This video depicts the patient centered medical home, which was modeled on concierge practice. Watching it will give you an overview of what my practice team does every day for our patients.
Monday, February 15, 2010
Orlistat or Prescription Xenical (over the counter ALLI)
How it works
Orlistat (Xenical), a novel drug was FDA approved in 1999 for use in those with obesity. It is different than over the counter “fat blockers” which are often soluble fibers (commonly found in psyllium –Metamucil-, beans, fruits and vegetables, especially prunes), chitins, or soap like substances. These may soak up variable amounts of fat or form fat globules in the stomach or a test tube, but the digestive process usually breaks these down later.
This new drug actually chemically binds and inactivates the enzyme that is produced in stomach and pancreatic juices called lipase. Lipase works by cleaving off the fatty fingers from the comb-like dietary fats, breaking the dietary fats down into an absorbable form. By dulling this lipase enzyme, absorption of fat is decreased by over thirty percent. This non-irritating fat passes through the small intestine undigested, and passes in the stool.
There is no significant absorption of Xenical into the blood stream. The medication appears to be harmlessly passed in the stool as well. There are almost no known significant drug-to-drug interactions, making it a safer alternative for those with other medical problems.
More is not better. The standard dose of one pill with each fat containing meal seems to give maximum fat blocking benefit. Conversely, if one eats a nonfat or very low fat meal (for instance bran cereal with skim milk, fruit and a multivitamin for breakfast), there is no weight loss benefit in taking the medication at this time. Xenical should be taken an hour before or up to an hour after eating a fat containing meal.
Cost saving tip
One can save significantly on the cost of this medication by avoiding fat in one or two meals a day, therefore only needing the Xenical once or twice, not three times a day. Fruit, fiber cereal, skim milk and a multivitamin for breakfast, low fat turkey or other healthy choice sandwich (with fat free cheese or mayo) and a V-8 for lunch, and a regular dinner with a Xenical is a cost effective way to save calories and money with this weight loss program. It is best to keep a small store of medication in a wallet or purse compartment for those unexpected meal times.
Based on the mechanism of action, there are expected but largely avoidable side effects. These side effects can also be looked at as a major benefit to this weight loss program as it trains the user not to binge on high fat foods or else pay the consequences. Bright orange or brown oily drops are often found floating in the toilet water for several days after a high fat meal. Initially, increased frequencies of BMs are common. At times, a small amount of relatively odorless orange or brown oil may slip out when passing gas, so one needs to be watchful for hygiene, and avoid gas forming foods or take beano to help lessen potentially embarrassing events. Patients on Xenical may need to do periodic “Xenical checks” after passing gas, using a restroom to test wipe. These side effects are generally short lived in the first weeks of starting Orlistat, but may continue for months or recur after a high fat meal. You rapidly become more attuned to throwing out scraps and not finishing the high fat items leftover by the kids or at restaurants. Even so, only about five percent of people tested on the medication stopped it due to side effects.
Theoretically, Xenical may inhibit the absorption of fat-soluble vitamins in our diet. One should therefore take a multivitamin at bedtime or at a time several hours separate from the Xenical to ensure proper nutrition.
Avoiding side effects
One can avoid side effects and improve the weight loss potential from Xenical by decreasing fat and increasing fiber intake. Studies have shown that side effects can be lowered by fifty percent in those on high fiber diets. Before starting Xenical, I suggest you get used to a high fiber diet first. The average American diet has 10-12 grams of fiber per day. We really need 20-30 grams a day. It may take two or three weeks for your intestines to adjust to this high level of fiber. Only after you have adjusted to a high fiber diet should you start your Xenical treatment program.
Whole grain foods as well as beans, fruits and vegetables (and lots of them) are good sources of fiber. Lettuce is not. Cereals (if you can tolerate fat free milk or milk substitutes) such as Fiber One or All Bran (extra fiber or bran buds) are excellent sources of high fiber. Kashi “Go Lean” cereal tends to cause gas but can be tried. You can sprinkle some of your preferred cereal on top of the fiber for flavor. I also suggest adding fruit (other than starchy bananas) for flavor and nutritional value. Other options for those on the go are the Metamucil fiber bars or Citrucel or Fibercon tablets with plenty of water, or you can add the new tasteless powdered soluble “Benefiber” to your food and drink. Have a bowl of fiber cereal if you are feeling the urge to nibble, or before or after dinner if you are feeling hungry. For variety, try a piece of fruit and lots of water as a chaser to take the edge off your hunger.
Also, you should avoid the Olestra (non-absorbable fat) snack products recently made available. These also increase the delivery of non-absorbed fat through the intestinal tract and increase the risk of side effects on Xenical.
Due to its mode of action, Xenical lowers cholesterol, blood sugar in diabetics, and blood pressure in hypertensive patients to a modest degree. It also may help those suffering from constipation. It also discourages people from eating high fat meals and hopefully helps them make healthier food choices incorporating more fruits and vegetables into the diet.