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Sir,
We agree with Stephen Head in his call for a drug formulary to guide prescription of medicines for obese patients[1]. We share his concerns about efficacy and safety of medicines in the obese as the evidence base is often absent or suboptimal.
The concerns about efficacy and safety are of particular relevance in antimicrobial therapy of acute bacterial infections. Antibacterial therapeutic action relies on exceeding the minimum inhibitory concentration (MIC) of the bacterial pathogen in the relevant tissues/organs in the patient. As Head points out, most drugs doses assume a patient of “average” or ideal body mass index/body mass.
If inadequate doses of antibiotics are administered to patients with bacterial infections, we risk therapeutic failure, worsening sepsis and possibly the generation of antimicrobial resistance.
In our field of infectious diseases, there is some evidence to guide antibiotic dose adjustment for obesity. Dosage adjustment for antibacterial agents in obesity has been recently reviewed[2]. The picture is complex, strengthening the case for a formulary for obese patients.
Evidence for the need to adjust doses for antiviral drugs in obese patients appears to be limited. A rare example of a therapeutic trial which explicitly considered obesity was the OPTIMO trial of oseltamivir pharmacokinetics in obese adults[3]
We believe that giving the patients the correct dose, adjusted for body mass index/obesity status, where the evidence supports this is as important as selecting the correct antimicrobial agent (or any other medicine). For our patients’ sakes, we must look critically at dose adjustment of medicines for the growing population of obese people or we risk therapeutic failure in this hitherto neglected group. We agree there is a need for a formulary for obese patients.
References
1. We need a drug formulary for obese people. Head S. BMJ 2015;350:h1356 doi: http://dx.doi.org/10.1136/bmj.h1356
2. Dosing of antibacterial agents in obese adults: does one size fit all? Payne KD, Hall RG. Expert Rev Anti Infect Ther 2014 Jul;12(7):829-54. doi: 10.1586/14787210.2014.912942
3. Oseltamivir pharmacokinetics in morbid obesity trial (OPTIMO) trial. Thorne-Humphrey LM, Goralski KB et al. J Antimicrob Chemother. 2011 Sep;66(9):2083-91 doi: 10.1093/jac/dkr257
Competing interests:
The authors work for Public Health England for whom obesity is a top policy priority. The views expressed are our own and not those of our employer(s). Neither GYS nor RJM are obese.
29 April 2015
Gee Yen Shin
Consultant Virologist
Rohini J. Manuel
Public Health England
Public Health laboratory London, 3/F Pathology & Pharmacy Building, The Royal London Hospital, London E1 2ES
A drug formulary for obese patients would also facilitate effective antimicrobial therapy
Sir,
We agree with Stephen Head in his call for a drug formulary to guide prescription of medicines for obese patients[1]. We share his concerns about efficacy and safety of medicines in the obese as the evidence base is often absent or suboptimal.
The concerns about efficacy and safety are of particular relevance in antimicrobial therapy of acute bacterial infections. Antibacterial therapeutic action relies on exceeding the minimum inhibitory concentration (MIC) of the bacterial pathogen in the relevant tissues/organs in the patient. As Head points out, most drugs doses assume a patient of “average” or ideal body mass index/body mass.
If inadequate doses of antibiotics are administered to patients with bacterial infections, we risk therapeutic failure, worsening sepsis and possibly the generation of antimicrobial resistance.
In our field of infectious diseases, there is some evidence to guide antibiotic dose adjustment for obesity. Dosage adjustment for antibacterial agents in obesity has been recently reviewed[2]. The picture is complex, strengthening the case for a formulary for obese patients.
Evidence for the need to adjust doses for antiviral drugs in obese patients appears to be limited. A rare example of a therapeutic trial which explicitly considered obesity was the OPTIMO trial of oseltamivir pharmacokinetics in obese adults[3]
We believe that giving the patients the correct dose, adjusted for body mass index/obesity status, where the evidence supports this is as important as selecting the correct antimicrobial agent (or any other medicine). For our patients’ sakes, we must look critically at dose adjustment of medicines for the growing population of obese people or we risk therapeutic failure in this hitherto neglected group. We agree there is a need for a formulary for obese patients.
References
1. We need a drug formulary for obese people. Head S. BMJ 2015;350:h1356 doi: http://dx.doi.org/10.1136/bmj.h1356
2. Dosing of antibacterial agents in obese adults: does one size fit all? Payne KD, Hall RG. Expert Rev Anti Infect Ther 2014 Jul;12(7):829-54. doi: 10.1586/14787210.2014.912942
3. Oseltamivir pharmacokinetics in morbid obesity trial (OPTIMO) trial. Thorne-Humphrey LM, Goralski KB et al. J Antimicrob Chemother. 2011 Sep;66(9):2083-91 doi: 10.1093/jac/dkr257
Competing interests: The authors work for Public Health England for whom obesity is a top policy priority. The views expressed are our own and not those of our employer(s). Neither GYS nor RJM are obese.