BUY PHENTERMINE

Important Info about Tumescent Liposuction

2011-07-31T19:51:00.000-07:00

Important Information about Tumescent Liposuction

Risks of Liposuction Surgery: Any surgery involves the risk of infection, bleeding, scarring or serious injury, however tumescent liposuction has an amazingly good safety record. One of the reasons that tumescent liposuction is so safe is that neither general anesthesia nor signification IV sedation is required. A recent survey involving over 15,000 patients who had tumescent liposuction without general anesthesia revealed no serious complications, no serious infection, no hospitalizations, no blood transfusions, and no deaths. The greatest risks of liposuction are those associated with general anesthesia. By eliminating general anesthesia, the risks of liposuction are dramatically reduced. Patients can minimize the risk of surgical complications by not taking medications or over-the-counter preparations that might adversely affect the surgery. Patients should inform the surgeon of any medications being taken either regularly, or occasionally, including herbal remedies and dietary supplements.

Risk of Irregularities of the Skin: Tumescent liposuction using microcannulas is the least likely to cause any significant or noticeable post-surgical irregularities of the skin. By magnifying the fatty compartment, the tumescent technique permits more accurate removal of fat, with greater assurance that the liposuction cannula will not inadvertently approach too near the undersurface of the skin and thereby cause irregularities. Thus the tumescent technique helps to minimize the risk of post-surgical irregularities or rippling of the skin. Liposuction might improve pre-existing irregularities of the skin such as dimpling or cellulite, but prospective patients should not assume that there will be significant improvement. It is unrealistic to expect perfectly smooth skin. Patients should expect that their skin will have approximately the same degree of dimpling and irregularities as existed before tumescent liposuction surgery. After tumescent liposuction the skin texture should be within normal limits. A casual observer should not notice any evidence of surgical irregularities of the skin. However, it is possible that a noticeable irregularity of skin may result. If an irregularity occurs, it may require a corrective procedure for which there will be a fee to cover the operating room and nursing staff expenses. Because skin tends to lose some of its elasticity with increasing age and with cumulative sun exposure, older patients might notice some subtle increase fine wrinkles in areas such as the upper abdomen after liposuction.

Risk of Scarring of the Skin: Incisions for liposuction may result in scarring. Tiny (1 to 4 millimeter) round holes in the skin, called adits, are used for inserting the cannulas through the skin and into the fat. Typically, when adits heal they become virtually invisible. Although you may be able to find them upon close examination, most other people would not be able to see them. Some patients may experience temporary hyper-pigmentation (darkening) that usually fades after several months. Some patients may have a genetic predisposition for persistent discoloration at incision sites. Any one who has previously experienced hyper-pigmentation or hypo-pigmentation (pale or light colored scars) of the skin in the past might expect to also experience it with liposuction adits or incisions. Certain areas of the body, such as the back or upper flanks, may be more likely to have pigmentation changes.

Cellulite: Liposuction of the thighs, while improving the silhouette, does not necessarily eliminate the subtle “puckering” of the skin often called “cellulite”. Cellulite results from the pull of fibrous tissue that connects skin to underlying muscle. While tumescent liposuction may reduce the degree of cellulite, it is unlikely to eliminate it. Liposuction should not worsen cellulite.

Smoothness of Results: Liposuction some produce some irregularities of the skin, which can be visible in certain conditions of lighting. In general the smoothness of the skin is much improved after microcannular liposuction. These are usually rather subtle, and imperceptible to the casual observer. It reasonable to expect significant improvement, but the results are rarely perfect.

Obesity & Liposuction: Liposuction is not an appropriate treatment for obesity. Liposuction is not a substitute for a prudent diet, good nutrition, and regular exercise. Obese patients may be good candidates for limited liposuction if their goal is simply to improve the shape of certain limited areas of the body. Obesity is associated with an increased risk of surgical complications.

Postoperative Healing: Normal healing after tumescent liposuction involves a limited but definite degree of soreness, swelling, bruising, itching and lumpy firmness. A temporary mild numbness, itching or burning of the skin may persist for 2 to 10 months. Most patients can actually see some improvement of their silhouette with one week after surgery. However, because of the slow resolution of post-surgical swelling, the ultimate results following liposuction usually require 12 to 20 weeks to be achieved.

Realistic Expectations: Although the results of liposuction are often quite spectacular, it is not realistic to expect perfection. It is impossible to guarantee the precise amount of improvement that will result from liposuction. Patients should not have unrealistic expectations. Although patients can usually expect to achieve at least a 50% improvement, it is unreasonable to expect 95% improvement or near perfection. For the perfectionist, or for liposuction of a very large area, maximum improvement may require a second procedure for which there would be an additional fee.

Patients who would be satisfied with a 50% improvement would be reasonably good candidates for liposuction. The “50% improvement” is intentionally a vague measure. It indicates a definite perceptible improvement, but something short of perfection. If a 50% improvement would make a patient happy, then it is likely that these expectations will be met. Our patients generally achieve more than a 50% improvement.

Longevity of Results: The fat cells that are removed by liposuction do not grow back. If the patient later gains or loses weight, the change tends to be distributed proportionately over the entire body. For the best results the patient’s post-op weight should be less than the pre-op weight. Although one can expect some changes with aging, provided that the patient does not gain large amounts of weight, the patient’s new more pleasing silhouette is relatively permanent.

What to Expect on the Day of Tumescent Liposuction

Pre-Op Preparations: In the operating room pre-operative photographs will be taken and then the areas on your body to be treated with liposuction are marked with a permanent marker. Additional photos of the markings on the body will be taken, and the patient will be asked to initial these photos to confirm agreement with the areas to be treated by liposuction. This process of preoperative documentation typically requires 45 to 60 minutes before beginning the infiltration of the tumescent local anesthesia.

Local Anesthesia: Using the smallest needles available, the doctor or the nurse will anesthetize the skin at sites through which the longer needles or cannulas will be inserted to anesthetize the subcutaneous fat. Patients usually experience a slight pricking sensation as the skin becomes “numb”. A large volume of dilute tumescent anesthetic solution is carefully and gently injected into the targeted fat. Once an area has been well infiltrated with the anesthetic solution, the fat is usually completely numb. The infiltration of the local anesthetic is a slow careful process that can take as long to complete as the liposuction itself. After the infiltration of the anesthetic is complete, but before beginning liposuction, you will be escorted to the bathroom one more time.

Sedatives: Experience has shown that giving a sedative by mouth permits better local anesthesia than when intravenous sedatives are used. This is because an alert patient is more capable of detecting subtle areas of incomplete anesthesia. A patient who is too sedated might easily ignore an incompletely anesthetized area, and then feel more discomfort later during liposuction. Therefore avoiding excessive sedation actually maximizes patient comfort during liposuction.

Liposuction is accomplished through tiny (1 to 4 millimeter) round holes in the skin, called adits. The adits, which are made in the skin with 1 to 4 mm biopsy punches, are so small that they need not be closed with stitches. After surgery, adits remain open for 2 to 5 days and facilitate the post-operative drainage of residual blood-tinged anesthetic solution.

After Liposuction: After completing liposuction, absorbent pads are placed over the adits. Finally, after the Tumescent Liposuction Compression Garments are pulled on, and you are ready to get up and go home. Because of residual local anesthesia, it is several hours after completing the liposuction before any significant soreness begins. The tumescent technique minimizes post-operative discomfort. Because the residual local anesthesia lasts for over 18 to 24 hours, plain Tylenol is usually sufficient to treat post-operative discomfort. Post-operative nausea is unusual after tumescent liposuction. When nausea or vomiting does occur it typically happens 6 to 12 hours after surgery after the patient awakens from a nap. This type of nausea and vomiting usually last for only one to three hours.

Transportation Home after Liposuction: Patients are not permitted to drive themselves home after liposuction except in the case of an especially small amount of liposuction where the patient has not received sedation. Although most patients feel well enough to drive a care immediately after surgery, you must not do so because of the large amounts of local anesthesia may cause some drowsiness. The person who will be driving you home should have a flexible schedule for the afternoon, although patients are typically discharged in the mid to late afternoon, the exact time cannot be precisely predicted.

BEFORE LIPOSUCTION INSTRUCTIONS

Our office wants to provide you with the very best surgical care. You can help to minimize the risk of complications by carefully reading and following your preoperative and postoperative instructions. Ask us to clarify any item about which you have questions.

1. For seven (7) days before surgery do not take ASPRIN (Anacin, or Bufferin, or Baby asprin) or IBUPROFEN (Advil, Mortin, or Nuprin), or NAPROXEN (Aleve) or any other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that impair platelet function in the normal blood-clotting process. It is permissible to take an acetaminophen (Tylenol or Anacin-3). Please see page 7 for a list of common drugs that contain aspirin.

2. Do not take decongestants such as Sudafed or Actifed for 5 days before surgery. Do not take appetite suppressants such as phentermine (Fastin) for at least 2 weeks before surgery. Do not take Zoloft or other antidepressants and all herbal remedies, unless specifically approved by your surgeon, for two (2) weeks before surgery. Please see page 6 for list of drugs that might have adverse drug interactions with the local anesthetic lidocaine.

3. Avoiding alcohol. We suggest no alcohol during the two days before and two days after surgery) alcohol decreases resistance to infection). Otherwise drinking a small amount of alcohol (for example no more than a glass of wine or beer per day) is permissible during the other days of the week before or after surgery. Avoid red wine for 4 days before surgery to minimize bruising.

4. Do Not Drive Home: Arrange to have someone drive you home after surgery. It is the patient’s responsibility to make prior arrangements to have a responsible adult to meet and accompany the patient after surgery.

5. Do not wear unnecessary jewelry, no perfume (deodorant is OK), and minimize use of cosmetics (survival rations only).

6. Diet before surgery: You should eat a light, low fat meal, such as toast and juice, fruit, dry cereal and/or non-fat milk no closer than two hours prior to surgery. Avoid whole milk, cream, butter, cheese and other foods that are high in fat content as dietary fat slows digestion and delays stomach emptying. Please minimize caffeine the day of surgery. You will be give a snack as soon as surgery is completed.

7. Changing your dressing the morning after surgery is easier if you have someone help you.

8. Loose Clothing on the day of surgery: There is usually quite a lot of drainage of slightly blood-tinged anesthetic solution after surgery. Since this drainage might stain clothing, we suggest that you choose your clothing with this in mind. Because we will apply elastic support garments on top of some bulky absorbent gauze padding your clothing should be very loose and comfortable.
Women: Wear a comfortable bra that you would not mind getting stained from the blue ink that is used to mark the surgical areas. Do not wear an exercise sports bra if you are having liposuction on your abdomen or torso.
Men: Speedo-type swim trunks are the easiest type of garment to wear into the operating room for surgery. Jockey-type underpants are acceptable. Boxer-type underpants are less convenient during the surgery, and may interfere with the surgeon’s liposuction technique. Bring extra underpants to wear after surgery.

9. Bring socks to prevent cold toes during surgery. If you ten to get cold hands, you are welcome to bring clean mittens (no leather gloves) to wear during the surgery. The operating room is kept relatively warm, about 72 to 75 degrees.

10. Do not use moisturizers or soap that contains moisturizers for at least a week before surgery. Tape and EKG electrodes will not adhere or stick well to moisturized skin. The ink markers used to outline the areas of your body to be treated by liposuction will rub-off too easily if you have recently used a moisturizer.

11. Towels & Plastic Sheets. Plan ahead and avoid staining the car seat with blood tinged anesthetic solution: Bring a towel, and a plastic sheet (such as a trash can liner) to cover the seat during your ride home. Prior to surgery pad your bed at home, and your living room chair with towels and plastic. Some patients have found it comfortable and convenient to place a felt-backed vinyl tablecloth on the bed, with the felt-side up. Be careful to avoid allowing drainage to stain carpets.

12. Do not fast or undergo dramatic weight loss just prior to surgery. All patients should be on a stable, healthy, well balanced diet for at least 2 weeks before surgery. Liquid diets, extreme low calorie diets, and rapid weight loss diets may predispose to cardiac irregularities, surgical complications, poor wound healing.

13. Music to Relax/DVD to watch: Patients usually enjoy listening to soothing quite music during surgery or watching a movie on our 50 inch plasma T.V. If you have any favorite CDs/DVDs which you would like to share with use on the day of surgery, you are welcome to bring them with you. Please label the plastic case that holds you CD so that we will know to whom it belongs.

AFTER LIPOSUCTION INSTRUCTIONS

1. Going Home: You should not drive yourself home. It is recommended that a responsible adult be with you on the day of surgery.
Diet: Resume your usual diet immediately. Drink adequate amounts of water, fruit juices or soft drinks to prevent dehydration.
DO NOT drink alcohol 48 hours before or after surgery.

2. Activities: Quiet rest is recommended immediately after surgery. After surgery do not drive or operate hazardous machinery the rest of the day. Do not make any important personal decisions for 24 hours after surgery. Late in the day or evening you are welcome to take a short walk if desired. The day after liposuction surgery you should feel well enough to drive your car and engage in light to moderate physical activities. You may carefully resume exercise and vigorous physical activity 2 to 4 days after surgery. It is suggested that you begin with 25% of your normal work-out and the increase your activity daily as tolerated. Most people can return to a desk job within one to two days after surgery, although one must expect to be sore and easily fatigued for several days.

3. Absorbent Pads are placed over the treated areas to absorb the large volume of drainage of blood-tinged anesthetic solution during the first 24 to 48 hours after surgery. Beginning the next morning after surgery, change the Pads twice daily. During the first few hours after surgery, if you discover some drainage leaking around the larger Pads, simply apply a small absorbent ABD/Sanitary Pads pad over the area by sliding it under the garment.

4. Post-Op Elastic Compression Garments. After tumescent liposuction post-op garments are word in order to: hold the absorbent pads in place, proved compression to minimize bruising, and maximize the drainage of blood-tinged anesthetic solution. The morning after surgery, when the garments is first removed in order to take a shower, the patient may experience brief dizziness and lightheadedness similar to what one experiences when standing-up too quickly. It is the result of rapid decompression of the legs after the elastic garments is removed. If dizziness occurs, sit or lie down until it passes. Dizziness is reduced by first removing the outer garment and waiting 5 to 10 minutes before removing the second garment. Beginning the day after surgery, you must remove the post-op Garments twice daily and take a shower. You may was the garments at these times. Some body areas require two garments, other areas only one garment plus elastic binders (belts).
These should be worn day and night until all the drainage has completely stopped plus and additional 24 hours. Do not be concerned if you drain for several days. Notify us if the drainage persists for more than 8 days. Discontinuing the use of the garments and binders too soon may result in more prolonged drainage. Typically, patients will need to wear the garments for a minimum of 3 to 6 days, although many choose to wear the garments longer because of the comfort they provide. Wearing the post-op garments for a minimal number of days is of no significant advantage in terms of the ultimate cosmetic results. After liposuction of Chin, Cheek, & Jowls, first a spandex head garment is placed to provide mild compression and to hold the absorptive pads in place; next a 2 inch-wide elastic band is placed under the chin and over the top of the head and worn for one hour giving extra compression to minimize bruising. Drainage lasts 1 to 2 days.

5. Managing Post-Op Drainage: One should expect a large volume of blood-tinged anesthetic solution to drain from the small incisions during the firs 24 to 48 hours after liposuction. In general, the more drainage there is, the less bruising and swelling there will be. During the first 36 hours, you should sit or lie on towels. When there is a large amount of drainage, it is advisable to place a plastic sheet beneath the towel. Super-absorbent dressings are worn under the compression garment for at least the first 36 hours. When drainage has nearly stopped, patients need only place a thin absorbent gauze dressings or small pads on incision sites that continue to drain.

6. Wound Care & Bathing: Keep adits (tiny round incision holes) clean. Shower once or twice daily. First wash your hands, then wash adits gently with soap and water; afterwards gently pat adits dry with a clean towel. Apply new absorbent dressings. Adits that have stopped draining no longer need padding. Take antibiotics as directed until the prescription is finished. Take antibiotics with food. Call our office if you notice signs of infection such as fever, foul smelling drainage, or focal redness, swelling, and pain in a treated area. DO NOT apply ice-packs or a heating pad to the skin of liposuction areas for at least 4 weeks following liposuction. DO NOT apply hydrogen peroxide or plastic Band-Aids to incision sites. DO NOT soak in a bath, Jacuzzi, swimming pool, or ocean for 7 days after surgery.

7. Common side-effects of tumescent liposuction: Menstrual irregularities with premature or delayed onset of monthly menstruation are a common side effect of any significant surgery. Flushing of the face, neck and upper chest may occur after liposuction surgery and usually lasts for a day or two. Slight temperature elevation during the first 48 hours after surgery is a natural consequence of the body’s reaction to surgical trauma. Discomfort and soreness is worse the second day after surgery, then improves daily. Two extra-strength Tylenol taken every 4 hours, while awake, for the first 48 hours, will reduce the inflammation, swelling, and soreness associated with surgery. Do not take aspirin or ibuprofen or medications that contain these drugs, such as Bufferin and Anacin, or Advil or Nuprin for 3 days after surgery; these can promote bleeding. Bruising is minimal with tumescent liposuction. Nevertheless, the more extensive the liposuction surgery, the more bruising one can expect. Pain and swelling due to an inflammatory reaction to surgical trauma may occur and increase 5 to 10 days after surgery; this is treated with antibiotics and anti-inflammatory drugs. Itching of the treated areas several days after surgery may occur as part of the normal healing process. To help relieve the itching, you may try taking Benadryl as directed on the packaging. Be aware that Benadryl causes drowsiness. Provided all incisions are closed, soaking in an Oatmeal bath preparation may relieve some of the itching. Benadryl and Oatmeal products may be purchased without prescription at most drugstores.

8. Schedule Follow-up Appointment at our office for approximately 6 to 12 weeks after surgery. You are welcome to return to our office for follow-up visits at no charge as often as you like. Please contact us by telephone if you have any urgent questions, (815) 937-4500.

Patient Signature ________________________Staff Signature ______________________Date: ________

Medications and Foods that POTENTIALLY Interact with Tumescent Anesthetic

Consult Dr. Sarat Yalamanchili/Dr. Saroja Yalamanchili if you are taking any of the following:

Anesthetics

Propofol (Diprovan)

Anti-Arrhithymics

Mexiletine (Mexitil)

Propafenone (Rythmol)

Quinidine (Quinaglute, Quinidex)

Anti-Asthmatics

Zafirlukast (Accolate)

Zileuton (Zyflo)

Antibiotics/Anti-Microbials/Anti-Infectives

Ciprofloxacin (Cipro)

Clarithromycin (Biaxin)

Chloramphenicol (Chloromycetin)

Enoxacin (Penetrex)

Erythromycin

Isoniazid

Norfloxacin (Noroxin)

Tetracycline

Telithromycin (Ketek)

Troleandomycin (Tao)

Anti-Convulsants

Acetazolamide (Daimox) (also a diuretic)

Carbamazepine (Tegretol)

Divalproex (Depakote)

Stiripeentol

Valproic acid (Depakene)

Anti-Depressants

Amitriptyline (Elavil)

Clomipramine (Anafranil)

Flouxetine (Prozac)

Fluvoxamine (Luvox)

Nefazodone (Serzone)

Paroxetine (Paxil)

Sertraline (Zoloft)

Anti-Diabetics

Troglitazone (Rezulin)

Anti-Fungal Medications

Fluconazole (Diflucan)

Itraconazole (Sporanox)

Ketoconazole (Nizoral)

Metronidazole (Flagyl)

Miconazole (Monistat)

Anti-Histamines

Astemizole (Hismanol)

Anti-Neoplastics

Tamoxifen (Nolvadex)

Letrozole (Femara)

Anti-Psychotics

Clozapine (Clozaril)

Sertiadole

Pimozide (Orap)

Anti-Secretory

Omeprazole (Prilosec)

Benzodiazepines

Alprazolam (Xanax)

Flurazepam (Dalmane)

Midazolam (Versed)

Triazolam (Halcion)

Beta Blockers

Propranolol (Inderol)

Calcium Channel Blockers

Amiodarone (Cardarone)

Diltiazam (Cardiazam)

Felodipine (Cardene)

Nicardipine (Procardia)

Verapamil (Calan)

Corticosteroids

Dexmethazone (Decadron)

Methylprednisolone

Hormones

Ethinylestradiol (Estinyl Feminone)

Danozol (Danocrine)

Thyroxine

H2 Blockers

Cimetidine (Tagamet)

Immunosuppresants

Cyclosporine (Neoral, Sandimmune)

Miscellaneous

Anastrozole (Arimidex)

(nonsteroidal aromatase inhibitor)

Caffeine

Cannabinoids

Cortisporin (Cortisol)

Methadone (Narcotic)

Mibefradil dihydrocholride (Posicor)

Pentoxifylline (Trental)

Ramacemide

Tacrine (Cognex)

(Reversible cholinesterase)

Protease inhibitors/Antivirals

Diethyldithiocarbamate (Imuthiol)

Indinavir (Crixivan)

Nevirapine (Viramune)

Nelfinavir (Viracept)

Ritonavir (Norvir)

Saquinavir (Invirase)

MAO inhibitors may interact with certain sedatives and are relatively contraindicated.

Information about Prescriptions & Medications

Antibiotics, such as cephalexin (Keflex) relatives of penicillin, doxycycline a relative of tetracycline, or Levaquin are to be taken twice daily in order to minimize the risk of a surgical infection. Antibiotics should be taken with food to reduce the risk of gastric upset. Please start taking your antibiotic the day before surgery, and continue until the entire supply is completed. If your surgery is scheduled to begin in the early morning (before 9:00 a.m.), taking your antibiotic and eating should be postponed until after surgery.
Lorazepam (Ativan) is a mild sedative, and a mild sleeping pill, that does not make one feel “drugged”. Surgery is more easily tolerated if the patient is well rested and relaxed. We suggest that you take one lorazepam (1 mg) the night before surgery.
Mephytone (Vitamin K) will theoretically minimize bleeding and postoperative bruising. Although it is not essential to take vitamin K, we do recommend it. Take one 5 mg tablet daily, beginning two weeks before the surgery.
Acetaminophen (Tylenol Extra Strength), 500 mg capsules or tablets, does not require a prescription. Taking two tablets, three to four times daily, beginning after surgery, should help minimize postoperative swelling. To treat any minor pains before surgery take 2 Extra Strength Tylenol (500 mg), as needed. If Tylenol is not acceptable, notify us so that we can arrange a suitable substitute.
Diphenhydramine (Benadryl) 25 mg capsules or tablets, doe not require a prescription. Taking as directed can help to reduce postoperative itching. Be aware that Benadryl may cause drowsiness.

Medication Precautions for Surgery Patients

Do Not Take ASPIRIN (Anacin, or Bufferin or IBUPROFEN (Advil, Motrin, or Nuprin), or NAPROXEN (Aleve), or any medications that contain these drugs or any similar anti-inflammatory medications, for seven (7) days before and 3 days after surgery. These drugs will promote bleeding and bruising. Check the labels of all your medications, even those which you purchase without a doctor’s prescription, to be sure you are not taking any aspirin or aspirin-like substances. Remove any products containing aspirin from your medicine chest so that you do not inadvertently take it during the week before surgery. Consult your physician before you stop taking any prescribed medicines. Please inform us if you are taking any medications to treat arthritis, or any blood-thinning anti-coagulant medications. Below is a list of medications that must be stopped sever (7) days before surgery.

Advil Bufferin Doan’s Pills Haltran Nalfon Rexolate Trental

Aleve Butazolidin Dolobid Halfprin Naprosyn Robasissal Trigesic

Alcohol Cephalgesic Dristan Ibuprin Naproxen Roxiprin Trilisate

Alka Seltzer Cheracol Caps Easprin Ibuprofen Norgesic Rufin Tusal

Amigesic Children’s Asprin Ecotrin Ibuprohm Norwich Ex. Str. Saleto Vanquish

Anacin Choline Salicylate Empirin Indameth Nuprin Salflex Vitamin E

Anaprox Clinoril Emprazil Indocin Ocufen Salsalate Voltaren

Anaproxin Congesprin Endodan Indomethacin Orudis Salsitab Warfarin

Ansaid Cope Excedrin Ketoprofen Oruvail Sine Off Willow Bark

APC Coricidin Feldene Ketorolac Oxyphenbutazon Sine Aid Zactrin

Argesic Corticosteroid Fenoprofen Lortab ASA Oxybutazone Thiosalicylate Zorprin

Arthra G Coumadin Feverfew Magan Oxaprozin Soma-Compund

Arthropan Darvon ASA Fiorinal Mg Sallicylate Pamprin sulindac

A.S.A. Darvon Flurbiprofen Meclofen Pepto-bismal Synalgos DC

Ascodeen Compund Froben Medipren Percodan Tanacetum

Ascriptin Daypro 4-Way-Cold Tabs Mefenamic Persantine parthenium

Aspergum Depakote Garlic Capsules Menadob Phenylbutazone (feverfew)

Aspirin Dexamethasone Gelpirin Midol Piroxicam Tolectin

BC Powder Diclofenac Genpril Mobidin Ponstel tolmetin

Baby Aspirin dipyridamole Genprin Monogesic Prednisone Toradol

Bayer Disalcid Ginko Biloba Motrin Quagesic Trandate

Brufen Divalproex Goody’sBody Pain Nabumetone Relafen Trendan

Do not take decongestant medication containing pseudoephedrine (Sudafed, Actifed) for 5 days prior to surgery. These can cause the heart rate to be too rapidly.
Appetite suppressant drugs phentermine (Fastin), should not be taken for at least 14 days before surgery. Do not stop appetite suppressants abruptly as you may have side effects. To avoid side effects such as depression, it is better to begin decreasing the dose gradually two weeks before surgery. Maintain a healthy diet and stop aggressive weight loss diets for a safe surgery and good healing.
Do not take antidepressants, such as Zoloft or tricyclics for 14 days before surgery. Please consult you prescribing physician before discontinuing any of your prescribed medications.

Liposuction Preoperative Check-List. Please initial each item to confirm your agreement. Print “NO” if you disagree.

____ Circle the following locations where we can telephone you (Cross-out if NO): Home Work Cell

____ Circle the following locations where we can leave a message (Cross-out if NO): Home Work Cell

Please provide the telephone number(s) where we can call you.

(____ )________________ (______)________________ (______)___________________

Home Telephone Work Telephone Other Telephone

____ I permit visiting physicians or nurses to observe my surgery.

____ I permit Dr. Yalamanchili to show my pre-op & post-op photos to prospective patients, (no name will identify the photo).

____ I agree to avoid aspirin and ibuprofen for 7 days prior to surgery, and to avoid decongestants for 5 days prior to surgery, and not to take Fastin (phentermine), Zoloft and all herbal remedies (unless specifically approved by my surgeon) two (2) days before surgery. I understand it is recommended that you remove all aspirin and ibuprofen products from my medicine chest.

____ If, before surgery, another physician prescribes new medications for me, then I will notify the nursing staff as soon as possible.

____ I agree to leave valuables at home or in the care of a responsible “family member”. Dr. Yalamanchili is not responsible for lost valuables.

____ I agree: it is my responsibility to have a responsible adult to accompany me after surgery, to not drive myself home after surgery, and to not drive an automobile until the day after surgery.

____ If I develop a rash, skin infection, open wound or illness anytime prior to surgery, then I will notify my surgeon.

____ If your pre-op exam and labs are done out of town by your own primary care doctor, then you guarantee that the results will arrive at our office at least one month prior to surgery.

____ If my surgeon requires a clearance-letter from my primary care physician or a specialist to verify liposuction will be a safe procedure fro me, I understand this letter must arrive at least 3-4 weeks before surgery. My surgery date cannot be finalized until this letter is received. If this letter is not received two weeks before surgery, then my liposuction surgery may have to be rescheduled to a later date. I authorize the disclosure/exchange of protected health information for the purpose of treatment and obtaining medical clearance.

Cosmetic Surgery Policies

____ Payment Schedule: It is our office policy to ask patients to pay half of the total surgery fee as a down payment at the time the surgery is scheduled. The balance of the fee is to be paid 14 days before the surgery. Final payment may be made with either Visa, MasterCard, or cashier’s check. Please make checks payable to Dr. Sarat Yalamanchili M.D. S. C. If final payment is now received by 14 days before surgery, your surgery date will be automatically cancelled and your deposit, minus $500 for expenses, will be returned.

____ Rescheduling Charges: If it is necessary to change or cancel the date of the surgical procedure, then at least two week notice is required. A $400 rescheduling fee will be charged for any schedule change requested by the patient with less than two weeks notice. A $300 additional rescheduling fee will be charged if your surgery date is rescheduled more than a total of two times for your convenience or by manner. If all preoperative laboratory results and any necessary medical clearance letters are not obtained a required letter of medical clearance in a timely manner. If all preoperative laboratory and any necessary medical clearance letter are not received by 14 days prior to surgery, your date will be forfeited and rescheduled. Last minute cancellations due to illness must be well documented in writing by a physician including a copy of the physician’s physical examination and diagnosis. It is the patient’s responsibility to document the date and time, as well as the name of our office staff member who received the notice of cancellation or change in schedule surgery date. If you would like to revise the plan of body areas designated for liposuction, you should notify us at leas one week before surgery.

____ Cancellation Charges:

With more than two weeks notice, $500 cancellation fee will be charged if surgery is cancelled for any reason after the pre-operative physical examination and laboratory studies have been completed. This includes a cancellation by you for any reason or a cancellation by us for medical reasons discovered from results of your preoperative medical examination or laboratory tests.

With less than two weeks notice, if you cancel for any reason, or if the surgeon must cancel the surgery because you have not complied with explicit instructions, then half of the total surgical fee will be forfeited. If, with less than two weeks notice, you first reschedule the surgery and later cancel the surgery altogether, then half of the total surgical fee will be forfeited. If a surgery is cancelled with less than two weeks notice, it is usually impossible to arrange for another patient to fill that surgical time-slot. Thank you for your understanding in this matter. Cancellation within less than 48 hours of scheduled time of surgery for any reason will result in forfeiture of the entire surgical fee.

____ Pre-Op Telephone Calls: Our staff routinely telephones patients for confirmation two to four days before surgery. If we are unable to reach you, please telephone us 48 hours before the surgery to confirm the exact date and time of arrival.

I have read the above policy and consent to the routine pre-operative laboratory studies including Hepatitis C and HIV tests. The results of these tests will be placed in the patient’s chart and will remain strictly confidential as required by law.

____________________________________ _____________________

Patient’s Signature Date

CHEAPEST DUROMINE Phentermine Adipex WEIGHTLOSS PILLS

2011-07-31T19:37:00.001-07:00

The weight loss drug Duromine® is an appetite suppressant. The active ingredient within Duromine® is the generic drug phentermine. Phentermine is combined with a resin to create slow release which prolongs the effects of Duromine®.

Duromine® is manufactured by 3M and distributed throughout Australia and New Zealand.
What does Duromine® look like?

Duromine capsules in two strengths:

Duromine 15mg capsules

* grey and green and marked DUROMINE 15

Duromine 30mg capsules

* grey and reddish brown and marked DUROMINE 30

What is Duromine prescribed for?

Duromine is an appetite suppressant and has successfully been helping people lose weight since it was released onto the market. It is designed to be used in combination with a healthy diet and regular exercise.
Who should Duromine be prescribed for?

Duromine is only recommended for use amongst patients who are medically classed as heavily overweight or obese. Only people with a BMI (Body Mass Index) greater than 27+ and who suffer from a related illness such as high cholesterol, high blood pressure or diabetes are normally considered as suitable candidates for the drug.

Duromine is not recommended for:

* Children of 16 years or younger
* The elderly

How does Duromine work?

Duromine is an appetite suppressant. Hunger cravings are reduced as the active chemical ingredient in Duromine effects the parts of the central nervous system. The active ingredient in Duromine is Phentermine. Phentermine is chemically similar to amphetamine and increased energy levels are common amongst patients.

It is recommended that Duromine be taken as an accompaniment to a healthy diet and regular exercise.
Is Duromine a prescription or over the counter drug?

Duromine is a prescription medication and can only be prescribed by a qualified doctor.

Duromine is a brand name given to a version of the generic medication phentermine which has been available throughout Europe and is still prescribed in Australia and New Zealand.
Duromine dosages

Duromine capsules should be taken once daily, either before breakfast or within 2 hours of eating breakfast. It is advised to take Duromine early in the day as it known to cause insomnia and increased energy levels.

Duromine capsules should be swallowed whole and with plenty of water.

Your doctor will tell you if Duromine 30mg or Duromine15mg is the correct dosage for you.

Duromine is not recommended for patients of 16 years old or younger. It is not recommend that the elderly be prescribed Duromine.
What precautions should be taken before using Duromine?

Inform your Doctor of the following:

* Any allergies that you may have, especially to if you have a known allergy to phentermine.
* Any other medicines that you are taking at the time (both prescription and over the counter)
* If your medical history includes high blood pressure, a heart condition, arteriosclerosis, overactive thyroid, diabetes, glaucoma or drug abuse.
* If know or suspect that you are pregnant or plan to become pregnant. If you become pregnant whilst taking Duromine tell your doctor.
* If you are breastfeeding a child.
* If you are prone to agitated states.

Duromine with fenfluramine (Phen-Fen)

The two substances, phentermine (Duromine) and fenfluramine are FDA approved medications. However, numerous instances of heart valve abnormalities have been recorded amongst patients who took the two medications in conjunction with one another. In 1997 the FDA issued a public health warning advising against the use of the Phen-Fen combination.
Duromine Ingredients

Duromine capsules contain

* phentermine
* lactosevliquid paraffin
* magnesium stearate
* gelatin
* titanium dioxide
* carbon black

The resin that is mixed with the generic ingredient phentermine to form Duromine creates a slow release effect which is designed to extend the effects of the pill throughout the day.

Duromine capsules are gluten-free.

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Supplemental Information of Weight Loss Phentermine and Other Pills

2011-07-31T19:25:00.000-07:00

SUPPLEMENTAL INFORMATION

Bupropion

Three long-term clinical trials have been conducted to evaluate the effectiveness of bupropion as a weight loss drug, two of which investigated the drug’s effect in depressed patients. For the studies investigating the drug’s use in depressed patients, one study of 422 obese adults (BMI = 30-44 kg/m²) not meeting criteria for major depression but with depressive symptoms (Beck Depression Inventory score 10-30) showed that those subjects who completed the study receiving bupropion-SR (300 mg/d) with a 500 kcal/d-deficit diet (n=109) lost an average of 5.8 kg (6.0 ± 0.5% body weight) vs. 2.8 kg (2.8 ± 0.5% body weight) for those on placebo (n=122) (p<0.001).¹ The other clinical trial investigated the effect of bupropion-SR in patients with major depression, and enrolled 423 patients whose depression had responded to treatment with bupropion-SR. Subjects were separated into groups based on BMI, and those treated with bupropion-SR (300 mg/d) showed mean change-from-baseline weights as follows: BMI< 22, -0.1 kg; BMI 22-26, -0.6 kg; BMI ≥ 27, -1.4 kg; and BMI ≥ 30, -2.4 kg following 44 weeks of treatment.²

The trial of 327 non-depressed obese patients (BMI 30-44 kg/m²) participating in a lifestyle intervention program, including counseling on energy-restricted diets, meal replacements, and exercise, showed that subjects receiving bupropion-SR at doses of 300 mg/d and 400 mg/d displayed weight loss of 7.2% and 10.1% initial body weight, respectively, compared to 5.0% loss for placebo following 24 weeks of therapy. A loss of ≥5% of body weight was observed in 46%, 59%, and 83% of placebo-, bupropion-SR 300-, and bupropion-SR 400-treated subjects, respectively (p<0.0001 vs placebo), while a loss of ≥10% of body weight was observed in 20%, 33%, and 46% of placebo-, bupropion-SR 300-, and bupropion-SR 400-treated subjects (p=0.0008 vs placebo). Finally, subjects receiving bupropion-SR 300 or bupropion-SR 400 maintained weight loss of 7.5% and 8.6%, respectively, following 48 weeks of therapy.³

Bupropion was well-tolerated in these trials, but, as bupropion activates the noradrenergic system, there was an increase in dry mouth, with a non-significant increase in diarrhea and constipation.⁴ Cardiovascular effects, such as a rise in blood pressure and tachycardia are usually mild, and the risk of seizure, which was high with the original bupropion formulation, has been significantly reduced with the advent of bupropion-SR and bupropion-ER.

Fluoxetine & Sertraline

Both fluoxetine and sertraline are FDA-approved for the treatment of clinical depression. In a meta-analysis of 7 studies of fluoxetine treatment reporting weight loss outcomes at ≥6 months, 6 of the 7 studied reported significant weight loss in fluoxetine-treated patients at 6 months, with weight losses ranging from 0.9 kg to 9.1 kg, and 3 studies reported significant weight loss in fluoxetine-treated patients at 12 months, with weight losses ranging from 0.4 kg gained to 14.5 kg lost.⁴ Fluoxetine dosage for weight loss was 60 mg, which is 3-times higher than the dosage used for depression (20 mg). In another review of four RCTs investigating the utility of fluoxetine as a long-term anti-obesity therapeutic, fluoxetine-treated subjects lost an average of 2.6 kg and 0.6 kg more weight than placebo-treated patients, at 6 months and 12 months, respectively.⁵ Both reviews indicate that fluoxetine-treated patients, on average, lose weight during the first 6 months of treatment but experience weight regain thereafter, indicating that the drug loses its effectiveness on inducing weight loss following 6 months of therapy.

One study investigated the use of sertraline and relapse prevention training in maintaining weight loss following treatment by a very low-calorie diet. In this study a total of 53 women who had lost a mean of 22.9 ± 7.1 kg were assigned to a 54-week weight maintenance program and administered sertraline (200 mg/d) or placebo. Sertraline-treated subjects lost significantly more weight and showed greater reductions in hunger during the first 6 weeks of therapy, but women in both treatment groups steadily regained weight thereafter, and no significant differences in the degree of weight regain between setraline- and placebo-treated women remained by the end of the 54 week study.⁶ These data suggest that these drugs are not effective as long-term anti-obesity pharmacotherapeutics, as they lose their efficacy over the course of weeks to months. However, these drugs may be useful in treating obese patients suffering from depression or depressed individuals who are concerned about gaining weight from anti-depressant medication.

An analysis of adverse effects observed in RCTs investigating fluoxetine use in obesity reported that fluoxetine-treated patients experienced increased nervousness, sweating, and tremors (relative risk, 6.37), nausea and vomiting (relative risk, 2.68), fatigue, asthenia, hypersomnia, and somnolence (relative risk, 2.36), insomnia (relative risk, 2.06), and diarrhea (relative risk, 1.74) compared to placebo-treated patients.⁴ These same side effects have been associated with sertraline use.

Lorcaserin HCl

Lorcaserin has been shown to be a full agonist of the 5-HT_2Creceptor and to bind to the 5-HT_2C receptor with 18- and 104-fold selectivity over 5-HT_2A and 5-HT_2B receptors, respectively. Further, it was shown to induce a reduction in food intake in rats, which was abolished by pre-treatment with the 5-HT_2C, but not a 5-HT_2A, antagonist, and to induce weight loss over a 4-week period, with weights returning to baseline following discontinuation of the drug.⁷ In a 12-week RCT enrolling 469 obese subjects (BMI = 30-45 kg/m²), individuals were administered placebo, lorcaserin (10 mg q.d.), lorcaserin (15 mg q.d.), or lorcaserin (10 mg b.i.d.) and were instructed to maintain their normal diet and exercise patterns. Weight losses of 0.3 kg, 1.8 kg, 2.6 kg, and 3.6 kg were observed for the placebo, 10 mg q.d., 15 mg q.d., and 10 mg b.i.d. groups, respectively (p < 0.001 for each group), and the percentage of patients completing the trial who lost ≥5% of their initial body weight was 2.3%, 12.8%, 19.5%, and 31.2% for the placebo, 10 mg q.d., 15 mg q.d., and 10 mg b.i.d. groups, respectively.⁸

The serotonergic drug fenfluramine was removed from the market due to incidences of heart valve disease with use of the drug. Since lorcaserin is a serotonergic drug, the effect of lorcaserin use on heart valve function was investigated. Echocardiograms showed no drug-related effects on cardiac valves or pulmonary arterial pressure. The only side effects which were reported more frequently in the lorcaserin-treated subjects were transient headache, nausea, and dizziness.⁸

Cetilistat

Cetlistat is a novel lipase inhibitor which is currently the furthest in the clinical development. In a 5-day trial of cetilistat treatment in 90 healthy volunteers, cetilistat was associated with a 3- to 7-fold increase in fecal fat with only 11% of subjects experiencing >1 episode of oily stool. Thus it had the potential to be more tolerable than orlistat. In a 12-week trial, patients were prescribed a hypocaloric diet (500 kcal deficit) for a 2-week run-in period and were then randomized to placebo or cetilistat (60, 120, or 240 mg t.i.d.) groups and treated for 12 weeks. Treatment with cetilistat was observed to reduce weight to similar extents in each cetilistat dosage groups (60 mg t.i.d. 3.3 kg, p<0.03; 120 mg t.i.d. 3.5 kg, p=0.02; 240 mg t.i.d. 4.1 kg, p<0.001). Total and LDL cholesterol were also reduced by 3-11% in all three dosage groups. Importantly, the frequency of withdrawal due to adverse events was similar between cetilistat-treated (5.3-7.6%) and placebo (7.6) groups.⁹

A recent trial compared efficacy and safety of cetilistat and orlistat relative to placebo in obese patients with type II diabetes, on metformin. Following a 2-week run-in, subjects were randomized to placebo, cetilistat (40, 80, or 120 mg t.i.d.), or orlistat (120 mg t.i.d.) for 12 weeks. The 80 mg and 120 mg cetilistat groups showed similar significant reductions in weight relative to placebo compared to the orlistat group (3.85 kg, p=0.01; 4.32 kg, p=0.0002; 3.78 kg, p=0.008, respectively). Further, significant reductions in waist circumference relative to placebo were observed in the cetilistat 80 and 120 mg groups (4.3 cm, p=0.033; 4.5 cm, p = 0.037 vs. 3.2 cm) and in the orlistat group (4.4 cm; p=0.019). Significant reductions in HbA1c levels were also observed in the cetilistat 80 mg and 120 mg as well as the orlistat group. Thus, cetilistat (80 mg or 120 mg t.i.d.) appeared to be similarly efficacious to orlistat (120 mg t.i.d.) in this study, but importantly, while the proportion of patients in the orlistat group reporting adverse events (93%) was similar to that in the cetilistat groups, the patients in the orlistat group reported more events (541 AEs vs. 428 AEs in the 120 mg cetilistat group, p=0.0148), with more being severe (55 vs. 31 in the 120 mg cetilistat group, p=0.0546).¹⁰

Diazoxide

In an 8-week RCT of diazoxide use in overweight and obese individuals, subjects were administered diazoxide (2 mg/kg/d, maximum 200 mg/d) or placebo, and it was observed that diazoxide-treated subjects decreased insulin and C-peptide responses to glucose but did not improve glycemic control or experience weight loss.¹¹ However, another 8-week RCT of diazoxide (2 mg/kg/d, maximum 200 mg/d) therapy administered in combination with a low-calorie diet to obese, hyperinsulinemic adults reported more promising results, as subjects treated with diazoxide over 8 weeks experienced greater weight loss (9.5 ± 0.69% vs. 4.6 ±0.61%, p < 0.001) and a greater decrease in body fat with no effect on glycemic control.¹² A study investigating the effectiveness of high-dose diazoxide in combination with moderate calorie restriction (30% deficit) and increased physical activity to induce weight loss in obese, hyperinsulinemic men also reported positive results. Subjects were administered diazoxide (50 mg t.i.d.) and had their dosage increased by 50 mg per dose every 4 weeks, up to a maximum of 300 mg t.i.d. over a 6-month period. Subjects treated with diazoxide experienced an average weight loss of 9.4 kg (95% CI: 5.6–13.2 kg, p < 0.001), waist circumference reduction of 9.2 cm (95% CI: 5.3–12.9 cm, p < 0.001) and total body fat mass decrease of 23.3% (95% CI: 13.7–32.9%, p < 0.001). The degree of fat loss was inversely correlated to fasting insulin levels (r = −0.76, p < 0.002). Furthermore, diastolic blood pressure decreased by 10.9 mmHg (95% CI: 6.5–15.4 mmHg, p < 0.002) in the diazoxide-treated patients, presumably due to weight loss in combination with the ability of diazoxide to induce relaxation of vascular smooth muscle.¹³

L-796568 – β3AR Agonist

In 2000, a selective human β3-agonist, L-796568, was developed¹⁴ and in 2002 a single 1000mg dose was shown to significantly increase energy expenditure by ~8%. The drug also increased plasma levels of glycerol and free fatty acids, markers of lipolysis, in overweight human subjects during a 4-hr period.¹⁵ However, a clinical trial investigating the efficacy of chronic use of L-796568 revealed that overweight and obese non-diabetic men (BMI = 28-35 kg/m²) receiving the drug (350 mg/d) do not display any significant changes in body composition or 24-hour energy expenditure over a 28-day trial period.¹⁶ The cause for the ineffectiveness of β3-adrenreceptor activation to induce significant and sustained lipolysis in humans may be explained by studies revealing the differential expression of the receptor between rodent and human adipocytes. Human brown adipose tissue (BAT) expresses 3-fold lower β3-adrenoreceptors compared to rodent BAT and human white adipose tissue express minimal levels of β3-adrenoreceptors, determined by specific ligand-binding analyses.¹⁷ Furthermore, β3-adrenoreceptor activation has been observed to play a weak role in lipolysis of human subcutaneous adipose tissue, compared to β1- and β2-adrenoreceptor activation.¹⁸

11β-HSD1 Inhibtors

Pharmacologic inhibition of 11β-HSD1 in humans with the nonselective 11β-HSD inhibitor, carbenoxolone (100 mg every 8 hrs for 7 days), improved whole body insulin sensitivity in seven healthy male volunteers, measured by euglycemic hyperinsulinemic clamp studies.¹⁹ However, in a trial of lean and obese individuals, obese subjects were observed to have more rapid conversion of cortisone to cortisol in adipose tissue, and carbenoxolone treatment did not inhibit adipose 11β-HSD1 activity or improve insulin sensitivity.²⁰

Sirtuin 1 Activators

In rodent studies, mice administered chow supplemented with RSV (400 mg/kg/d) for 15 weeks were protected from both diet-induced obesity and insulin resistance. These mice displayed increased endurance, enhanced mitrochondrial activity in brown adipose tissue and skeletal and enhanced aerobic capacity of skeletal muscle, which are all presumably effects due to increased PGC-1α activity.²¹ Moreover, mice started on a diet containing RSV (400-2400 mg/kg food) at 12 months of age exhibited improvements in aortic elasticity, motor coordination, bone mineral density, as well as reduced albuminuria, inflammation, apoptosis in vascular endothelium, and cataract formation. However, RSV-treated elderly mice did not exhibit increased survival.²²

Beyond inducing SIRT1 activation, RSV has also been observed to activate both AMP-activated protein kinase (AMPK) and mitochondrial superoxide dismutase (MnSOD), among other effects.²³ However, mice treated with SRT1720, a potent, selective synthetic activator of SIRT1, were observed to be resistant to diet-induced obesity and obesity and insulin resistance due to enhanced oxidative metabolism in skeletal muscle, liver, and brown adipose tissue, indicating the positive metabolic consequences of specific SIRT1 activation.²⁴

Contrave (Bupropion + Naltrexone)

In one trial, 238 obese subjects randomized to 4 groups: placebo + placebo (P+P), BUP (300 mg) + placebo (BUP + P), NTX (50 mg) + placebo (NTX + P), and BUP (300 mg) + NTX (50 mg) (BUP + NTX) groups. Over the 24-week trial, the BUP+NTX exhibited sustained weight loss which did not plateau. The weight loss curve of the BUP+NTX diverged from the NAL+P (p<0.01) and P+P (p<0.001) curves at week 16 and diverged from the BUP+P curve by week 24 (p<0.05).²⁵

In a subsequent 24-week trial, three doses of naltrexone (16, 32, and 48 mg) combined with bupropion 400 mg/day all produced significant weight loss (4.3, 5.4, and 5.4%, respectively vs. 0.8% for placebo).²⁶ On this basis, four 56-week phase III trials investigating BUP+NTX (Contrave) combination therapy in producing weight loss in obese patients with and without type II diabetes were undertaken. The results of one trial of 793 obese patients receiving Contrave-32 [BUP (360 mg/d) + NTX (32 mg/d)] or placebo along with behavior modification intervention indicated that those subjects receiving Contrave-32 achieved 9.3% weight loss vs. 5.1% in the placebo group. Also, twice as many Contrave-32 subjects lost ≥10% of their baseline weight compared the placebo group (41.5 vs. 20.2%).²⁶

In July 2009, the Contrave trial sponsor, Orexigen, announced the results of the three other trials. In one trial, obese patients receiving Contrave-32 along with a diet and exercise regimen experienced a mean weight loss of 8.1%, compared to only 1.8% in the placebo group. Another trial of 1,496 obese subjects yielded similar results with no significant difference in patients treated with Contrave-32 vs. Contrave-48 [BUP (360 mg/d) + NTX (48 mg/d)]. Finally, in a trial of 505 obese patients with type II diabetes, subjects treated with Contrave-32 along with a diet and exercise regimen experienced a mean weight loss of 5.9% vs. 2.2% in the placebo group.²⁷

Empatic (Bupropion + Zonisamide)

A 12-week trial was undertaken comparing the effectiveness of zonisamide monotherapy to a combination of bupropion and zonisamide in reducing the weight of 18 obese women. All subjects were prescribed a hypocaloric diet (500 kcal deficit) and half the subjects were administered zonisamide (100 mg/d gradually increased to 400 mg/d) while the other half were administered a combination of zonisamide (same dosing) and bupropion (100 mg/d gradually increased to 200 mg/d). Following 12-weeks, the combination therapy group exhibited significantly greater weight loss (8.1 ± 1.4 kg (8.5%) vs. 3.0 ± 0.9 kg (3.3%) in the zonisamide group).²⁸ This trial prompted further studies of bupropion-zonisamide combination therapy in combating obesity.

In a subsequent 24-week RCT, obese subjects receiving zonisamide (400 mg/d) + bupropion (300 mg/d) achieved more weight loss than zonisamide (400 mg), bupropion (300 mg), or placebo (-9.2, -6.6, -3.6, and -0.4%, respectively).²⁹ A Phase IIb trial investigated the efficacy of different ratios of bupropion and zonisamide in the combination, and every different combination elicited significant more weight loss compared to placebo, with bupropion (360 mg) + zonisamide (360 mg) having the greatest efficacy (8.6% weight loss vs. 1.1% for placebo).²⁶

Another Phase IIb trial investigated the efficacy of Empatic-360 (bupropion 360 mg/zonisamide 120 mg) and Empatic-120 (bupropion 360 mg/zonisamide 120 mg) vs. placebo. In this trial of 729 obese subjects, those receiving either Empatic-360 or Empatic-120 experienced significantly greater weight loss compared to the placebo group (9.9%, 7.7% vs. 1.7%, respectively (p<0.001)). There were also a significantly greater number of subjects losing ≥5% and ≥10% baseline weight in the Empatic-360 and Empatic-120 groups compared to the placebo group (82.6%, 59.3% vs. 18.9%, respectively (p<0.001) and 47.7%, 35.2% vs. 5.7%, respectively (p<0.001)). Thus, both drugs appear effective, with Empatic-360 having slightly greater efficacy. Adverse events were similar to those reported for each of the individual drugs, with headache, nausea, insomnia, anxiety and dry mouth being the most commonly reported adverse events.²⁶

Qnexa (Topiramate + Phentermine)

In a 24-week RCT involving 200 obese patients, the efficacy of topiramate + phentermine (100 mg/15 mg) compared to topiramate (100 mg), phentermine (15 mg), and placebo revealed that combination treatment led to a mean weight loss of 11.4 kg, which is significantly greater than the mean weight losses observed with topiramate (6.6 kg), phentermine (5.3 kg), or placebo (2.2 kg)³⁰. In a subsequent 28-week RCT, 756 obese patients were randomized to receive topiramate (92 mg or 46 mg), phentermine (15 mg or 7.5 mg), combination therapy (92 mg/15 mg or 46 mg/7.5 mg), or placebo. High-dose combination therapy was effective in achieving a mean weight loss of 9.2%, compared to high-dose topiramate (6.4%), high-dose topiramate (6.1%), and placebo (1.7%). Low-dose combination therapy was also effective in achieving a mean weight loss of 8.5%, compared to low-dose topiramate (5.1%), low-dose phentermine (5.5%), and placebo (1.7%).³¹

A 56-week RCT in which obese subjects with type II diabetes were randomized to either placebo or combination topiramate + phentermine therapy, reported that subjects receiving combination therapy achieved a mean weight loss of 9.4% compared to 2.7% in the placebo group. Furthermore, combination therapy led to a mean 1.6% decrease in HbA1c, compared to a 1.1% decrease in the placebo group.³²

As reported by the sponsor, Vivus, Inc., in a 24-week trial 756 obese subjects were randomized to receive mid-dose Qnexa (46 mg topiramate/7.5 mg phentermine), full-dose Qnexa (92 mg topiramate/15 mg phentermine), topiramate (46 mg or 92 mg), phentermine (7.5 mg or 15 mg), or placebo groups. Subjects receiving mid-dose and full-dose Qnexa experienced mean weight losses of 8.5% and 9.2%, compared to 1.7% in the placebo group (p<0.0001). The proportion of subjects losing ≥5% their baseline weight for mid-dose and full-dose Qnexa was 62% and 66%, respectively, compared to 15% in the placebo group (p<0.0001). The proportion of subjects losing ≥10% their baseline weight for mid-dose and full-dose Qnexa was 39% and 41%, respectively, compared to 7% in the placebo group (p<0.0001).³³

Two 1-year phase III trials of Qnexa therapy for the treatment of obesity were completed in 2009. In the first study, 1,267 morbidly obese (mean BMI = 42.1 kg/m²) were randomized to receive mid-dose Qnexa, full-dose Qnexa, or placebo along with a hypocaloric diet (500 kcal deficit) and advised to implement a lifestyle modification program. For those who completed the 52-week study, subjects receiving mid-dose and full-dose Qnexa experienced mean weight losses of 7.0% and 14.7%, respectively, compared to 2.5% in the placebo group (p<0.0001). In the second study, 2,487 overweight and obese patients with high blood pressure, high cholesterol, or type II diabetes were placed on the same regimen, and mid-dose and full-dose Qnexa subjects who completed the study experienced mean weight losses of 10.5% and 13.2%, respectively, compared to 2.4% in the placebo group (p<0.0001). Qnexa therapy was also associated with significant improvements in blood pressure, triglycerides, and HbA1c levels.³⁴

ReferenceS

(1) Jain, A.K. et al. Bupropion SR vs. placebo for weight loss in obese patients with depressive symptoms. Obesity 10, 1049-56 (2002).

(2) Croft, H. et al. Effect on body weight of bupropion sustained-release in patients with major depression treated for 52 weeks. Clinical Therapeutics 24, 662-72 (2002).

(3) Anderson, J.W., Greenway, F.L., Fujioka, K., Gadde, K.M., McKenney, J. & O'Neil, P.M. Bupropion SR enhances weight loss: a 48-week double-blind, placebo-controlled trial. Obesity 10, 633-41 (2002).

(4) Li, Z. et al. Meta-analysis: Pharmacologic treatment of obesity. Annals of Internal Medicine 142, 532-46 (2005).

(5) Goldstein, D.J. et al. Efficacy and safety of long-term fluoxetine treatment of obesity--maximizing success. Obesity Research 3 Suppl 4, (1995).

(6) Wadden, T.A. et al. Sertraline and relapse prevention training following treatment by very-low-calorie diet: a controlled clinical trial. Obesity Research 3, 549-57 (1995).

(7) Thomsen, W.J. et al. Lorcaserin, a novel selective human 5-hydroxytryptamine2C agonist: In vitro and in vivo pharmacological characterization. Journal of Pharmacology and Experimental Therapeutics 325, 577-87 (2008).

(8) Smith, S.R., Prosser, W.A., Donahue, D.J., Morgan, M.E., Anderson, C.M. & Shanahan, W.R. Lorcaserin (APD356), a selective 5-HT 2C agonist, reduces body weight in obese men and women. Obesity 17, 494-503 (2009).

(9) Kopelman, P. et al. Cetilistat (ATL-962), a novel lipase inhibitor: A 12-week randomized, placebo-controlled study of weight reduction in obese patients. International Journal of Obesity 31, 494-9 (2007).

(10) Kopelman, P. et al. Weight loss, HbA 1c reduction, and tolerability of cetilistat in a randomized, placebo-controlled phase 2 trial in obese diabetics: Comparison with orlistat (xenical). Obesity 18, 108-15 (2010).

(11) Due, A. et al. No effect of inhibition of insulin secretion by diazoxide on weight loss in hyperinsulinaemic obese subjects during an 8-week weight-loss diet. Diabetes, Obesity and Metabolism 9, 566-74 (2007).

(12) Alemzadeh, R., Langley, G., Upchurch, L., Smith, P. & Slonim, A.E. Beneficial effect of diazoxide in obese hyperinsulinemic adults. J Clin Endocrinol Metab 83, 1911-5 (1998).

(13) Boekel, G.v., Loves, S., Sorge, A.v., Ruinemans-Koerts, J., Rijnders, T. & Boer, H.d. Weight loss in obese men by caloric restriction and high-dose diazoxide–mediated insulin suppression. Diabetes, Obesity and Metabolism 10, 1195-203 (2008).

(14) Mathvink, R.J. et al. Discovery of a potent, orally bioavailable β3 adrenergic receptor agonist, (R)-N-[4-[2-[[2-Hydroxy-2-(3-pyridinyl)ethyl]amino]ethyl]phenyl]-4-[4-[4-(tri fluoromethyl)phenyl]thiazol-2-yl]benzenesulfonamide. Journal of Medicinal Chemistry 43, 3832-6 (2000).

(15) Van Baak, M.A. et al. Acute effect of L-796568, a novel β3-adrenergic receptor agonist, on energy expenditure in obese men. Clinical Pharmacology and Therapeutics 71, 272-9 (2002).

(16) Larsen, T.M. et al. Effect of a 28-d treatment with L-796568, a novel β3-adrenergic receptor agonist, on energy expenditure and body composition in obese men. American Journal of Clinical Nutrition 76, 780-8 (2002).

(17) Deng, C. et al. Respective degree of expression of β1-, β2- and β3-adrenoceptors in human brown and white adipose tissues. British Journal of Pharmacology 118, 929-34 (1996).

(18) Barbe, P., Millet, L., Galitzky, J., Lafontan, M. & Berlan, M. In situ assessment of the role of the β1-, β2- and β3-adrenoceptors in the control of lipolysis and nutritive blood flow in human subcutaneous adipose tissue. British Journal of Pharmacology 117, 907-13 (1996).

(19) Walker, B.R., Connacher, A.A., Lindsay, R.M., Webb, D.J. & Edwards, C.R.W. Carbenoxolone increases hepatic insulin sensitivity in man: A novel role for 11-oxosteroid reductase in enhancing glucocorticoid receptor activation. Journal of Clinical Endocrinology and Metabolism 80, 3155-9 (1995).

(20) Sandeep, T.C., Andrew, R., Homer, N.Z.M., Andrews, R.C., Smith, K. & Walker, B.R. Increased in vivo regeneration of cortisol in adipose tissue in human obesity and effects of the 11β-hydroxysteroid dehydrogenase type 1 Inhibitor carbenoxolone. Diabetes 54, 872-9 (2005).

(21) Lagouge, M. et al. Resveratrol improves mitochondrial function and protects against metabolic disease by activating SIRT1 and PGC-1[alpha]. Cell 127, 1109-22 (2006).

(22) Pearson, K.J. et al. Resveratrol Delays Age-Related Deterioration and Mimics Transcriptional Aspects of Dietary Restriction without Extending Life Span. Cell Metabolism 8, 157-68 (2008).

(23) Baur, J.A. et al. Resveratrol improves health and survival of mice on a high-calorie diet. Nature 444, 337-42 (2006).

(24) Feige, J.N. et al. Specific SIRT1 activation mimics low energy levels and protects against diet-induced metabolic disorders by enhancing fat oxidation. Cell Metabolism 8, 347-58 (2008).

(25) Greenway, F.L. et al. Rational design of a combination medication for the treatment of obesity. Obesity 17, 30-9 (2009).

(26) Gadde, K.M. & Allison, D.B. Combination therapy for obesity and metabolic disease. Current Opinion in Endocrinology, Diabetes and Obesity 16, 353-8 (2009).

(27) Contrave(R) obesity research phase 3 Program meets co-primary and key secondary endpoints; exceeds FDA efficacy benchmark for obesity treatments. Available from: http://ir.orexigen.com/phoenix.zhtml?c=207034&p=irol-newsArticle&ID=1308920&highlight.

(28) Gadde, K.M., Yonish, G.M., Foust, M.S. & Wagner Ii, H.R. Combination therapy of zonisamide and bupropion for weight reduction in obese women: A preliminary, randomized, open-label study. Journal of Clinical Psychiatry 68, 1226-9 (2007).

(29) Greenway, F., Anderson, J. & Atkinson, R. Bupropion and zonisamide for the treatment of obesity. Obes Res 14, (2006).

(30) Gadde, K.M., Yonish, G.M. & Foust, M.S. A 24-week randomized controlled trial of VI-0521, a combination weight loss therapy, in obese adults. Obesity 14, (2006).

(31) Aronne, L.J., Peterson, C. & Troupin, B. Weight loss with VI-0521 (phentermine/ controlled release topiramate) stops progression toward type 2 diabetes in obese nondiabetic subjects. Meeting Abstracts of the 69<sup>th</sup> Annual Meeting of the American Diabetes Association, June 5-9, 2009, New Orleans.

(32) Garvey, W.T., Troupin, B. & Tam, P. One-year treatment with VI-0521 in type 2 diabetes demonstrates continued glycaemic improvement and weight loss. Meeting Abstracts of the 69<sup>th</sup> Annual Meeting of the American Diabetes Association, June 5-9, 2009, New Orleans.

(33) Results from phase 3 EQUATE trial of Vivus' Qnexa highlighted at European Congress on Obesity. Available from: http://ir.vivus.com/releasedetail.cfm?ReleaseID=382339.

(34) VIVUS announces positive results from two phase 3 studies; obese patients on Qnexa achieve average weight loss up to 14.7% and significant improvements in co-morbidities. Available from: http://ir.vivus.com/releasedetail.cfm?ReleaseID=407933.

BANGKOK PILLS THE ORIGINAL FROM ''yanhee hospital" BANGKOK THAILAND

2011-07-31T19:16:00.000-07:00

The most effective slimming pills ever made! You can lose 15-20 lbs. per set! All are good for 28 days. meet-ups are not possible for these transactions.

COURIERS: JRS EXPRESS / AIR21 / LBC / 2GO / WWWEXPRESS

I DO NOT SHIP ABROAD FOR THE PILLS BUT IF YOU HAVE A PHILIPPINE ADDRESS I CAN SHIP IT THERE AND JUST HAVE YOUR RELATIVES BRING IT TO YOU.

The slimming pills are taken according to schedule. I will send the instructions right away upon purchase. Gcash payment only.
prices are available upon request.

MUST READ!!!

* Pregnancy, diabetes, and any kind of heart problems prohibit the intake of the pill.
* Must be 18 yrs. of age but not over 50.
* Not advisable to take with other prescription drugs.

available in:

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                                                   strong
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       duro 45 (duromine 30mg original and duromine 15mg original)
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"The wide range of cosmetic services offered – from breast augmentation to facelift, from tummy-tuck to liposuction, from botox injection to dental whitening, from facial treatment to hair transplant, and weight loss – makes Yanhee a 'one-stop shop' for beauty."

FAQ'S

1. Side effects?
-Palpitation. When this occurs, I advise you to switch to a lower dosage.

2. How do I know what dosage to take?
-The dosages don’t mean losing more on a higher one. It is just for the user's immunity. Beginners should start with low.

3. The pills are formulated with methamphetamine.
-Yes but that was the older ones. These new releases have no more methamphetamine in them. Main component is Phentermine; a prescribed medication in USA.

4. What are these rumors going on about taking Bangkok pills and getting over dosed?
-That is why I recommend using the lowest dose (strong) for beginners. It is just the same in any kind of medicine, when you use the unperceived dosage, you really get over dosed.

5. How long should I use them?
-I don't recommend being dependent to the pills. When you reach your ideal weight loss, it is important to keep your lifestyle fit and maintain a healthy diet.

6. What is the effect of the pills?
-The pills simply reduce your appetite. Doing exercise can also help hasten your diet but of course always do take care of yourself. The pills are not to blame on any mishaps if you are also being abusive to your body.

DUROMINE Weight Loss Capsule CHEAPEST!!!

2011-07-31T19:13:00.001-07:00

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DETAILS:

he weight loss drug Duromine® is an appetite suppressant. The active ingredient within Duromine® is the generic drug phentermine. Phentermine is combined with a resin to create slow release which prolongs the effects of Duromine®.

Duromine® is manufactured by 3M and distributed throughout Australia and New Zealand.
What does Duromine® look like?

Duromine capsules in two strengths:

Duromine 15mg capsules

* grey and green and marked DUROMINE 15

Duromine 30mg capsules

* grey and reddish brown and marked DUROMINE 30

What is Duromine prescribed for?

Duromin is an appetite suppressant and has successfully been helping people lose weight since it was released onto the market. It is designed to be used in combination with a healthy diet and regular exercise.
Who should Duromine be prescribed for?

Duromine is only recommended for use amongst patients who are medically classed as heavily overweight or obese. Only people with a BMI (Body Mass Index) greater than 27+ and who suffer from a related illness such as high cholesterol, high blood pressure or diabetes are normally considered as suitable candidates for the drug.

Duromine is not recommended for:

* Children of 16 years or younger
* The elderly

How does Duromine work?

Duromine is an appetite suppressant. Hunger cravings are reduced as the active chemical ingredient in Duromine effects the parts of the central nervous system. The active ingredient in Duromine is Phentermine. Phentermine is chemically similar to amphetamine and increased energy levels are common amongst patients.

It is recommended that Duromine be taken as an accompaniment to a healthy diet and regular exercise.
Is Duromine a prescription or over the counter drug?

Duromine is a prescription medication and can only be prescribed by a qualified doctor.

Duromine is a brand name given to a version of the generic medication phentermine which has been available throughout Europe and is still prescribed in Australia and New Zealand.
Duromine dosages

Duromine capsules should be taken once daily, either before breakfast or within 2 hours of eating breakfast. It is advised to take Duromine early in the day as it known to cause insomnia and increased energy levels.

Duromine capsules should be swallowed whole and with plenty of water.

Your doctor will tell you if Duromine 30mg or Duromine15mg is the correct dosage for you.

Duromine is not recommended for patients of 16 years old or younger. It is not recommend that the elderly be prescribed Duromine.
What precautions should be taken before using Duromine?

Inform your Doctor of the following:

* Any allergies that you may have, especially to if you have a known allergy to phentermine.
* Any other medicines that you are taking at the time (both prescription and over the counter)
* If your medical history includes high blood pressure, a heart condition, arteriosclerosis, overactive thyroid, diabetes, glaucoma or drug abuse.
* If know or suspect that you are pregnant or plan to become pregnant. If you become pregnant whilst taking Duromine tell your doctor.
* If you are breastfeeding a child.
* If you are prone to agitated states.

Duromine with fenfluramine (Phen-Fen)

The two substances, phentermine (Duromine) and fenfluramine are FDA approved medications. However, numerous instances of heart valve abnormalities have been recorded amongst patients who took the two medications in conjunction with one another. In 1997 the FDA issued a public health warning advising against the use of the Phen-Fen combination.
Duromine Ingredients

Duromine capsules contain

* phentermine
* lactosevliquid paraffin
* magnesium stearate
* gelatin
* titanium dioxide
* carbon black

The resin that is mixed with the generic ingredient phentermine to form Duromine creates a slow release effect which is designed to extend the effects of the pill throughout the day.

Duromine capsules are gluten-free.

Phentermine Adipex 37.5mg by Tewa Pharmaceuticals

2011-07-31T19:12:00.000-07:00

ADIPEX 37.5MG Tablet (Phentermine) Generic made by Tewa Pharmaceuticals in Israel
Weight management aid for Obese persons.
Min. order 30 Tablets P2995 (Introductory promo) Normally P3995
OFFER EXTENDED UNTIL JULY 31, 2011
email: asiameds@hushmail.com (Please leave your cell Phone number
and you will be text-ed regarding delivery.)
FREE DELIVERY IN METRO MANILA
Adipex helps in four ways:
Prevents overeating by reducing your appetite Boosts your metabolism Burns calories and fat 24 hours a day

Achieves rapid weight loss results Phentermine is a phenethylamine, more importantly a derivative of amphetamine, primarily used as an appetite suppressant. It is typically prescribed for individuals who are at increased medical risk because of their weight, as opposed to cosmetic weight loss.Phentermine is sold either as an immediate-release formulation (Adipex?®) or as a slow-release resin (Ionamin?®, Duromine?® in Australia and New Zealand). Mechanism of action Phentermine, like many other prescription drugs, works with neurotransmitters in the brain. It is a centrally-acting stimulant and is a constitutional isomer of methamphetamine. It stimulates neuron bundles to release a particular group of neurotransmitters known as catecholamines; these include dopamine, epinephrine (also known as adrenalin), and norepinephrine (noradrenaline). The anorectic activity seen with these compounds would thus seem likely due to this effect on the central nervous system, which is consistent with current knowledge about central nervous system systems and feeding behavior. This is the same mechanism of action as other stimulant appetite suppressants such as diethylpropion, and phendimetrazine. The neurotransmitters signal a fight-or-flight response in the body which, in turn, puts a halt to the hunger signal. As a result, it causes a loss in appetite because the brain does not receive the hunger message. Phentermine HCL is usually available in these FDA-approved doses: - Phentermine HCL 8mg tablet - Phentermine HCL 15mg capsule - Phentermine HCL 18.75mg capsule - Phentermine HCL 30mg capsule - Phentermine HCL 37.5mg capsule - Phentermine HCL 37.5mg tablet Clinical use Generally, it is recommended by the Food and Drug Administration (FDA) that phentermine should be used short-term (usually interpreted as up to 12 weeks), while following nonpharmacological approaches to weight loss such as healthy dieting and exercise. However, recommendations limiting its use for short-term treatment may be controversial. One reason given behind limiting its use to 12 weeks is drug tolerance, whereby phentermine loses its appetite-suppressing effects after the body adjusts to the drug. On the contrary, it has been shown that phentermine did not lose effectiveness in a 36-week trial. Due to the risk of insomnia, it is generally recommended that the drug be taken either before breakfast or 1-2 hours after breakfast. Adipex Frequently Asked QuestionsQ. What is the difference between Brand and Generic AdipexA. The active ingredient in both brand and generic Adipex is the same. There are many generic variants of Adipex drug in the market today. You can however buy cheap Adipex if it is a generic variant. Both brand and generic Adipex have the same mechanism of action. Q. Why is the price of Adipex here so cheap?A. Because we sell generic Adipex, which means that we do not have to spend heavily on research and development of the drug. We also source the drugs directly from the manufacturer thereby eliminating any additional costs such as commissions to agents etc. All the savings accrued through various measures translates to the cheaper price of drugs at our pharmacy. You can also get additional price benefits by taking advantage of the volume discounts we offer. Q. Do I need a prescription for Adipex? A. You do not need a prescription to buy Adipex as we work under the laws of the country we ship from.Q. How can I buy Adipex?A. Send an email to asiameds@hushmail.com.Q.How to pay?A. Cash on Delivery COD in Metro Manila only.Q. When shall I receive my Adipex order?A. Order before 10am in the morning and delivery will be the same day just leave your cell phone number and first name.Q. Where do you ship Adipex to?A. Any where in the world.Q. Is it legal to buy Adipex?A. Yes. We do not know a case, that purchase Adipex for personal use had any problems. PLEASE NOTE: Buyer must research the positive and negative side of any medicines they buy to be sure the benefits outweigh the risks or potential side effects. See http://en.wikipedia.org/wiki/Phentermine for detailed information or consult your doctor if you are unsure.

Pharmacotherapy Diet Pills

2011-07-31T02:11:00.000-07:00

Traditional therapies for obesity have failed. Dietary and behavior modifications have been unsuccessful. In fact, studies have shown that 61-81% of initial weight loss is regained between 2.5 and 3.5 years. At five years, the numbers are more dismal. Seventy-five to 121% of the initial weight lost with dietary and/or behavior modifications is regained at five years 1. With 34% percent of the adult population in the United States classified as overweight and 27% of the adult population classified as obese 2, other approaches to weight loss are desperately needed. Pharmacotherapy with diet pills serves as a useful adjunct in the treatment of obesity.

Several paradigm shifts must occur when thinking about obesity and its treatment. First of all, obesity is a chronic disease, not a character flaw. Secondly, obesity is not merely cosmetic issue, but a disease with serious public health implications. Finally, weight gain after the cessation of treatment reflects the chronic nature of the disease and does not necessarily mean that the treatment was a failure 1.

The degree of excess weight is measured by the body mass index (BMI). The BMI is obtained by dividing the weight in kilograms by the height in meters squared. Normal BMI is 18.5 to 24.9. Overweight is defined as BMI from 25 to 25.9. Obesity is defined as BMI greater than 30. Obesity is associated with numerous medical conditions including: type II diabetes mellitus, hypertension, dyslipidemia, macrovascular disease, menstrual irregularities, sleep apnea, osteoarthritis, asthma, and certain types of cancer 1, 2, 3.

The National Institutes of Health (NIH) recommends non-pharmacologic weight loss methods for at least six months. If weight loss is less than 0.45 kg/month, weight loss drugs should be considered. Patients with BMIs that are 30 or greater and patients with BMIs that are 27 or greater with at least two obesity related risk factors or diseases are candidates for treatment with weight loss medications 2,3.

Weight loss medications have three main mechanisms of action. They may suppress appetite via central nervous system mechanisms, inhibit digestion, or increase metabolism. The appetite suppressants fall into three categories: noradrenergic agents, serotonergic agents, and the nonadrenergic/serotonergic agents.

Phentermine

Noradrenergic agents activate central alpha or dopamine receptors in the hypothalamus, enhance catecholamine transmission, increase sympathetic activity, and decrease appetite 3. Phentermine is the only FDA approved weight loss medication in this group. It is the “phen” of the “phen-fen” combination, and has been available since 1968. The only long-term, randomized double-blind, placebo controlled study of phentermine was done by Munro et al in 1968. In this study, 108 obese women were randomized to receive either phentermine 30 mg each day, four weeks on phentermine and four weeks off, or placebo. The women were followed for nine months. At the end of the study, the women in the continuous phentermine group lost 12.2 kg; those in the intermittent group lost 13.0 kg; those in the placebo group lost 4.8 kg 1. Side effects included: agitation, insomnia, headache, nervousness, irritability, palpitations, tachycardia, hypertension. Contraindications include: hyperthyroidism, glaucoma, agitated states, advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, and a history of drug abuse 3.

Fenfluramine

Appetite suppressants also act by serotonergic mechanisms. Fenfluramine, an agent in this class, inhibits the uptake of serotonin and releases serotonin in the synaptic cleft. As a result, food-seeking behavior is diminished and the amount of food consumed is decreased 3. Fenfluramine, its active form dexfenfluramine, and the combination phentermine-fenfluramine, “phen-fen”, were withdrawn from the market in 1997. Fenfluramine was shown to cause valvular heart disease. In addition to causing the release of serotonin and inhibiting the uptake of serotonin from the synaptic cleft, fenfluramine acts as a serotonin agonist. It is the agonistic effect that is responsible for valvular heart damage 1. Valvular heart disease is not associated with the selective serotonin reuptake inhibitor class of antidepressants, nor is it seen with the weight loss medication sibutramine. These agents do not have serotonergic agonist properties. They inhibit the uptake of serotonin from the synaptic cleft, and thus are not associated with valvular heart disease 1. Furthermore, use of dexfenfluramine for more than three months was associated with primary pulmonary hypertension 3.

Meridia

Sibutramine (Meridia) inhibits the uptake of serotonin and norepinephrine from the synaptic clefts in the hypothalamus 4. It increases satiety and may increase metabolic rate 5. Several studies have demonstrated the efficacy of sibutramine. A study by Bray et al enrolled 1047 obese subjects with BMIs between 30 and 40. After a two-week run-in period, the subjects were randomized to receive placebo or sibutramine (1mg, 5 mg, 10mg, 15 mg, 20 mg, or 30 mg) for 24 weeks. All subjects were encouraged to exercise by walking 20-30 minutes each day. Information on behavior modification was given. The women received instructions for a 1200 kcal/day diet, and the men received instructions for a 1500 kcal/day diet. After the end of six weeks, the placebo group lost 1.3 kg; 1mg group lost 2.4 kg; 5 mg group lost 3.7 kg; 10mg group lost 5.7 kg; 15mg group lost 7.0 kg; 20 mg group lost 8.2 kg; and the 30 mg group lost 9.0 kg.

The study had a high drop-out rate, with only 65% completing the study. Furthermore, the exclusion criteria were extensive and included: hypertension, cardiovascular disease, diabetes, depression, substance abuse, pulmonary disease, renal disease, hepatic disease, and other serious medical conditions. Adverse effects included dry mouth, insomnia, hypertension, palpitations, tachycardia, and dyspnea 6.

Because obesity is a risk factor for type II diabetes mellitus and so many type II diabetics are obese, Serrano-Rios et al conducted a study testing the efficacy of sibutramine in type II diabetics. The study enrolled 134 patients with stable type II diabetes with BMIs greater than 27 who were taking sulphonylureas. The participants were randomized to placebo or to sibutramine 15 mg per day for six months. At the end of the study, the sibutramine group lost 4.5 kg and the placebo group lost 1.7 kg. In addition to that, those in the sibutramine group who lost more than 10% of their body weight had a 1.8% decrease in their hemoglobin A1C levels. The placebo group’s hemoglobin A1C levels decreased 0.7%. The change in hemoglobin A1C was a result of the weight loss and not an independent drug effect 7.

The above two studies demonstrate the efficacy of sibutramine for a period of six months. A study by James et al shows that sibutramine is effective for long-term weight loss and weight maintenance. Six hundred and five patients with BMIs between 30 and 45 were enrolled in the study. All participants received a diet with a 600 kcal/day deficit and were encouraged to walk thirty minutes daily. All patients received sibutramine 15mg each day for six months. This was the six-month weight loss phase. At the end of six months, patients losing more than five percent of their body weight or regaining less than two kilograms were randomly assigned to placebo or sibutramine 15mg. The dose of sibutramine was increased to 20 mg if more than one kilogram of weight was gained at the end of the initial six months. The weight maintenance phase of the study lasted 18 months. Two hundred sixty one patients completed the study. Of the patients in the sibutramine group, 43% maintained 80% or more of the weight lost during the weight loss phase of the trial. Only 16% of the placebo group was able to do so. Furthermore, of those entering the maintenance phase on sibutramine, 69% maintained more than five percent of weight loss 18 months later, 46% maintained ten percent weight loss and 27% maintained the full weight loss 8 (see figure 1).

These studies demonstrate that sibutramine is effective for weight loss. However, these studies had high drop-out rates averaging about 20%. Patients with medical conditions including hypertension, heart disease, and diabetes (except in the study by Serrano-Rios et al) were excluded from most of the studies of sibutramine. Small increases in blood pressure and pulse are seen with higher doses of sibutramine 2,6. Headache, dry mouth, insomnia and constipation are other side effects 2. Use of sibutramine is associated with improvements in metabolic parameters. Lower LDL, triglyceride, and total cholesterol levels are seen with sibutramine use. Uric acid levels, glucose and hemoglobin A1C levels are lower as well 2,6. The typical starting dose is 10mg per day and may be increased after one month to 15 or 20 mg 3. Use of sibutramine for longer than two years is not recommended.

Xenical

In addition to suppressing appetite, weight loss medications may inhibit digestion as well. Orlistat (Xenical) is the only medication in this group. Orlistat inhibits lipase and thus decreases the absorption of dietary fat, which leads to decreased absorption of calories and decreased body weight. Approximately one-third of the ingested fat is excreted 2,3,9.

Sjostrom et al conducted a two-year study showing that orlistat was effective for weight loss and for slowing the rate of weight regain. Seven hundred forty-three patients with BMIs between 28 and 47 were enrolled. Each patient received a hypo-caloric diet consisting of 30% of the energy as fat. There was a single blind run-in period of four weeks in which each patient received placebo three times daily with meals. At the end of the run-in period, those who were compliant were randomized to placebo or orlistat 120mg three times daily with meals for 52 weeks. At the end of year one, compliant patients were further randomized to continue their current treatment or to switch regimens (see figure 2).

They were also given a eucaloric diet designed to maintain stable weight. Weight loss during year one and weight maintenance during year two were the two main variables. At the end of year one, the orlistat group lost 10.3 kg, and the placebo group lost 6.1 kg. At the end of year two, the placebo to orlistat group lost 3.6 kg; the orlistat to placebo group regained 4% of their weight; the orlistat to orlistat group regained 2% of their weight; and the placebo to placebo group regained 2% of their weight. In patients receiving 2 years of continuous orlistat treatment, 57% maintained a weight loss greater than five percent, compared to 37% of those receiving 2 years of placebo

As with other studies of weight loss medications, the drop-out rate in this study was high at 25%. Furthermore, patients with medical conditions including cardiovascular disease, diabetes, and hypertension were excluded from this study. Adverse effects included greasy stools, increased defecation, abdominal pain, flatulence. These occurred early in treatment and lasted less than four days. Also observed were slightly decreased levels of fat soluble vitamins in those taking orlistat. Sixteen patients in the orlistat group and four patients in the placebo group required supplementation. Orlistat treated patients also demonstrated lower LDL and total cholesterol levels 9.

Orlistat has also shown to be efficacious in diabetic patients. In a study by Hanefeld et al, 492 type II diabetic patients with BMIs greater than 27 who were either receiving treatment with sulphonylureas or no treatment for their diabetes were randomized to receive either orlistat 120 mg three times daily with meals or placebo for 48 weeks. At the end of the study the orlistat group lost 5.7 kg, and the placebo group lost 3.4 kg. Of the orlistat group, 51.3% lost more than five percent of their body weight as opposed to 31.6% of the placebo group. In regards of glycemic control, the hemoglobin A1C level went from 8.6 to 7.7 in the orlistat group, and from 8.6 to 8.1 in the placebo group. Total cholesterol and LDL levels decreased in the orlistat group vs. placebo. Increased levels of HDL were seen in the orlistat group as well 10.

These two studies demonstrate that orlistat is effective in weight loss. Orlistat also has favorable effects on total cholesterol, LDL cholesterol, and glycemic control. Most adverse effects consist of gastrointestinal symptoms. These usually resolve within several days of starting treatment. Furthermore, orlistat may reduce absorption of fat soluble vitamins and supplementation may be necessary 2,3. The usual dose of orlistat is 120 mg three times daily with meals. It may be taken up to one hour after meals 3. Use of orlistat for longer than two years is not recommended.

Ephedrine/Ephedra

In addition to suppressing appetite and inhibiting digestion of fat, weight loss medicines may also work by increasing metabolism. Ephedrine is one such medicine that has thermogenic properties. Ephedrine also suppresses appetite 3. Ephedrine is the synthetic form of ephedra which is found in the botanical Ma Huang 2. Neither ephedrine nor ephedra are FDA approved for weight loss. Despite this, ephedrine and ephedra, either alone or in combination with caffeine, are sold over the counter in the form of several weight loss products. Metabolife is one such product. Each tablet contains 12 mg of ephedra alkaloids and 40 mg of caffeine.

Ephedrine increases the release of norepinephrine which causes diminished food intake. It also acts as a sympathomimetic agent to increase blood pressure, heart rate, and thermogenesis. Caffeine decreases the breakdown of norepinephrine in the synaptic cleft, and thus acts in synergy with ephedrine 3.

A meta-analysis by Shekelle et al evaluated the safety and efficacy of ephedrine and ephedra. In terms of weight loss, they reviewed twenty trials that lasted for eight weeks or more. They reviewed five trials of ephedrine vs. placebo. The treatment groups lost an average of 0.6 kg/month more than the placebo groups. The average weight loss at four months was 11% in the ephedrine group. All trials had a 20% drop-out rate. They also looked at twelve trials of ephedrine and caffeine vs. placebo. These trials lasted between two and four months. The ephedrine-caffeine group lost an average of one kg/month more than the placebo group. The average percent weight loss in the treatment group was 11%. Three trials were reviewed consisting of ephedrine-caffeine vs. ephedrine. The ephedrine-caffeine group lost an average of 0.4 kg/month more than the ephedrine group. The group also reviewed two studies of ephedrine vs. other weight loss medications. No statistical difference was found in ephedrine vs. dexfenfluramine or in ephedrine vs. diethylproprion 11.

Trials of ephedra also demonstrated efficacy in weight loss. In one trial lasting three months patients treated with ephedra lost 0.8 kg/month more than those treated with placebo. In four trials ephedra with herbs containing caffeine vs. placebo, the treatment group lost 1.0 kg/month more weight than the placebo group. The average weight lost in the treatment group was 5.2% at four months 11 (see figure 4).

The meta-analysis by Shekelle et al also examined adverse events associated with ephedrine/ephedra usage. They examined 50 trials and grouped the symptoms into seven categories: psychiatric symptoms, autonomic hyperactivity, upper gastrointestinal symptoms, palpitations, hypertension, and headaches. They found that treatment with ephedrine/ephedra had a 2.2 to 3.6 increased odds for psychiatric symptoms, autonomic hyperactivity, upper gastrointestinal symptoms, and heart palpitations. The increase in blood pressure was not statistically significant. They also reviewed case reports of serious adverse events. They found two deaths, three myocardial infarctions, nine cerebral vascular accidents, three seizures and three psychiatric cases associated with prior ephedra consumption. Prior ephedrine consumption has been linked to three deaths, two myocardial infarctions, two cerebral vascular accidents, one psychiatric case, and one seizure. In the case studies of the serious adverse events, one-half occurred in persons younger than thirty years old 11.

In short, ephedrine and ephedra are effective for short-term (less than six months) weight loss. They are not FDA approved. Side effects include psychiatric disturbances, autonomic hyperactivity, upper gastrointestinal symptoms, and palpitations. There have been case reports of death, myocardial infarctions, strokes, and seizures associated with the use of these products 2,3,11.

Weight loss medications, in addition to diet and exercise, are useful adjuncts in the treatment of obesity. Patients with BMIs greater than 30 or greater than 27 with two obesity-related conditions or risk factors are candidates for treatment. There are only

three FDA approved drugs that have demonstrated efficacy in long-term (greater than nine months) trials: phentermine, sibutramine, and orlistat 1. Ephedrine and ephedra show efficacy, but they are not FDA approved. Unfortunately, the magnitude of weight loss with these medications is not great. However, even a five percent weight loss results in improvement in cardiovascular risk factors 9. Long-term use (greater than two years) is not recommended as there is no data on the safety and efficacy of these drugs for that length of time 2.

Product Availability

2011-07-31T01:44:00.000-07:00

Non Adrenergic

- Phentermine (Fastin, Adipex-P, Oby-Cap)

- Phentermine Resin (Ionamin)

- Benzphetamine (Didrex)

- Phendimetrazine (Bontril, Plegine, Prelu-2)

- Diethylpropion (Tenuate, Tenuate Dospan, Tepanil)

- Amphetamines (Ritalin, Adderall, Concerta)

Serotonergic

- Fluoxetine (Prozac)

- Sertraline (Zoloft)

- Fenfluramine

Mixed

- Sibutramine( Meridia)

Lipase Inhibitors

- Orlistat (Xenical)

Phentermine Frequently Asked Questions

2011-07-31T01:29:00.003-07:00

Does phentermine work? Yes. Studies have shown that individuals are able to lose weight and maintain their weight loss more effectively with prescription medications than with only a change in activity, diet and behavior alone.

How does phentermine work? The main action of phentermine is to reduce your appetite. Therefore you eat less and make healthier food choices.

Is phentermine safe? Yes. Phentermine has been around for over 50 years without problems when taken as prescribed. Also, phentermine is approved by the Food & Drug Administration (FDA) for both safety and efficacy.

Does phentermine cause heart valve damage or primary pulmonary hypertension? No. There are no cases or studies of heart valve disease in patients taking phentermine alone.

Does phentermine raise your blood pressure? Some forms of phentermine can raise your blood pressure. I prescribe the slow release form of phentermine and have never seen it raise anyone's blood pressure, even those who are controlled on blood pressure medication.

Is phentermine addictive? No. Phentermine is not an amphetamine and I have never seen any evidence that they are addictive, either in my experience or in the experience from other colleagues who specialize in weight loss. Also, phentermine, unfortunately, loses its effectiveness the longer you take it, thereby lowering its addictive potential.

What happens if phentermine stops working? Phentermine may be increased to higher doses than normally recommended in the prescribing information. This is in agreement with guidelines from the American Bariatric Society of Physicians (weight loss specialists).

Can I get phentermine if my Body Mass Index is less than 30%? Yes. Studies have shown that you are at increased risk for diseases if your Body Mass Index is over 22%. This is in agreement with guidelines from the American Bariatric Society of Physicians (weight loss specialists).

How long can I take phentermine? You can take phentermine for as long as you want to, for weight loss and/or weight maintenance. This is in agreement with guidelines from the American Bariatric Society of Physicians (weight loss specialists).

Can I take phentermine if I take antidepressants? Yes. I have not seen any problems with clients taking theses medications together. Although some literature states combining phentermine and antidepressants may cause serotonin syndrome, the condition is mild in most persons and resolve in less than 24 hours.

Will my insurance coverage the prescription for phentermine? Most insurance will not pay for phentermine. The cost of phentermine ranges from $85-$105 for one month's prescription.