Body Weight In Obese Patients Research Articles

Efficacy and Safety of Chemotherapy Dosed on Actual or Adjusted Body Weight in Obese Patients with Leukemia

Ji In Park, Yu Kyung Lee, Eun Hyung Koo, So Hee Lee, Ae Ryoung Park, Jeong Yi Yoon, Jin Suk Kanga and Sylvia Park. J. Kor. Soc. Health-syst. Pharm. 2023;40:47-58. https://doi.org/10.32429/jkshp.2023.40.1.001

Weight-adjusted dosing of tinzaparin for thromboprophylaxis in obese medical patients

BackgroundThe optimal dose of tinzaparin for prophylaxis in obese medical patients is not well defined. ObjectivesTo evaluate the anti-Xa activity in obese medical patients on tinzaparin prophylaxis adjusted for actual bodyweight. MethodsPatients with a body mass index of ≥30 kg/m2 treated with 50 IU/kg tinzaparin once daily were prospectively included. Anti-Xa and anti-IIa activity; von Willebrand factor antigen and von Willebrand activity; factor VIII activity; D-dimer, prothrombin fragments; and thrombin generation were measured 4 hours after subcutaneous injection between days 1 and 14 after the initiation of tinzaparin prophylaxis. ResultsWe included 121 plasma samples from 66 patients (48.5% women), with a median weight of 125 kg (range, 82-300 kg) and a median body mass index of 41.9 kg/m2 (range, 30.1-88.6 kg/m2). The target anti-Xa activity of 0.2 to 0.4 IU/mL was achieved in 80 plasma samples (66.1%); 39 samples (32.2%) were below and 2 samples (1.7%) above the target range. The median anti-Xa activity was 0.25 IU/mL (IQR, 0.19-0.31 IU/mL), 0.23 IU/mL (IQR, 0.17-0.28 IU/mL), and 0.21 IU/mL (IQR, 0.17-0.25 IU/mL) on days 1 to 3, days 4 to 6, and days 7 to 14, respectively. The anti-Xa activity did not differ among the weight groups (P = .19). Injection into the upper arm compared to the abdomen resulted in a lower endogenous thrombin potential, a lower peak thrombin, and a trend to a higher anti-Xa activity. ConclusionDosing of tinzaparin adjusted for actual bodyweight in obese patients achieved anti-Xa activity in the target range for most patients, without accumulation or overdosing. In addition, there is a significant difference in thrombin generation depending on the injection site.

1020: THERAPEUTIC ENOXAPARIN IN MORBIDLY OBESE PATIENTS: SINGLE-CENTER EXPERIENCE

Introduction: Enoxaparin is a low molecular weight heparin commonly used in the treatment of venous thromboembolisms (VTEs); however, evidence on optimal therapeutic dosing recommendations and bleeding adverse events are lacking in patients with morbid obesity (BMI > 35). Recommendation for VTE is 1 mg/kg every 12 hours using total body weight (TBW) for all patients. Methods: We performed a retrospective chart review of patients who were admitted to the ICU between 1/2020 and 9/2021 and were treated for VTE with 1 mg/kg TBW enoxaparin (full dose, FD) to look at bleeding complication rates in patients with BMI >35 and compared with patients who received 0.5 – 0.8 mg/kg TBW (adjusted dose, AD) and BMI > 35. Bleeding complications rates were defined as: needing one or more unit RBC transfusion (RBC), intracranial hemorrhage (ICH), retroperitoneal hemorrhage (RPH), or GI bleed (GIB). The following data were also collected from electronic medical records: Gender (Male), anti-Xa checked (AX), BMI (kg/m2), acute kidney injury (AKI based on KDIGO definitions), and hospital mortality. Results: We identified a total of 55 patients (42 in FD group and 13 in AD group). Compared to AD group, the FD group had more RBC transfusions (50% vs 31%), more ICH (7% vs 0 %), more RPH (9.5% vs 0 %), and more GIB (2.4 % vs 0%) respectively. Both groups were comparable regarding gender (M: 52 vs 38%, p = 0.4), anti-Xa (64% vs 62%, p = 0.9), BMI (44 +/- 7 vs 47 +/- 15, p = 0.3), AKI (17 % vs 15 %, p = 0.7), and mortality (29 % vs 31 %, p = 0.9). Conclusions: These data suggest that enoxaparin at recommended dosing of 1 mg/kg every 12 hours using total body weight for obese patients with BMI > 35 is associated with increased bleeding complications. These findings should be investigated in large multicenter prospective studies.

Impedance change during intentional weight loss in Thai obese patients

<h2>Summary</h2><h3>Background & aims</h3> Longitudinal measurements of raw bioelectrical impedance analysis (BIA) parameters suggested a worsening of the nutritional status in obese patients during weight loss after bariatric surgery. The effects of weight reduction through dietary intervention on raw BIA parameters is rarely described. <h3>Methods</h3> A retrospective observational study was conducted on obese patients who were in a weight-loss program. Dietary counseling, exercise, and lifestyle modification were suggested as the main approach to lose weight. Then longitudinal follow-up visits were scheduled every 1–3 months for up to 2 years. On each visit, body weight, waist, and hip circumferences were recorded along with BIA measurements. Repeated measures correlation (r_rm) was used to assess the relationship between BIA-derived impedance and body weight. <h3>Results</h3> A total of 116 obese patients were recruited. Participants had lost their weight from 113.47 ± 26.73 kg at the first visit to 103.69 ± 23.97 kg at the last visit (<i>P</i> < 0.001). A significant decrease of percentage of body fat was observed by −3.30 ± 4.33% from baseline. Total body water and fat-free mass were also significantly decreased. There was an increase in impedance from 483.55 ± 78.38 ohm at baseline to 496.11 ± 82.30 ohm at the last visit (<i>P</i> < 0.001). The r_rm between impedance and body weight was −0.31 (95% CI −0.37 to −0.25, <i>P</i> < 0.001). <h3>Conclusions</h3> Impedance had a significant negative correlation on body weight in obese patients during intentional weight loss, which might be due to decreased total body water and fat-free mass. Further study is required to explore the clinical meaning of these changes.

Abstract 12566: Use Of Aortic Valve Area Index By Actual Body Weight Overestimates Aortic Stenosis Severity In Obese Patients

Introduction: Guidelines recommend indexing aortic valve area (AVA) to body surface area in grading the severity of aortic stenosis (AS), which overestimates severity in obese patients. The indexing of AVA to ideal or adjusted body weight has not been explored. Hypothesis: We hypothesized that using actual body weight compared to ideal or adjusted body weight in obese patients would result in overestimation of the severity of AS using AVAi. Methods: We conducted retrospective chart review on 305 individuals who received a transthoracic echocardiogram (TTE) at Tufts Medical Center from June 2021 to Sept. 2021 with AVA &lt;1.5cm 2 . We selected 73 subjects with moderate AS (AVA 1-1.5cm 2 ). These subjects were divided into an overweight and obese group (BMI &gt; 25; n = 56) and a normal weight group (BMI 18-24.9; n = 17). We recorded baseline characteristics and TTE data. AVAi was calculated with actual, ideal, and adjusted body weight. The primary outcome was reclassification, defined as a change in severity from severe AS to mild or moderate AS after recalculating AVAi using adjusted or ideal body weight. Results: The overweight and obese group was significantly younger (age 74.4±11.2 versus 80.7±5.7 years, P=0.018) with higher BSA (2.0±0.2 versus 1.7±0.2, P=0.010) compared to the normal weight group. The recorded median AVAi was 0.61 with interquartile range(IQR) of 0.17. There was no significant difference in blood pressure, ejection fraction, AVA, peak aortic velocity, peak gradient, and mean gradient. After calculating AVAi with adjusted and ideal body weight, 18 patients in the overweight and obese group were reclassified to a lower grade of AS based on AVAi (median AVAi 0.58, IQR 0.17), compared with 0 reclassifications in the normal weight group (0.67, 0.18). Patients who were reclassified had a significantly smaller AVA compared to patients who were not reclassified (1.09±0.11 versus 1.23±0.19 cm 2 , P&lt;0.001), while no differences were observed in peak gradient, mean gradient, and peak velocity. Conclusions: Using actual body weight to calculate AVAi in overweight and obese patients can lead to overestimation of AS severity. Further research is needed to investigate the optimal indexing strategy for AVAi and the effects of classification on cardiovascular outcomes.

Tirzepatide Reduced Significantly the Body Weight in Obese Patients

Tirzepatide Reduced Significantly the Body Weight in Obese Patients

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

Expert consensus on the diagnosis and treatment of severe and critical coronavirus disease 2019.

Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review.

Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.

Современные аспекты диагностики и лечения рефрактерной гастроэзофагеальной рефлюксной болезни

Objective of the Review: To analyze current data on the diagnosis and treatment of refractory gastroesophageal reflux disease (GERD). Key points. Refractory GERD is diagnosed when there is insufficient response to proton pump inhibitors (PPIs) twice daily for 8 weeks with the presence of pathological gastroesophageal reflux. Possible mechanisms underlying PPI-refractory symptoms characteristic of GERD include persistence of pathological reflux, esophageal hypersensitivity to reflux, association of symptoms with other diseases, and functional nature of symptoms. To diagnose refractory GERD, a thorough analysis of symptoms, esophagogastroscopy with morphological examination, pH-impedancemetry and esophageal manometry are performed. Treatment includes dietary and lifestyle modifications to reduce body weight in obese patients, optimization of PPI prescribing, use of other drugs, and, if indicated, surgery. Conclusion. Diagnosing the reasons for the decrease in the effectiveness of PPIs in patients with GERD is a complex process that requires the use of modern endoscopic methods with the performance of a morphological study of the esophagus, pH-impedance testing and highresolution manometry to determine the nature of reflux, the relationship of reflux with symptoms of GERD and the differential diagnosis of various GERD syndromes. The choice of therapy for patients with refractory GERD is determined by the results of the examination and the final diagnosis. Keywords: refractory gastroesophageal reflux disease, proton pump inhibitors, diagnosis, treatment.

Effect of Sodium-Glucose Cotransporter 2 Inhibitors on Weight Reduction in Overweight and Obese Populations without Diabetes: A Systematic Review and a Meta-Analysis.

BackgroundWe aimed to evaluate the efficacy of sodium-glucose cotransporter 2 (SGLT2) inhibitors for managing obesity in non-diabetic overweight or obese patients.MethodsFor purposes of this study, PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched through May 2021. Randomized controlled trials published in English that compared SGLT2 inhibitors with placebo in overweight and obese patients without diabetes were included in the primary analysis. The random effects standardized mean difference ±95% confidence interval (95% CI) was calculated as the effect size.ResultsFive randomized controlled trials were included to evaluate body weight change, four trials to assess body mass index (BMI), and three trials to assess waist circumference were included. Results showed that the mean body weight loss on SGLT2 inhibitors in obese patients without diabetes was −1.62 kg (95% CI, −2.38 to −0.85 kg) when compared with placebo. Treatment with SGLT2 inhibitors was also associated with a greater reduction in BMI than placebo (weighted mean difference, −0.47 kg/m2; 95% CI, −0.62 to −0.31 kg/m2). The mean reduction in waist circumference with SGLT2 inhibitors versus placebo was 1.29 cm (95% CI, −2.62 to 0.04 cm), which was not statistically significant. There were no significant changes in fat mass, blood pressure, low-density lipoprotein cholesterol or high-density lipoprotein cholesterol with SGLT2 inhibitor treatment.ConclusionA meta-analysis demonstrated that although the weight lowering effect was mild, SGLT2 inhibitors significantly reduced body weight in obese patients without diabetes.

Abstract #1088564: The Efficacy and Safety of a SGLT2 Inhibitors on Body Weight in Obese Patients Without Diabetes: A Systematic Review and Meta-Analysis

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have been shown to improve glycemic control, lower blood pressure and body weight in patients with type 2 diabetes mellitus (T2DM). Despite obesity being linked to increased risk for numerous diseases, management largely relies on dietary and lifestyle modifications, which are difficult to sustain. The role of SGLT2i to promote weight reduction in non-diabetic patients is a promising venture. This meta-analysis aims to evaluate weight changes in obese, non-diabetic patients who received an SGLT2i. We employed a systematic search on PubMed, Cochrane, MEDLINE, and Google Scholar databases for relevant articles, using keywords' SGLT2 inhibitors', 'Sodium-glucose co-transporter-2 inhibitors', 'body weight' and 'weight loss,' 'non-diabetic patients.' All original articles published in the English literature on this topic are selected for this study. Six relevant randomized control trials were included, with a total of 863 patients were identified. The majority were female (79%) mean age of 45.7 ± 11.8 and a body mass index (BMI) of 36.6 ± 5.0. The studies used dapagliflozin, canagliflozin, remogliflozin or sergliflozin with a dosage ranging from 10-300 mg, once to three times a day for 12 to 52 weeks. Our analysis showed a significant weight reduction with the use of SGLT2i in obese non-diabetic patients [weighted mean difference (WMD) -1.56; 95% confidence interval (CI) -2.19, -0.93; I2 = 0%]. Furthermore, BMI and waist circumference were also significantly decreased in the treatment group compared to placebo [WMD -0.5; 95% CI -0.56, -0.44; I2 = 0% and WMD -2.10; 95% CI -3.49, -0.72; I2 = 0%]. Overall, the treatment with SGLT2 inhibitors was generally safe and well-tolerated. The most common adverse event for canagliflozin was mycotic infections (10.3%), pollakiuria (frequent daytime urination) for dapagliflozin (44%), while headache for sergliflozin (33%) and remogliflozin (44%). Urinary tract infection was an adverse event reported in 4/6 studies (7.7% for canagliflozin and 5% for dapagliflozin). SGLT2 inhibitors are well tolerated and significantly reduce body weight, BMI and waist circumference in obese non-diabetic patients compared to placebo. However, the studies are short-term and vary in specific SGLT2 inhibitor received, dosage and timing. Further studies are required for a definitive conclusion.

An exploratory double-blind, randomized, placebo-controlled study to assess the efficacy of CitruSlim on body composition and lipid parameters in obese individuals.

The prevalence of obesity in developing and developed countries has been well recognized, and the worldwide obesity rates have nearly tripled since 1975, according to the World Health Organization. CitruSlim, a standardized product containing a blend of Citrus bergamia and Eurycoma longifolia, can reduce cortisol, cholesterol, triglycerides, and hyperglycemia. These properties can contribute to reduction in body weight or body mass index (BMI) in obese patients. A randomized, double-blind, placebo-controlled clinical study was designed to evaluate the efficacy and tolerability of CitruSlim in body weight management in obese individuals, and the results were compared with that of placebo. A total of 97 participants were allocated, randomized, and treated with CitruSlim high-dose (HD, 400 mg), CitruSlim low-dose (LD, 200 mg), and placebo for 112 days. At the end of the study, CitruSlim HD and CitruSlim LD significantly reduced BMI compared to the placebo group and were well tolerated; however, it did not improve parameters associated with dyslipidemia and metabolic disturbances. The study findings suggested that CitruSlim was effective in reducing body weight in obese patients.

GLP-1 Induces the Expression of FNDC5 Derivatives That Execute Lipolytic Actions.

Multiple GLP-1-derived therapeutics are clinically used to treat type 2 diabetes and obesity. However, the underlying mechanism of how these drugs regulate the body weight of obese patients remains incompletely understood. Here, we report that the lipolysis effects of GLP-1 on β cells can depend on its induced expression of fibronectin type III domain containing 5 (FNDC5). The transmembrane FNDC5 is a precursor of the recently identified hormone irisin that possesses a range of bioactivities, including anti-obesity and anti-diabetes. We revealed that GLP-1 upregulates the expression and secretion of FNDC5 in β cells, while GLP-1 itself fails to activate the lipolysis genes in FNDC5-knockout β cells. In addition, liraglutide, a clinically used GLP-1 receptor agonist, induced the expression of FNDC5 in mouse pancreas and brain tissues and increased the serum level of secreted FNDC5. Furthermore, we observed the expression of the well-known membrane-associated FNDC5 and a novel, secretable FNDC5 (sFNDC5) isoform in β cells and multiple rat tissues. Recombinant sFNDC5 stimulated lipolysis of wild type and FNDC5-knockout β cells. This new isoform further induced lipolysis and browning of adipocytes, and similar to irisin, executed potent anti-obesity activities in an obese mouse model. Overall, our studies provided new mechanistic insights into GLP-1’s anti-obesity actions in which GLP-1 induces the secretion of FNDC5 derivatives from its responsive organs that then mediate its anti-obesity activities.

Evaluation of Dexmedetomidine Dosing in Obese Critically Ill Patients

Background: Dexmedetomidine is a highly selective α2-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Due to these ideal sedative properties, there has been increased interest in utilizing dexmedetomidine as a first-line sedative for critically ill patients requiring light sedation. Objective: To evaluate the ability to achieve goal intensive care unit (ICU) sedation before and after an institutional change of dosing from actual (ABW) to adjusted (AdjBW) body weight in obese patients on dexmedetomidine. Methods: This study included patients ≥ 18 years old, admitted to a surgical or medical ICU, required dexmedetomidine for at least 8 hours as a single continuous infusion sedative, and weighed ≥ 120% of ideal body weight. Percentage of RASS measurements within goal range (−1 to +1) during the first 48 hours after initiation of dexmedetomidine as the sole sedative agent or until discontinuation dosed on ABW compared to AdjBW was evaluated. Results: 100 patients were included in the ABW cohort and 100 in the AdjBW cohort. The median dosing weight was significantly higher in the ABW group (95.9 [78.9-119.5] vs 82.2 [72.1-89.8] kg; p = 0.001). There was no statistical difference in percent of RASS measurements in goal range (61.5% vs 69.6%, p = 0.267) in patients that received dexmedetomidine dosed based on ABW versus AdjBW. Conclusion: Dosing dexmedetomidine using AdjBW in obese critically ill patients for ongoing ICU sedation resulted in no statistical difference in the percent of RASS measurements within goal when compared to ABW dosing. Further studies are warranted.

Comments on the updated recommendations of the American College of Rheumatology (ACR) for the treatment of gout. Lifestyle (part 2)

Updated ACR recommendations for the treatment of gout concerning lifestyle are discussed. Factors related to a lifestyle, above all food habits, for many years were of leading importance in the treatment of patients with gout, even after application of effective drugs. The authors of the updated ACR recommendations for the first time offered to reconsider the role of environmental factors in the genesis of gout and objectively assess the possibility of its non-drug treatment. On the one hand, regardless of the activity of the disease, the need for restrictions of the alcohol, purine-rich products and fructose-containing beverages, as well as the decrease of body weight in obese patients and vitamin C usage unviability are confirmed. On the other hand, these recommendations are conditional. Their new version of ACR recommendations is significantly different from both its previous version and other international and national recommendations, including recommendations on the diagnosis and treatment of gout used in the Russian Federation.

Effect of liraglutide 3.0mg treatment on weight reduction in obese antipsychotic-treated patients

BackgroundPatients treated with antipsychotics experience significant weight gain and accompanying metabolic disorders. We investigated the efficacy of liraglutide 3.0 mg in reducing the weight of antipsychotic-treated obese patients. MethodWe retrospectively reviewed 16 obese patients with schizophrenia or bipolar disorder who were treated with 3.0 mg of liraglutide each. During the 16 weeks of treatment, changes in body weight and Clinical Global Impression-Severity scale (CGI-S) were analyzed. The participants were divided into responders (lost at least 5% of body weight) and non-responders for analysis. ResultsTreatment with liraglutide 3.0 mg significantly decreased body weight (estimated marginal mean, 93.2 kg at baseline and 88.9 kg at 16 weeks; p < 0.001) as well as waist circumference, BMI and plasma glucose levels. Six of 16 patients (37.5%) complained of a modest degree of nausea. Six of the 12 subjects (50%) completing 16 weeks of treatment were responders. There were no significant differences in baseline characteristics between responders and non-responders. There was no worsening of CGI-S scores. ConclusionLiraglutide 3.0 mg significantly decreased body weight in obese patients treated with antipsychotics without altering the status of psychiatric diseases. A randomized controlled study is required to corroborate the results of this study.

The Effectiveness of Electroacupuncture in Reducing Body Weight in Obese Patients: A Meta-Analysis

The Effectiveness of Electroacupuncture in Reducing Body Weight in Obese Patients: A Meta-Analysis

The efficacy of once-daily liraglutide as an add-on to oral antidiabetic agents on weight reduction and glycemic control in obese patients with inadequately controlled type 2 diabetes: a retrospective analysis in relation to liraglutide dose escalation within a 7-month treatment period

This study aimed to evaluate the efficacy of once-daily liraglutide as an add-on to oral antidiabetics (OADs) on glycemic control and body weight in obese patients with inadequately controlled type 2 diabetes (T2D). A total of 27 obese T2D patients who received 7 months (0.6 mg/day for the first month, 1.2 mg/day for 3 months, and 1.8 mg/day for 3 months) of liraglutide treatment as an add-on to OADs were included. Data on body weight (kg), fasting plasma glucose (FPG, mg/dL), postprandial glucose (PPG, mg/dL), and HbA1c (%), were recorded. Liraglutide doses of 1.2 mg/day and 1.8 mg/day were associated with significant decreases in body weight (by 8.0% and 11.9%, respectively, p < 0.01 for each) and HbA1c (by 20.0 and 26.5%, respectively, p < 0.01), while all liraglutide doses yielded significant reductions in FPG (p ranging from < 0.001 to < 0.01) and PPG (p ranging from < 0.001 to < 0.01). Glycemic parameters showed a significant reduction from the 1.2 mg/day dose to the 1.8 mg/day dose (p < 0.01 for each), whereas no further reduction in body weight was noted. Our findings indicate favorable efficacy of liraglutide as an add-on to OADs in weight reduction and improving glycemic parameters in obese patients with inadequately controlled T2D. Once-daily liraglutide treatment was associated with significant weight loss and improved HbA1c levels only at 1.2-mg and 1.8-mg doses, while a 1.8-mg dose compared with a 1.2-mg dose seemed to enable a further improvement in glycemic control but not in weight loss.

Acute renal and neurotoxicity due to weight-based dosing of intravenous acyclovir: How to dose in obese patients?

Abstract Background Acyclovir is a hydrophilic drug that is mainly distributed in the lean compartments of the body. Consequently, dosing on total body weight in obese patients may lead to drug overdosing. Inconsistency in clinical guideline recommendations and a lack of clear recommendations in the Summary of Product Characteristics on how to dose acyclovir in obese patients can impede safe and effective treatment. Case report This report describes a 71-year-old obese patient (body mass index 35 kg/m2) with herpes zoster ophthalmicus and meningoencephalitis. The patient had normal renal function and was treated with acyclovir with a dosage based on actual body weight (10 mg/kg q8h intravenously). Supratherapeutic acyclovir concentrations probably induced acute kidney injury (AKI) and neurotoxicity. Results Due to the severity of the toxic effects, multiple sessions of hemodialysis were necessary, with eventual full recovery of the renal function and neurotoxic symptoms. Low dose haloperidol and lorazepam were not effective in resolving audiovisual hallucinations in our patient. Conclusion This case report emphasizes the need for adjusted dosing and subsequent close monitoring of obese patients who are treated with hydrophilic drugs, such as acyclovir, to avoid patient harm. We discuss prevention and management strategies for acyclovir toxicity in obese patients based on the current literature.

Management of Neuromuscular Blockade in the Elderly and Morbidly Obese Patient: What Does the Data Show?

This review addresses considerations for optimal neuromuscular blockade management in the elderly and obese. The evidence for adjusting dosing for common neuromuscular blocking drugs (NMBDs) and their antagonists are discussed. In the elderly patient, aminosteroidal NMBDs have a slower onset and prolonged duration of action. Aging has minimal effects on the organ-independent metabolism of the benzylisoquinolinium NMBDs. Slower circulatory times and reduced renal function in the elderly also have implications on the clinical effects of NMBD antagonists. Since drug clearance and distribution is not the same in obese and in lean patients, dosing based on the total body weight (TWB) will result in excess NMBD administration. Various dosing scalars such as ideal body weight (IBW), lean body weight (LBW), and fat-free mass (FFM) have been proposed but each has its own limitations. NMBDs should be dosed based on ideal body weight in obese patients. Optimal sugammadex dosing in obese patients remains controversial while neostigmine administration should not exceed 5 mg. Elderly and obese patients have an increased risk of developing complications in the perioperative period, particularly when NMBDs are administered. Vigilance, careful titration, and quantitative monitoring are warranted to care for these challenging patients.