415.3 🩺 內科專科考前版

415.3.0.1 📌 䞀頁重點

  • 22E:
    • Tirzepatide (Zepbound, FDA 2023) for obesity — best-in-class
    • Retatrutide (phase 3) triple agonist (GLP-1+GIP+glucagon) ~ 24%
    • Survodutide (phase 3) GLP-1+glucagon
    • Cagrilintide + semaglutide (REDEFINE) amylin + GLP-1 combo
    • Setmelanotide expansion: MC4R, POMC, LEPR, BBS, Alström
    • AACE 2024 obesity guideline: bariatric BMI 32-35 + comorbidity
    • Pediatric guidelines (AAP 2023): aggressive treatment paradigm
    • Tirzepatide for HFpEF + obesity SUMMIT 2024 NEJM
  • Taiwan: 國健眲肥胖蚈畫; 健保 metformin/GLP-1/SGLT2 (DM 條件); 健保 phentermine 條件; 健保 orlistat; 健保 bariatric 條件 (BMI 37.5 or 32.5+ comorbidity, NHIA 2020); tirzepatide/setmelanotide/retatrutide/cagrilintide-semaglutide 自費 倚

415.3.0.2 🌟 Pearls (15)

415.3.0.2.1 Drug-Specific
  1. Tirzepatide titration slow to mitigate GI: 2.5 → 5 → 7.5 → 10 → 12.5 → 15 mg/wk over 24 wk
  2. GLP-1 + tirzepatide perioperative: hold 1 wk pre-elective surgery (gastroparesis / aspiration risk)
  3. Pancreatitis class warning for GLP-1 / tirzepatide: small absolute risk
  4. MTC family Hx contraindication for GLP-1 / tirzepatide (rodent C-cell tumors)
  5. Diabetic retinopathy worsening with rapid HbA1c drop — monitor in long-standing DM
415.3.0.2.2 Bariatric
  1. Pre-op weight loss 5-10% improves surgery outcomes (multidisciplinary nutrition program)
  2. Post-RYGB hypoglycemia: late dumping + reactive hyperinsulinemic; manage with dietary, acarbose, octreotide
  3. Post-bariatric pregnancy: wait 12-18 mo; close monitoring for nutritional + glycemic
  4. Bariatric + GLP-1 add-on: emerging for weight regain + maintenance
  5. Endoscopic procedures emerging: ESG (endoscopic sleeve gastroplasty) less invasive
415.3.0.2.3 Pediatric
  1. AAP 2023 obesity guideline: aggressive management paradigm shift
  2. Liraglutide ≥ 12 yr approved (FDA, EMA)
  3. Semaglutide ≥ 12 yr approved (STEP TEEN)
  4. Pediatric bariatric (ASMBS guidelines): severe + comorbidity ≥ 13 yr; outcome favorable
415.3.0.2.4 Special
  1. Set point biology: chronic weight regain after lifestyle alone; biological resistance; explains why drugs + surgery often needed

415.3.0.3 📍 Taiwan + 健保

415.3.0.3.1 Drugs
  • 健保 metformin
  • 健保 GLP-1 RA (CV/CKD/DM 條件)
  • 健保 SGLT2 (CV/CKD 條件)
  • 健保 phentermine 條件 (短期; 限制䞭心)
  • 健保 orlistat (Xenical)
  • 健保 phentermine-topiramate (Qsymia) 自費 倚
  • 健保 naltrexone-bupropion (Contrave) 自費 倚
  • 健保 liraglutide (Saxenda) 自費 倚
  • Tirzepatide (Zepbound) 自費 倚 (健保條件 expanding)
  • Setmelanotide 自費 (rare 眕病)
  • Retatrutide / cagrilintide-semaglutide 未䞊垂 / phase 3
415.3.0.3.2 Surgery
  • 健保 bariatric BMI ≥ 37.5 (or 32.5+ comorbidity, NHIA 2020)
  • 健保 sleeve gastrectomy + RYGB
  • 健保 endoscopic balloon (限制 / 自費)
  • 健保 ESG 自費 倚
415.3.0.3.3 Workup
  • 健保 lab + DEXA + LFT + lipid + BP
  • 健保 sleep study 條件
  • 健保 genetic testing (條件; 眕病 panel)
415.3.0.3.4 孞會 + 指匕
  • TES + Taiwan Obesity Society + DAROC + Taiwan Bariatric & Metabolic Surgery Society
  • AACE 2024 Obesity
  • ADA 2026
  • WHO
  • IDF

415.3.0.4 🎓 內專必懂 (15)

  1. Comprehensive evaluation + comorbidity workup
  2. Asian-specific BMI + WC thresholds
  3. Set point biology + adaptive thermogenesis
  4. Lifestyle + behavioral foundation
  5. GLP-1/GIP/glucagon-based pharmacology
  6. Tirzepatide as best-in-class
  7. Setmelanotide for monogenic / syndromic
  8. Bariatric procedure selection + AACE 2024
  9. Pre-op + post-op multidisciplinary care
  10. Post-bariatric hypoglycemia (Ch 418)
  11. Drug-induced obesity recognition + switch
  12. Pediatric obesity management (AAP 2023)
  13. Pregnancy + obesity considerations
  14. HFpEF + obesity (SUMMIT)
  15. 22E new: tirzepatide expansion, retatrutide phase 3, AAP pediatric paradigm

415.3.0.5 ⚙ Bariatric Multidisciplinary Workflow (內專)

Pre-op (3-6 mo before surgery):
- Multidisciplinary clinic: surgeon, endocrine, nutrition, psych, cardiology
- Nutritional assessment + supplementation correction
- Comorbidity optimization (DM, HTN, OSA)
- Weight loss target 5-10% (improves outcomes + technical)
- Mental health evaluation
- Patient education + commitment

Day of Surgery:
- Continue stress dose if cortisol-deficient
- Hold GLP-1 / tirzepatide 1 wk
- Hold SGLT2 3 d (eu-DKA)
- DVT prophylaxis
- Multimodal anesthesia

Post-op (acute):
- Monitor for leak, bleeding
- Pulmonary toilet
- Early mobilization
- Diet progression: clear liquid → full liquid → soft → solid (4-6 wk)
- Pain control without NSAIDs (mucosal)

Long-term Follow-up:
- 1, 3, 6, 12 mo, then annual
- Labs: B12, iron, ferritin, Ca, Vit D, PTH, lipid, glucose, HbA1c, LFT, Cr
- DEXA q1-2 yr
- Surveillance for hypoglycemia (post-RYGB)
- Weight regain prevention (lifestyle, GLP-1 add-on)
- Pregnancy: wait 12-18 mo; monitoring intense

Complications:
- Acute: leak, bleeding, DVT/PE, infection
- Late: anastomotic stricture, dumping, hypoglycemia, vitamin deficiency, GERD (sleeve), gallstone, bowel obstruction
- Weight regain (~ 20-30%)
- Mental health (post-op depression rare)

415.3.0.6 ⚙ Combination Therapy + Sequential (內專)

Many patients now receive combinations:

Lifestyle + GLP-1 RA:
- Foundation
- Most starting combination

Lifestyle + Tirzepatide:
- Most effective non-surgical

Lifestyle + Bariatric:
- Best for severe + comorbidity

Sequential:
- Initial GLP-1 → if 侍 response sufficient → bariatric
- Bariatric → maintenance with GLP-1
- Bariatric → weight regain → re-bariatric or GLP-1 add-on

Specific Subgroups:
- DM + obesity: tirzepatide + metformin + lifestyle
- HFpEF + obesity: tirzepatide (SUMMIT 2024)
- NASH + obesity: tirzepatide off-label + resmetirom
- Pre-bariatric: GLP-1 for pre-op weight loss
- Post-bariatric weight regain: GLP-1 add-on

Pediatric:
- Lifestyle + family-based behavioral
- Drug ≥ 12 yr (semaglutide, liraglutide; FDA-approved)
- Bariatric ≥ 13 yr (selected)

Pregnancy planning:
- Stop GLP-1 / tirzepatide 2-3 mo before conception
- Stop phentermine-topiramate (teratogenic)
- Continue lifestyle + metformin if PCOS

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