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Managing Pain in Obese ED Patients

Managing Pain in Obese ED Patients

Weight-based dosing of opioids is a commonly used approach for managing patients who present to the ED with more severe pain. “Many patients who present to the ED with pain are obese or morbidly obese,” says Asad E. Patanwala, PharmD. “Heavier patients often receive larger total doses of opioids when compared with normal weight individuals. This can potentially increase the risk of serious adverse events.” He adds that morphine is one of the most commonly used opioids in EDs, but data on morphine dosing are limited among obese individuals. Studies are needed to evaluate the analgesic response to morphine, especially in patients with very high BMIs. Comparing Analgesic Responses In a study published in the Emergency Medicine Journal, Dr. Patanwala and colleagues retrospectively reviewed 300 consecutive patients who received intravenous morphine (4 mg) for pain. Patients were categorized into three groups based on their BMI: non-obese, obese, and morbidly obese. The authors then compared analgesic responses to morphine in the three groups. “Our primary goal was to see if patient weight really matters with regard to analgesic response to morphine,” Dr. Patanwala says. Using a scale of 0 being no pain and 10 being worst possible pain, the median baseline pain scores were 8.5, 8.0, and 8.5 in the non-obese, obese, and morbidly obese groups, respectively. The median analgesic response after morphine administration was 2.0, 3.0, and 2.0 in the non-obese, obese, and morbidly obese groups, respectively. In a linear regression analysis, BMI was not predictive of analgesic response. The analgesic response to a fixed dose of morphine did not appear to change as a function of BMI, says...
Battling Severe Obesity in Children & Adolescents

Battling Severe Obesity in Children & Adolescents

Recent data suggest that overall rates of obesity among children and adolescents have slowed, but worrisome trends have emerged in the form of severe pediatric obesity. “Severe obesity is the fastest-growing subcategory of obesity in children and adolescents, affecting 4% to 6% of all youths in the United States,” says Aaron S. Kelly, PhD. Severe obesity in childhood has both immediate and long-term health consequences, including a greater risk for adverse cardiometabolic risk factors and earlier signs of vascular dysfunction and subclinical atherosclerosis. High BMI and adiposity levels in childhood have been associated with a higher risk of cardiovascular disease (CVD), diabetes, and premature death. “Unfortunately,” says Dr. Kelly, “many of the treatment approaches commonly used in overweight and obese youths are less effective for cases in which severe obesity is present. Treatment options for children with severe obesity are limited, and most standard approaches to weight loss are insufficient for them. Novel treatment strategies must be tailored for severe obesity in order to alter the health trajectory of children and adolescents afflicted with this disease.” Defining Severe Obesity To begin addressing the challenges of managing this patient population, the American Heart Association (AHA) published a scientific statement in Circulation. “A key component of the statement was to develop a standardized definition of severe obesity in children and adolescents,” says Dr. Kelly, who co-chaired the AHA writing group’s scientific statement. The statement defines children older than 2 (and adolescents) as severely obese if they either have a BMI that is at least 20% higher than the 95th percentile for their gender and age, or a BMI of 35 kg/m2...
Gaining Control of Hypertension Early in Patients With Diabetes

Gaining Control of Hypertension Early in Patients With Diabetes

Hypertension is a common comorbidity of diabetes that increases risks for cardiovascular disease (CVD) and microvascular complications. Most patients with diabetes have hypertension, but the prevalence can vary depending on the type of diabetes, age, obesity, and ethnicity. For example, in type 1 diabetes, hypertension is often the result of underlying nephropathy. In type 2 diabetes, hypertension usually coexists with other cardiometabolic risk factors. Important Revisions Each year, the American Diabetes Association updates its Standards of Medical Care in Diabetes. In the 2013 update, the standards revised recommendations to include changing the treatment goal for high blood pressure (BP) from less than 130 mm Hg to less than 140 mm Hg (Table 1). “This change to the standards of medical care was made based on several new meta-analyses that showed there is little additional benefit to achieving the lower BP targets,” explains Richard W. Grant, MD, MPH. Clinical trials have shown that the health benefits to targeting a BP goal of less than 140 mm Hg—including the reduction of CVD events, stroke, and nephropathy—offered little benefit with more intensive BP treatment. Research has shown that such approaches do not significantly reduce mortality rates or the rate of non-fatal heart attacks. There is a small but statistically significant benefit in terms of reducing the risk of stroke, but this comes at the expense of needing more medications and higher rates of side effects. According to Dr. Grant, the change in the “default” systolic BP target is not meant to downplay the importance of treating hypertension in patients with diabetes. “Untreated hypertension can be very dangerous,” he says. “The change also doesn’t imply that...
Substance & Alcohol Use After Weight Loss Surgery

Substance & Alcohol Use After Weight Loss Surgery

Weight loss surgery (WLS) has been an effective treatment for many patients with clinically severe obesity and comorbid medical con­ditions. Despite its merits, WLS requires major lifestyle changes for potential candidates, and many patients may not be adequately prepared to make such changes. Studies have suggested that substance and alcohol abuse is more common among patients undergoing WLS, but this research has been limited by the lack of preoperative baseline data as well as longitudinal data. The symptom substitution theory states that eliminating a particular symptom without treating the underlying cause will lead to the development of a substitute symptom. Under this theory, it’s possible that the risk of substance use may rise after WLS; while the surgery helps eliminate excessive eating, it doesn’t address any potential underlying psychopathology. Since drugs, alcohol, and other substances trigger responses in the brain similar to that of food, it’s possible that they can serve as a food substitute in the WLS population. A Closer Look At Substance Use After Weight Loss Surgery My colleagues and I had a study published in JAMA Surgery that examined the likelihood of WLS patients to develop substance use—specifically alcohol, cigarettes, and recreational drugs—after their operation. We analyzed 155 patients undergoing WLS—100 who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) surgery and 55 who received laparoscopic adjustable gastric band (AGB) surgery. Participants undergoing either RYGB or AGB surgery reported significant increases in the frequency of substance use—using a composite of drug use, alcohol use, and cigarette smoking—when assessed 2 years after surgery. Notably, patients in the RYGB group reported a significantly higher frequency of alcohol use at 2...
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