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Review of the Roles of Health Professionals about the Use of Anorectics: A Narrative Review Article



Nam Ji Kwon and Eunyoung Han
 
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ABSTRACT

Anorectic drugs have been misused and abused because the desire for weight loss has increased worldwide. To prevent the misuse and abuse of anorectic drugs, the roles of health professionals are important. Therefore, this narrative review about anorectic drugs was performed. The aim of this narrative review was to investigate types of anorectic drugs, drugs prone to misuse and abuse and the roles of health professionals-pharmacists, doctors and nurses. The studies on anorectics used globally were found via researches on scholarly databases related with health professionals in the field of public health. Here investigated anorectic drugs used worldwide and several supplements. In particular, this narrative review focused on drugs likely to be misused and abused (e.g., fenfluramine, orlistat, phendimetrazine, phentermine and sibutramine). In addition, the abuse and the side effects of anorectic drugs were investigated. To prevent the misuse and abuse of anorectic drugs, health professionals should prescribe, dispense and administer drugs carefully and provide educational programs. This narrative review considers the individual roles of and cooperation between health professionals and suggests the provision of appropriate policies and programs against the abuse of anorectics.

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Nam Ji Kwon and Eunyoung Han , 2017. Review of the Roles of Health Professionals about the Use of Anorectics: A Narrative Review Article. International Journal of Pharmacology, 13: 218-226.

DOI: 10.3923/ijp.2017.218.226

URL: https://scialert.net/abstract/?doi=ijp.2017.218.226

INTRODUCTION

Recently, the desire for weight loss, in particular in women has increased around the world. There are some ways to lose weights, such as eating habit modification, exercise, anorectics and bariatric surgery1. Among them, anorectic drugs were originally designed to cure people suffering from obesity or complications of obesity. However, some studies have reported the problems with the abuse of anorectics2-18.

In this narrative review, it investigated anorectic drugs used worldwide (amfepramone, amphetamine, benzphetamine, diethylpropion, fenproporex hydrochloride, liraglutide, lorcaserin, naltrexone/bupropion, orlistat, phendimetrazine, phentermine, rimonabant, sibutramine and topiramnate)1-7,19-23 and several supplements (α-amylase inhibitor, α-lipoic acid, caffeine, chitin, cocoa, dietary fiber, green tea, Phyillyrea latifolia leaves and rimonabant)2,21,24-26.

Although anorectic drugs, such as, orlistat should only be used by overweight adults, Alli (OTC name of orlistat) can be purchased online regardless age or weight in the USA26. Accordingly, it focused on drugs likely to be misused or abused (e.g., fenfluramine, orlistat, phendimetrazine, phentermine and sibutramine) and investigated their abuse and side effects. To prevent the misuse and abuse of anorectic drugs, the roles of health professionals are indispensable. Pharmacists deliver interventions for weight management, help select and monitor anorectics and provide patients with comprehensive dietary advice and information19,26-34. Doctors assess patient’s habits and provide counseling regarding weight loss1,35-39 and nurses provide weight-related interventions and conduct training and organizational support for obesity management40-42.

The objectives of this narrative review were to identify types of anorectic drugs (anorectics) likely to be misused or abused, to define the roles of health professionals, to determine levels of cooperation between health professionals and to suggest appropriate policies and programs. This narrative review will be able to stimulate health professionals, who have continued to make efforts to protect people from abuse of anorectics and will give an opportunity for health professionals to be more interested in the abuse of anorectics than now.

APPROACH TO A NARRATIVE REVIEW

It was conducted comprehensive study to obtain information on types of anorectics, their abuse and roles of health professionals in the context of anorectic abuse. Searches of PubMed, Science Direct and Google Scholar were conducted to identify documents published between 1996 and 2016. To identify overall information about anorectics including types and abuse aspects, it searched the following keywords: "Anorectics", "Anorectic drug abuse", "Weight control drug", "Weight loss" and "Drug abuse". After collecting information about anorectics, it focused on the roles of health professionals in the prevention of anorectic abuse and then, it searched for the following keywords: "Anorectic abuse", "Health professional", "Pharmacist", "Doctor", "Nurse" and "Intervention". In particular, a search for "Obesity" plus "Pharmacist" identified 153 papers, including 75 papers published during the last 5 years. Among 153 papers, it excluded duplicates from difference sites and checked the relevance with our narrative review. The criteria for choosing references was the roles of pharmacists, doctors, nurses and other health professionals about the abuse of anorectics and then 92 papers were excluded in the final reference list and it referred to four studies to figure out characteristics about narrative reviews43-46. Finally, it selected a total of 65 papers as references.

TYPES OF ANORECTICS

Anorectic drugs are being used worldwide (Table 1). Amfepramone is a schedule 3 controlled drug in the UK47 and has been used to treat obesity for more than 50 years, but is abused due to its low-cost in Brazil48. In fact, about 1,277 adults who were using amfepramone in Southern Brazil, 81% had an anorectic prescription. Mean period of usage was 8.7 months49.

Benzphetamine and diethylpropion are used for short term treatment and approved by FDA as schedule III and IV drug, respectively. They are used much less than phentermine, though they tend to suppress the appetite of patients. Also, they are possible to cause side effects and have considerable problems from latent ability about abuse1.

In 1999, fenproporex was withdrawn from market in France because it is inefficient for treating obesity. At time of discontinuation, users experienced withdrawal syndromes including anxiety and nightmares followed by depression Pelissier-Alicot et al.50.

Some anorectics, including phentermine are recommended for short term use. The US Food and Drug Administration (FDA) had approved 5 anorectic drugs, that were orlistat, lorcaserin, phentermine/topiramate, naltrexone/bupropion and liraglutide for long term use1,19. Although some weight loss drugs have been withdrawn because of severe side effects, the FDA and the European Medicines Agency (EMA) differ in terms of approvals and/or withdrawals of anorectics.

Table 1: Several kinds of anorectic drugs and supplements
Image for - Review of the Roles of Health Professionals about the Use of
Anorectics: A Narrative Review Article

Sibutramine, orlistat and rimonabant have been used as anorectics for 15 years in Sweden and although sibutramine was withdrawn from the European market, it can be purchased on the web and is considered as a main drug for weight loss2. In Brazil, the drugs most used for weight loss are amphetamine, sympathomimetic amines (40.5%), amfepramone, fenproporex hydrochloride and sibutramine23.

Rimonabant has been used for treatment of anti-obesity in Sweden. Rimonabant was reported that it had potential for malformation and health problems, such as pes equinovarus and coarctation of aorta in case study for infants from mothers who took rimonabant in early pregnancy2.

Some agents, not medicines are also available for weight loss. For example, α-lipoic acid induced weight loss in over-weight diabetes mellitus type 2 patients25 and Phillyrea latifolia leaves are considered weight loss agents due to their ability to reduce obesity associated with cellular problems24.

Caffeine, cocoa and green tea have also been used to induce weight loss. Dietary fiber not digested carbohydrates can reduce weight by disturbing energy intake21. To lose weight, youths have abused OTC drugs and supplements including laxatives in the USA. However, these agents are not used to lose weight and abuse can cause severe health problems26. Though there is no evidence about losing weight, α-amylase inhibitor and chitin are used to decrease calorie intake by inhibiting nutrients, such as carbohydrates and fat, from absorption in the body21.

ABUSE OF ANORECTICS

Young women in particular misuse and abuse drugs to reduce weight despite having a normal body weight after purchasing drugs illegally online. For this reason, it focused on anorectics likely to be misused or abused (e.g., fenfluramine, orlistat, phendimetrazine, phentermine and sibutramine) and investigated their abuse and side effects (Table 2).

In one Brazilian study, 31.1% of college students took anorectics prescribed by doctors (31.1%) and 17.8% took non-prescribed drugs23. After long-term treatment, abrupt cessation of fenfluramine and its derivative (dexfenfluramine) can induce depressive withdrawal symptoms6,21. The seriousness of the side effects of fenfluramine and its derivatives have been well discussed and include a significant risk of heart disease. For this reason, they were withdrawn from market in 19976-9.

In the case of orlistat, western countries, including the USA have mostly reported results of orlistat abuse, which is viewed as a compensatory behavior in those with an eating disorder. In India, orlistat is an abused OTC drug due to its availability, peer pressure and the desire to wear western dress10. Orlistat has also been misused among normal weight patients with bulimia nervosa and caused severe problems. Patients who took Alli (OTC name of orlistat) at ten times recommended doses, which surpasses the intensity of prescription orlistat, experienced more serious side effects.

Table 2: Abuse and side effects of anorectic drugs
Image for - Review of the Roles of Health Professionals about the Use of
Anorectics: A Narrative Review Article

Also, patients that misused orlistat with laxatives experienced fluid and electrolyte imbalances, which sometimes resulted in a heart accident of medical concern or death12. Main side effects of orlistat are associated with the gastrointestinal tract and include fatty/oily stools, fecal incontinence, repeated or sudden bowel movements and flatulence7,11,12.

Phendimetrazine is a prodrug for the monoamine releaser phenmetrazine and an anorectic that has an analogous process with norepinephrine14,21. Phendimetrazine is known as a treatment for patients with cocaine use disorder and has been reported to be associated with abuse in cocaine-dependent patients5. It was mentioned that sympathomimetric drugs, including phendimetrazine have potential for adverse effects similar to amphetamine, such as insomnia. Therefore, phemdimetrazine was used for short-term treatment (less than 12 weeks)21.

Although some researchers have reported that phentermine does not induce dependence or withdrawal syndrome after short or long-term treatment3,4 and through several studies, it is recommended that phentermine be taken for less than 12 weeks due to the possibility of addiction and uncertain long-term safety7,15. However, phentermine is often prescribed as off label and sold in the market as obermine, phenterex, obephe and etc., in US.1 Phentermine has been associated with serious health problems, such as, hypertension, vasculopathy and mental illness15.

Sibutramine is an anorectic and a serotonin and noradrenalin re-uptake inhibitor in the hypothalamus17,18. One Korean patient who ingested 280 mg of sibutramine presented thyrotoxicosis with thyroiditis17. In addition, sibutramine has been associated with elevations in blood pressure, heart rate and adverse heart events7,18. Also, it was reported that babies from mother who used sibutramine for anti-obesity tend to have high potential for serious malformation2. In 2010, sibutramine was withdrawn by the FDA and in European market due to the risk of cardiovascular events7,9. However, sibutramine is still sold through the internet and used for making some items which are not medical drugs but products related to anti-obesity2.

Roles of pharmacists, doctors and nurses and the prevention of the abuse of anorectic drugs: To prevent the misuse and abuse of anorectic drugs, the roles of the health professionals are indispensable. Health professionals should pay attention to anorectic drugs because these drugs have often been abused by patients with an Eating Disorder (ED)10. In one case, a person with an ED misused Alli and experienced diarrhea. To prevent this type of accident, health professionals should monitor orlistat because it can be accessed easily and is prone to abuse in the short and long-term51. Attitudes of health professionals are also important because they effect obese patients52.

Although guidelines have been established to support health professionals regarding the treatment of obesity in USA, UK and Europe22 several barriers remain with respect to the counseling of obese patients. The main barriers are lack of time (76.8%), lack of patient interest (55.8%) and lack of reward/return (49.3%)53. Actually, many patients are not prepared to pay pharmacists for management of obesity54.

Health professionals make efforts to ensure the appropriate use of anorectics. The roles of individual health professionals are shown in Table 3.

Roles of pharmacists: In Australia, pharmacists educate consumers about prevalently used anorectics28. As consumers regarded pharmacists as important health professionals for weight management, pharmacists are able to deliver appropriate advice about weight management. They can provide female consumers who need to manage weight with proper advice and knowledge about meal replacement products and herbal products27. In USA, to meet the need to manage weight effectively32, pharmacists help consumers to choose and monitor anorectics properly19 and reclassify anorectics by developing regulations regarding 3rd class of BTC (behind-the-counter) drugs26. In addition, they provide interventions for preventive health services in rural areas on a clinic basis with follow-up to manage weight loss extensively30. In USA, it would be better for pharmacists to combine both behavioral and pharmacological treatment. Also, there was a need to determine how to combine treatments properly, because many efficient, secure anorectic drugs were available on prescription and as OTC drugs31. In UK, many services for public health are provided including telephone counseling, which is efficient and cost-effective for long-term weight management29. Individuals can use a telephone or request person-to-person care, which is a more efficient approach for maintaining weight loss than education alone30. In Thailand and Kuwait, obese patients are provided with programs to improve behavior and knowledge about weight and obesity33,34. In Thailand, Primary Care Units (PCUs) provided pharmacists with the opportunity of establishing weight loss programs. Also, PCUs enable various health professionals, such as, doctors, nurses and community staff, to offer health services to satisfy needs related to local health33. In Kuwait, plans were proposed to create behavioral changes to increase physical performance and improve aspects related to eating. Some of these proposals included improving of information regarding obesity, counseling skills and raising patient awareness of the value of communicating with pharmacists34.

Table 3: Roles of pharmacists, doctors and nurses against the abuse of anorectics
Image for - Review of the Roles of Health Professionals about the Use of
Anorectics: A Narrative Review Article

Roles of doctors: Doctors can contribute to reduce the obesity epidemic by adopting pharmacotherapies that meet consumer’s needs, comorbidities and drug safety criteria. Doctors should inform patients when and how to cease therapy if weight loss is not achieved or if side effects outweigh drug benefits. In USA, doctors provide information on effective drugs for weight loss and help to manage obese patients with a comorbid status1. It is important that patients are provided with accurate information about obesity and the opportunity to lose weight with the assistance of doctors38. To prevent and treat obesity, advice from doctors is important for obese patients38. If a chronic care model is adapted to treat obesity, it is expected to facilitate effective treatment and provide patients with scientific information suitable for the management of obesity55. Doctors can encourage obese patients to lose weight through counseling39. In Australia, doctors check and counsel patients about lifestyles and dietary habits. While many efficient ways have been developed to address obesity, doctors did not consider obesity treatment as their roles35. However, in UK, although doctors considered their advice useless, they were found to be critical for the treatment of obesity36.

Roles of nurses: In UK, nurses involved in primary care also participate in interventions targeting obesity40,42. To conduct intervention efficiently, it has been suggested that there is a need to develop an education program for nurses and to inform nurses and patients that self-assessment is important for treating obesity40. According to a study conducted in the UK, Chinese nurses conduct weight management programs better than English nurses42. Also, nurses who display confidence and a proper attitude when conducted weight counseling provide patients with organizational assistance41. It is important that patients consider interventions through nurses important for weight control and management40. To support nurses who are familiar with skills required for successful intervention, there are needs to establish standardized guidelines for obesity-related care, educate nurses to treat obesity properly and encourage nurses to provide appropriate intervention41,42.

Systematic programs against anorectics: There is a need for efficient educational programs to prevent the abuse of anorectic drugs by obese patients.

As obesity has increased among children, the Centers for Disease Control (CDC) and other related authorities have promoted increasing time spent on physical activities to prevent obesity56,57. Web-based programs are more efficient for teens with respect to changing dietary habits and health conditions58,59 and nutrition-related education is needed to encourage obese adults to consume more fruits and vegetables60. Also, there is a need to prepare programs for the illiterate and individuals with a poor educational background, because in one Iranian study it was found educational levels were related to obesity61. Some programs for health promotion are important for mothers to provide them with information about the risk of stillbirth, which is strongly related to maternal obesity and to encourage them to increase physical activity levels and take measures to prevent their children from becoming obese62-64. In USA, community based nutritional intervention programs have been reported to improve female health and reduce waist circumferences and depression65.

CONCLUSION

The misuse and abuse of anorectic drugs have resulted in their side effects. Several prescription drugs, over-the-counter drugs and non-drug supplements are used to treat obesity. This narrative review focused on drugs likely to be misused and abused and it is evident that to prevent misuse and abuse problems, the roles of health professionals are important. Therefore, health providers should make efforts to ensure the appropriate use of anorectic drugs. Also, every health professionals should pay attention to health condition of patients and need to be well informed of obesity for provision of adequate treatment. Pharmacists should provide weight management and lifestyle interventions and provide dietary advice for successful weight management and provide information on meal replacement products and herbal products and on weight-beneficial medications for specific diseases. In addition, doctors and nurses should provide weight-related interventions to manage obesity.

To minimize and prevent problems resulting from the misuse and abuse of anorectic drugs, there is a need to develop and improve institutional and educational programs. On-line or in-person nutritional education or intervention would teach people to prevent obesity or manage themselves properly and appropriate health promotion programs would raise mother's perceptions regarding the management of obesity in their children.

It is still deficient for health professionals to pay attention to the abuse of anorectics, though they did the best they could. Therefore, this narrative review will be helpful for health professionals to make efforts to solve serious problems from abuse of anorectics.

ACKNOWLEDGMENT

This study was supported by the Duksung Women’s University Research Grants 2014 (3000002185), Korea.

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