein thrombosis
B. heart failure
C. stroke
D. all of the above
_____4. Physiological changes commonly associated with obesity include:
A. increased lean body mass
B. reduced blood volume
C. higher percentage of total body water
D. decreased cardiac output
_____5. Changes in renal function associated with obesity include increased renal blood flow and a
higher glomerular filtration rate.
A. True
B. False

_____6. Because drug trials typically include obese patients, most drugs currently on the market
have specific data available to guide dosage and frequency for obese patients.
A. True
B. False
_____7. The processes of drug absorption, distribution, metabolism and elimination are known as:
A. pharmacodynamics
B. pharmacokinetics
C. pharmacocompatibility
D. pharmacodiffusion
_____8. Drugs with which of the following characteristics are most likely to require increased
loading doses in the patient with obesity:
A. low volume of distribution
B. water-soluble
C. remains primarily in the blood stream
D. lipid-soluble
_____9. Common renal changes associated with obesity cause:
A. faster clearance of water-soluble drugs from the body
B. faster clearance of lipid-soluble drugs from the body
C. slowed clearance, resulting in drug accumulation in the body
D. no effect on drug levels in the body
_____10. Drug toxicity in obese patients is most likely to occur with drugs that:
A. are eliminated by the kidneys
B. have a narrow therapeutic index
C. are protein-bound
D. are administered orally

Competency Assessment Tool


Obesity: Pharmacologic Implications

Page 2

Peak Development for ...


Medication Administration

Month: July 2015


Issue:
Obesity: Pharmacologic Implications

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Obesity: Pharmacologic Implications


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