Letters
screening and treatment in childhood; receiving funding from the Patient Centered Outcomes Research Institute on research related to cholesterol screening and treatment; and serving on the American Academy of Pediatrics Committee on Nutrition and the American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee. No other disclosures were reported.
Corresponding Author: Alison Poulton, MA, MBBChir, MD, Sydney Medical School Nepean, PO Box 63, Penrith, NSW, Australia 2751 (alison.poulton @sydney.edu.au).
1. Kit BK, Carroll MD, Lacher DA, Sorlie PD, DeJesus JM, Ogden C. Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010. JAMA. 2012;308(6):591-600.
1. Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74-86.
2. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-S256. 3. Haney EM, Huffman LH, Bougatsos C, Freeman M, Steiner RD, Nelson HD. Screening and treatment for lipid disorders in children and adolescents: systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2007;120(1):e189-e214. 4. Gillman MW, Daniels SR. Is universal pediatric lipid screening justified? JAMA. 2012;307(3):259-260. 5. Kimm SY, Payne GH, Stylianou MP, Waclawiw MA, Lichtenstein C. National trends in the management of cardiovascular disease risk factors in children: second NHLBI survey of primary care physicians. Pediatrics. 1998;102(5):50. 6. Centers for Disease Control and Prevention. About the Ambulatory Health Care Surveys. www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed November 12, 2012.
COMMENT & RESPONSE
Drugs for the Treatment of Obesity To the Editor The review1 by Dr Yanovski and Dr Yanovski on the treatment of obesity focused on drugs currently approved by the US Food and Drug Administration for longterm treatment, which includes orlistat, phenterminetopiramate, and lorcaserin. The discussion of the mechanisms of action of the latter 2 drugs was limited to their appetitesuppressive effects. However, these medications also have major psychotropic properties. Phentermine is structurally and functionally similar to dexamphetamine, with similar clinical effects on mood and motivation.2 Topiramate can lead to mood changes, including improvement or worsening of depression.3 Lorcaserin reduces impulsive responses.4 The psychotropic effects of these medications on mood, motivation, and impulse control are related to dosage and are of great relevance to the success of the lifestyle interventions that are combined with medication for achieving long-term weight control. The review reported that these important psychotropic properties tend to be overlooked. Future research should consider all the clinical effects of these drugs, with the aim of titrating the dose to maximize their therapeutic potential. This includes optimizing the psychotropic effects that could assist with establishing the lifestyle changes that are integral to the success of the long-term treatment of obesity. Alison Poulton, MA, MBBChir, MD Ralph Nanan, DrMedHabil Author Affiliations: Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Brauer LH, Johanson CE, Schuster CR, Rothman RB, de Wit H. Evaluation of phentermine and fenfluramine, alone and in combination, in normal, healthy volunteers. Neuropsychopharmacology. 1996;14(4):233-241. 3. Besag FM. Behavioural effects of the newer antiepileptic drugs: an update. Expert Opin Drug Saf. 2004;3(1):1-8. 4. Higgins GA, Silenieks LB, Rossmann A, et al. The 5-HT2C receptor agonist lorcaserin reduces nicotine self-administration, discrimination, and reinstatement: relationship to feeding behavior and impulse control. Neuropsychopharmacology. 2012;37(5):1177-1191.
In Reply We agree with Drs Poulton and Nanan that the psychotropic actions of weight-loss medications are potentially of great importance, particularly given that most obesity medications approved or in development affect neurotransmitters that may have an effect on mood, cognition, or behavior. Some of these effects, such as negative mood or irritability, may be problematic, whereas others may potentially enhance ability to adhere to diet and exercise recommendations. Assessment of all risks and benefits should be part of the considerations for clinicians selecting obesity medications for their patients. Space considerations limited discussion of many adverse consequences of medications in the text but they were included in the online Supplement. Additional studies are required to elucidate how psychotropic effects, such as reduction in impulsivity, may help to determine response to specific obesity medications. Susan Z. Yanovski, MD Jack A. Yanovski, MD, PhD Author Affiliations: Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland (S. Z. Yanovski); Section on Growth and Obesity, National Institute of Child Health and Human Development, Bethesda, Maryland (J. A. Yanovski). Corresponding Author: Susan Z. Yanovski, MD, National Institute of Diabetes and Digestive and Kidney Diseases, 6707 Democracy Blvd, Bethesda, MD 20892 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr J. Yanovski reported receiving an institutional grant from the Prader-Willi Syndrome Association (United States) and being a commissioned officer in the US Public Health Service. No other disclosures were reported.
Discharges Against Medical Advice To the Editor In their Viewpoint about discharges against medical advice, Drs Alfandre and Schumann1 asked, “Why would you discharge a patient against medical advice?” Until this question is answered, they argued, “continued use of the practice does not seem justified.” We believe the authors conflated 3 different scenarios, a clarification of which may help to answer their question.
jama.com
JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 06/13/2015
1807
screening and treatment in childhood; receiving funding from the Patient Centered Outcomes Research Institute on research related to cholesterol screening and treatment; and serving on the American Academy of Pediatrics Committee on Nutrition and the American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee. No other disclosures were reported.
Corresponding Author: Alison Poulton, MA, MBBChir, MD, Sydney Medical School Nepean, PO Box 63, Penrith, NSW, Australia 2751 (alison.poulton @sydney.edu.au).
1. Kit BK, Carroll MD, Lacher DA, Sorlie PD, DeJesus JM, Ogden C. Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010. JAMA. 2012;308(6):591-600.
1. Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74-86.
2. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-S256. 3. Haney EM, Huffman LH, Bougatsos C, Freeman M, Steiner RD, Nelson HD. Screening and treatment for lipid disorders in children and adolescents: systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2007;120(1):e189-e214. 4. Gillman MW, Daniels SR. Is universal pediatric lipid screening justified? JAMA. 2012;307(3):259-260. 5. Kimm SY, Payne GH, Stylianou MP, Waclawiw MA, Lichtenstein C. National trends in the management of cardiovascular disease risk factors in children: second NHLBI survey of primary care physicians. Pediatrics. 1998;102(5):50. 6. Centers for Disease Control and Prevention. About the Ambulatory Health Care Surveys. www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed November 12, 2012.
COMMENT & RESPONSE
Drugs for the Treatment of Obesity To the Editor The review1 by Dr Yanovski and Dr Yanovski on the treatment of obesity focused on drugs currently approved by the US Food and Drug Administration for longterm treatment, which includes orlistat, phenterminetopiramate, and lorcaserin. The discussion of the mechanisms of action of the latter 2 drugs was limited to their appetitesuppressive effects. However, these medications also have major psychotropic properties. Phentermine is structurally and functionally similar to dexamphetamine, with similar clinical effects on mood and motivation.2 Topiramate can lead to mood changes, including improvement or worsening of depression.3 Lorcaserin reduces impulsive responses.4 The psychotropic effects of these medications on mood, motivation, and impulse control are related to dosage and are of great relevance to the success of the lifestyle interventions that are combined with medication for achieving long-term weight control. The review reported that these important psychotropic properties tend to be overlooked. Future research should consider all the clinical effects of these drugs, with the aim of titrating the dose to maximize their therapeutic potential. This includes optimizing the psychotropic effects that could assist with establishing the lifestyle changes that are integral to the success of the long-term treatment of obesity. Alison Poulton, MA, MBBChir, MD Ralph Nanan, DrMedHabil Author Affiliations: Sydney Medical School Nepean, University of Sydney, Sydney, New South Wales, Australia.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Brauer LH, Johanson CE, Schuster CR, Rothman RB, de Wit H. Evaluation of phentermine and fenfluramine, alone and in combination, in normal, healthy volunteers. Neuropsychopharmacology. 1996;14(4):233-241. 3. Besag FM. Behavioural effects of the newer antiepileptic drugs: an update. Expert Opin Drug Saf. 2004;3(1):1-8. 4. Higgins GA, Silenieks LB, Rossmann A, et al. The 5-HT2C receptor agonist lorcaserin reduces nicotine self-administration, discrimination, and reinstatement: relationship to feeding behavior and impulse control. Neuropsychopharmacology. 2012;37(5):1177-1191.
In Reply We agree with Drs Poulton and Nanan that the psychotropic actions of weight-loss medications are potentially of great importance, particularly given that most obesity medications approved or in development affect neurotransmitters that may have an effect on mood, cognition, or behavior. Some of these effects, such as negative mood or irritability, may be problematic, whereas others may potentially enhance ability to adhere to diet and exercise recommendations. Assessment of all risks and benefits should be part of the considerations for clinicians selecting obesity medications for their patients. Space considerations limited discussion of many adverse consequences of medications in the text but they were included in the online Supplement. Additional studies are required to elucidate how psychotropic effects, such as reduction in impulsivity, may help to determine response to specific obesity medications. Susan Z. Yanovski, MD Jack A. Yanovski, MD, PhD Author Affiliations: Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland (S. Z. Yanovski); Section on Growth and Obesity, National Institute of Child Health and Human Development, Bethesda, Maryland (J. A. Yanovski). Corresponding Author: Susan Z. Yanovski, MD, National Institute of Diabetes and Digestive and Kidney Diseases, 6707 Democracy Blvd, Bethesda, MD 20892 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr J. Yanovski reported receiving an institutional grant from the Prader-Willi Syndrome Association (United States) and being a commissioned officer in the US Public Health Service. No other disclosures were reported.
Discharges Against Medical Advice To the Editor In their Viewpoint about discharges against medical advice, Drs Alfandre and Schumann1 asked, “Why would you discharge a patient against medical advice?” Until this question is answered, they argued, “continued use of the practice does not seem justified.” We believe the authors conflated 3 different scenarios, a clarification of which may help to answer their question.
jama.com
JAMA May 7, 2014 Volume 311, Number 17
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Georgia User on 06/13/2015
1807
