Abstract
The increasing prevalence of obesity in developed nations has far-reaching implications for medical toxicology. The management of obese patients is complicated by comorbid illnesses, changes in cardiovascular and respiratory physiology, alterations in pharmacokinetics, and a lack of studies to identify appropriate dosing for current therapeutics and antidotes. In this review article, we examine obesity-associated physiologic and pharmacokinetic changes that may increase the vulnerability of obese patients to overdose. Further research is needed to characterize the relationship between drug toxicity and obesity.
Similar content being viewed by others
References
Freedman DS, CDC. Obesity—United States, 1988–2008. MMWR Surveill Summ. 2011;60(Suppl):73–7.
May AL, Freedman D, Sherry B, Blanck HM, CDC. Obesity—United States, 1999–2010. MMWR Surveill Summ. 2013;62 Suppl 3:120–8.
Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25 Pt B):2985–3023. doi:10.1016/j.jacc.2013.11.004.
Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i–xii, 1–253.
Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Am J Clin Nutr. 1998;68(4):899–917.
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14. doi:10.1001/jama.2014.732.
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief. 2012;(82):1–8.
NCHS. Health, United States, 2012: with special feature on emergency care. Hyattsville, Maryland; 2013.
Finkelstein EA, Khavjou OA, Thompson H, Trogdon JG, Pan L, Sherry B, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med. 2012;42(6):563–70. doi:10.1016/j.amepre.2011.10.026.
Hill JO. Environmental contributions to the obesity epidemic. Science. 1998;280(5368):1371–4.
Cutler D, Glaeser E, Shapiro J. Why have Americans become more obese? J Econ Perspect. 2003;17(3):93–118.
Du H, Feskens E. Dietary determinants of obesity. Acta Cardiol. 2010;65(4):377–86.
Mitchell JA, Byun W. Sedentary behavior and health outcomes in children and adolescents. Am J Lifestyle Med. 2013. doi:10.1177/1559827613498700.
McVinnie DS. Obesity and pain. Br J Pain. 2013;7(4):163–70.
Health implications of obesity. National Institutes of Health Consensus Development Conference Statement. Ann Intern Med. 1985;103(1):147–51.
Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625–38. doi:10.1056/NEJMoa021423.
Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309(1):71–82. doi:10.1001/jama.2012.113905.
Mack KA, CDC. Drug-induced deaths—United States, 1999–2010. MMWR Surveill Summ. 2013;62 Suppl 3:161–3.
Lemmens HJ, Bernstein DP, Brodsky JB. Estimating blood volume in obese and morbidly obese patients. Obes Surg. 2006;16(6):773–6. doi:10.1381/096089206777346673.
Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321(4):225–36.
Ferraro S, Perrone-Filardi P, Desiderio A, Betocchi S, D’Alto M, Liguori L, et al. Left ventricular systolic and diastolic function in severe obesity: a radionuclide study. Cardiology. 1996;87(4):347–53.
Lee JF, Harrison ML, Christmas KM, Kim K, Hurr C, Brothers RM. Elevated resting heart rate and reduced orthostatic tolerance in obese humans. Clin Auton Res. 2013. doi:10.1007/s10286-013-0222-x.
Stamler R, Stamler J, Riedlinger WF, Algera G, Roberts RH. Weight and blood pressure. Findings in hypertension screening of 1 million Americans. JAMA. 1978;40(15):1607–10.
Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113(6):898–918. doi:10.1161/CIRCULATIONAHA.106.171016.
Strandgaard S, Andersen GS, Ahlgreen P, Nielsen PE. Visual disturbances and occipital brain infarct following acute, transient hypotension in hypertensive patients. Acta Med Scand. 1984;216(4):417–22.
McLaren GD, Danta G. Cerebral infarction due to presumed haemodynamic factors in ambulant hypertensive patients. Clin Exp Neurol. 1987;23:55–66.
Honiden S. Caring for the critically ill, obese patient. PCCSU; 2011.
Wang D, Teichtahl H. Opioids, sleep architecture and sleep-disordered breathing. Sleep Med Rev. 2007;11(1):35–46. doi:10.1016/j.smrv.2006.03.006.
Mogri M, Desai H, Webster L, Grant BJ, Mador MJ. Hypoxemia in patients on chronic opiate therapy with and without sleep apnea. Sleep Breath. 2009;13(1):49–57. doi:10.1007/s11325-008-0208-4.
Harris AT, Morell D, Bajaj Y, Martin-Hirsch DP. A discussion of airway and respiratory complications along with general considerations in obese patients. Int J Clin Pract. 2010;64(6):802–6. doi:10.1111/j.1742-1241.2010.02350.x.
Ramachandran SK, Haider N, Saran KA, Mathis M, Kim J, Morris M, et al. Life-threatening critical respiratory events: a retrospective study of postoperative patients found unresponsive during analgesic therapy. J Clin Anesth. 2011;23(3):207–13. doi:10.1016/j.jclinane.2010.09.003.
Mushref MA, Srinivasan S. Effect of high fat-diet and obesity on gastrointestinal motility. Ann Transl Med. 2013;1(2):14. doi:10.3978/j.issn.2305-5839.2012.11.01.
Cardoso-Junior A, Coelho LG, Savassi-Rocha PR, Vignolo MC, Abrantes MM, de Almeida AM, et al. Gastric emptying of solids and semi-solids in morbidly obese and non-obese subjects: an assessment using the 13C-octanoic acid and 13C-acetic acid breath tests. Obes Surg. 2007;17(2):236–41.
Acosta A, Camilleri M, Shin A, Vazquez-Roque MI, Iturrino J, Burton D, et al. Quantitative gastrointestinal and psychological traits associated with obesity and response to weight-loss therapy. Gastroenterology. 2015;148(3):537–46 e4. doi:10.1053/j.gastro.2014.11.020.
Wright RA, Krinsky S, Fleeman C, Trujillo J, Teague E. Gastric emptying and obesity. Gastroenterology. 1983;84(4):747–51.
Jackson SJ, Leahy FE, McGowan AA, Bluck LJ, Coward WA, Jebb SA. Delayed gastric emptying in the obese: an assessment using the non-invasive (13)C-octanoic acid breath test. Diabetes Obes Metab. 2004;6(4):264–70. doi:10.1111/j.1462-8902.2004.0344.x.
Horowitz M, Collins PJ, Cook DJ, Harding PE, Shearman DJ. Abnormalities of gastric emptying in obese patients. Int J Obes. 1983;7(5):415–21.
Festi D, Colecchia A, Sacco T, Bondi M, Roda E, Marchesini G. Hepatic steatosis in obese patients: clinical aspects and prognostic significance. Obes Rev. 2004;5(1):27–42.
Cikim AS, Topal E, Harputluoglu M, Keskin L, Zengin Z, Cikim K, et al. Epicardial adipose tissue, hepatic steatosis and obesity. J Endocrinol Investig. 2007;30(6):459–64.
Buechler C, Weiss TS. Does hepatic steatosis affect drug metabolizing enzymes in the liver? Curr Drug Metab. 2011;12(1):24–34.
Pan A, Sun Q, Czernichow S, Kivimaki M, Okereke OI, Lucas M, et al. Bidirectional association between depression and obesity in middle-aged and older women. Int J Obes (Lond). 2012;36(4):595–602. doi:10.1038/ijo.2011.111.
Dixon JB, Dixon ME, O’Brien PE. Depression in association with severe obesity: changes with weight loss. Arch Intern Med. 2003;163(17):2058–65. doi:10.1001/archinte.163.17.2058.
McElroy SL, Kotwal R, Malhotra S, Nelson EB, Keck PE, Nemeroff CB. Are mood disorders and obesity related? A review for the mental health professional. J Clin Psychiatry. 2004;65(5):634–51, quiz 730.
Alcaro A, Panksepp J. The SEEKING mind: primal neuro-affective substrates for appetitive incentive states and their pathological dynamics in addictions and depression. Neurosci Biobehav Rev. 2011;35(9):1805–20. doi:10.1016/j.neubiorev.2011.03.002.
Wang GJ, Volkow ND, Thanos PK, Fowler JS. Imaging of brain dopamine pathways: implications for understanding obesity. J Addict Med. 2009;3(1):8–18. doi:10.1097/ADM.0b013e31819a86f7.
Baik JH. Dopamine signaling in reward-related behaviors. Front Neural Circ. 2013;7:152. doi:10.3389/fncir.2013.00152.
Bluml V, Kapusta N, Vyssoki B, Kogoj D, Walter H, Lesch OM. Relationship between substance use and body mass index in young males. Am J Addict. 2012;21(1):72–7. doi:10.1111/j.1521-0391.2011.00192.x.
Gearhardt AN, Harrison EL, McKee SA. Does co-morbid depression alter the inverse relationship between obesity and substance use disorders? Drug Alcohol Depend. 2012;124(1–2):185–8. doi:10.1016/j.drugalcdep.2012.01.002.
Hitt HC, McMillen RC, Thornton-Neaves T, Koch K, Cosby AG. Comorbidity of obesity and pain in a general population: results from the Southern Pain Prevalence Study. J Pain. 2007;8(5):430–6. doi:10.1016/j.jpain.2006.12.003.
Counterweight Project Team. The impact of obesity on drug prescribing in primary care. Br J Gen Pract. 2005;55(519):743–9.
Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92. doi:10.7326/0003-4819-152-2-201001190-00006.
Manchikanti L, Helm S, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain Phys. 2012;15(3 Suppl):ES9–38.
Han PY, Duffull SB, Kirkpatrick CM, Green B. Dosing in obesity: a simple solution to a big problem. Clin Pharmacol Ther. 2007;82(5):505–8. doi:10.1038/sj.clpt.6100381.
Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet. 2010;49(2):71–87. doi:10.2165/11318100-000000000-00000.
Leykin Y, Miotto L, Pellis T. Pharmacokinetic considerations in the obese. Best Pract Res Clin Anaesthesiol. 2011;25(1):27–36.
Du BD, Du BE. Clinical calorimetry: tenth paper a formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916;XVII(6_2):863–71. doi:10.1001/archinte.1916.00080130010002.
Mosteller RD. Simplified calculation of body-surface area. N Engl J Med. 1987;317(17):1098. doi:10.1056/NEJM198710223171717.
Lopes-Serrao MD, Ussery SM, Hall RG, Shah SR. Evaluation of chemotherapy-induced severe myelosuppression incidence in obese patients with capped dosing. J Oncol Pract. 2011;7(1):13–7. doi:10.1200/JOP.2010.000045.
Griggs JJ, Mangu PB, Anderson H, Balaban EP, Dignam JJ, Hryniuk WM, et al. Appropriate chemotherapy dosing for obese adult patients with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2012;30(13):1553–61. doi:10.1200/JCO.2011.39.9436.
Cheymol G. Effects of obesity on pharmacokinetics implications for drug therapy. Clin Pharmacokinet. 2000;39(3):215–31. doi:10.2165/00003088-200039030-00004.
Green B, Duffull SB. What is the best size descriptor to use for pharmacokinetic studies in the obese? Br J Clin Pharmacol. 2004;58(2):119–33. doi:10.1111/j.1365-2125.2004.02157.x.
Morgan DJ, Bray KM. Lean body mass as a predictor of drug dosage. Implications for drug therapy. Clin Pharmacokinet. 1994;26(4):292–307. doi:10.2165/00003088-199426040-00005.
Janmahasatian S, Duffull SB, Ash S, Ward LC, Byrne NM, Green B. Quantification of lean bodyweight. Clin Pharmacokinet. 2005;44(10):1051–65. doi:10.2165/00003088-200544100-00004.
De Baerdemaeker LE, Mortier EP, Struys MM. Pharmacokinetics in obese patients. Contin Educ Anaesth Crit Care Pain. 2004;4(5):152–5. doi:10.1093/bjaceaccp/mkh042.
Casati A, Putzu M. Anesthesia in the obese patient: pharmacokinetic considerations. J Clin Anesth. 2005;17(2):134–45. doi:10.1016/j.jclinane.2004.01.009.
Lloret Linares C, Decleves X, Oppert JM, Basdevant A, Clement K, Bardin C, et al. Pharmacology of morphine in obese patients: clinical implications. Clin Pharmacokinet. 2009;48(10):635–51. doi:10.2165/11317150-000000000-00000.
Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth. 2010;105 Suppl 1:i16–23. doi:10.1093/bja/aeq312.
Alsio A, Rembeck K, Askarieh G, Christensen PB, Farkkila M, Langeland N, et al. Impact of obesity on the bioavailability of peginterferon-alpha2a and ribavirin and treatment outcome for chronic hepatitis C genotype 2 or 3. PLoS ONE. 2012;7(5), e37521. doi:10.1371/journal.pone.0037521.
Diepstraten J, Chidambaran V, Sadhasivam S, Esslinger HR, Cox SL, Inge TH, et al. Propofol clearance in morbidly obese children and adolescents: influence of age and body size. Clin Pharmacokinet. 2012;51(8):543–51. doi:10.2165/11632940-000000000-00000.
Mornar S, Chan LN, Mistretta S, Neustadt A, Martins S, Gilliam M. Pharmacokinetics of the etonogestrel contraceptive implant in obese women. Am J Obstet Gynecol. 2012;207(2):110 e1-6. doi:10.1016/j.ajog.2012.05.002.
Blouin RA, Warren GW. Pharmacokinetic considerations in obesity. J Pharm Sci. 1999;88(1):1–7. doi:10.1021/js980173a.
Kolka CM, Harrison LN, Lottati M, Chiu JD, Kirkman EL, Bergman RN. Diet-induced obesity prevents interstitial dispersion of insulin in skeletal muscle. Diabetes. 2010;59(3):619–26. doi:10.2337/db09-0839.
Sindelka G, Heinemann L, Berger M, Frenck W, Chantelau E. Effect of insulin concentration, subcutaneous fat thickness and skin temperature on subcutaneous insulin absorption in healthy subjects. Diabetologia. 1994;37(4):377–80.
Vora JP, Burch A, Peters JR, Owens DR. Relationship between absorption of radiolabeled soluble insulin, subcutaneous blood flow, and anthropometry. Diabetes Care. 1992;15(11):1484–93.
Dayananda L, Belaval VV, Raina A, Chandana R. Intended intramuscular gluteal injections: are they truly intramuscular? J Postgrad Med. 2014;60(2):175–8. doi:10.4103/0022-3859.132334.
Chantel S, Martin P, Petit P, Massignon D, Dode X, Maire P, et al. Pharmacokinetic variability of the absorption of enoxaparin used subcutaneously for venous thromboembolism prophylaxis. Population Approach Group Europe; 2006.
Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200(3):378–85. doi:10.1016/j.amjsurg.2009.11.007.
Edwards A, Ensom MH. Pharmacokinetic effects of bariatric surgery. Ann Pharmacother. 2012;46(1):130–6. doi:10.1345/aph.1Q414.
Braghetto I, Davanzo C, Korn O, Csendes A, Valladares H, Herrera E, et al. Scintigraphic evaluation of gastric emptying in obese patients submitted to sleeve gastrectomy compared to normal subjects. Obes Surg. 2009;19(11):1515–21. doi:10.1007/s11695-009-9954-z.
Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41–50. doi:10.1111/j.1467-789X.2009.00614.x.
Olson K. Poisoning and drug overdose. 6th ed. New York: McGraw-Hill Education; 2007.
Corcoran GB, Salazar DE. Obesity as a risk factor in drug-induced organ injury. IV. Increased gentamicin nephrotoxicity in the obese overfed rat. J Pharmacol Exp Ther. 1989;248(1):17–22.
Schwartz AE, Matteo RS, Ornstein E, Young WL, Myers KJ. Pharmacokinetics of sufentanil in obese patients. Anesth Analg. 1991;73(6):790–3.
Egan TD, Huizinga B, Gupta SK, Jaarsma RL, Sperry RJ, Yee JB, et al. Remifentanil pharmacokinetics in obese versus lean patients. Anesthesiology. 1998;89(3):562–73.
Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The effects of cisatracurium on morbidly obese women. Anesth Analg. 2004;99(4):1090–4. doi:10.1213/01.ANE.0000132781.62934.37.
Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients. Anesth Analg. 2004;99(4):1086–9. doi:10.1213/01.ANE.0000120081.99080.C2.
Sparreboom A, Wolff AC, Mathijssen RH, Chatelut E, Rowinsky EK, Verweij J, et al. Evaluation of alternate size descriptors for dose calculation of anticancer drugs in the obese. J Clin Oncol. 2007;25(30):4707–13. doi:10.1200/JCO.2007.11.2938.
Allard S, Kinzig M, Boivin G, Sorgel F, LeBel M. Intravenous ciprofloxacin disposition in obesity. Clin Pharmacol Ther. 1993;54(4):368–73.
Taivainen T, Tuominen M, Rosenberg PH. Influence of obesity on the spread of spinal analgesia after injection of plain 0.5% bupivacaine at the L3-4 or L4-5 interspace. Br J Anaesth. 1990;64(5):542–6.
Hogan QH, Prost R, Kulier A, Taylor ML, Liu S, Mark L. Magnetic resonance imaging of cerebrospinal fluid volume and the influence of body habitus and abdominal pressure. Anesthesiology. 1996;84(6):1341–9.
Ellero S, Chakhtoura G, Barreau C, Langouet S, Benelli C, Penicaud L, et al. Xenobiotic-metabolizing cytochromes p450 in human white adipose tissue: expression and induction. Drug Metab Dispos. 2010;38(4):679–86. doi:10.1124/dmd.109.029249.
Brill MJ, Diepstraten J, van Rongen A, van Kralingen S, van den Anker JN, Knibbe CA. Impact of obesity on drug metabolism and elimination in adults and children. Clin Pharmacokinet. 2012;51(5):277–304. doi:10.2165/11599410-000000000-00000.
Snawder JE, Roe AL, Benson RW, Roberts DW. Loss of CYP2E1 and CYP1A2 activity as a function of acetaminophen dose: relation to toxicity. Biochem Biophys Res Commun. 1994;203(1):532–9. doi:10.1006/bbrc.1994.2215.
Murphy R, Swartz R, Watkins PB. Severe acetaminophen toxicity in a patient receiving isoniazid. Ann Intern Med. 1990;113(10):799–800.
Abernethy DR, Greenblatt DJ. Ibuprofen disposition in obese individuals. Arthritis Rheum. 1985;28(10):1117–21.
Abernethy DR, Divoll M, Greenblatt DJ, Ameer B. Obesity, sex, and acetaminophen disposition. Clin Pharmacol Ther. 1982;31(6):783–90.
Abernethy DR, Greenblatt DJ, Divoll M, Shader RI. Enhanced glucuronide conjugation of drugs in obesity: studies of lorazepam, oxazepam, and acetaminophen. J Lab Clin Med. 1983;101(6):873–80.
Bentley JB, Borel JD, Vaughan RW, Gandolfi AJ. Weight, pseudocholinesterase activity, and succinylcholine requirement. Anesthesiology. 1982;57(1):48–9.
Tanaka E, Yamazaki K, Misawa S. Update: the clinical importance of acetaminophen hepatotoxicity in non-alcoholic and alcoholic subjects. J Clin Pharm Ther. 2000;25(5):325–32.
Vuilleumier N, Rossier MF, Chiappe A, Degoumois F, Dayer P, Mermillod B, et al. CYP2E1 genotype and isoniazid-induced hepatotoxicity in patients treated for latent tuberculosis. Eur J Clin Pharmacol. 2006;62(6):423–9. doi:10.1007/s00228-006-0111-5.
Salazar DE, Schentag JJ, Corcoran GB. Obesity as a risk factor in drug-induced organ injury. V. Toxicokinetics of gentamicin in the obese overfed rat. Drug Metab Dispos. 1992;20(3):402–6.
Jesudason DR, Clifton P. Interpreting different measures of glomerular filtration rate in obesity and weight loss: pitfalls for the clinician. Int J Obes (Lond). 2012;36:1421–7. doi:10.1038/ijo.2011.242.
Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. N Engl J Med. 2002;347(5):305–13. doi:10.1056/NEJMoa020245.
Abrass CK. Overview: Obesity: what does it have to do with kidney disease? J Am Soc Nephrol. 2004;15(11):2768–72. doi:10.1097/01.ASN.0000141963.04540.3E.
Lavie CJ, Mehra MR, Milani RV. Obesity and heart failure prognosis: paradox or reverse epidemiology? Eur Heart J. 2005;26(1):5–7. doi:10.1093/eurheartj/ehi055.
Praga M. Obesity—a neglected culprit in renal disease. Nephrol Dial Transplant. 2002;17:1157–9.
Amann K, Benz K. Structural renal changes in obesity and diabetes. Semin Nephrol. 2013;33:23–33. doi:10.1016/j.semnephrol.2012.12.003.
Penzak SR, Gubbins PO, Rodvold KA, Hickerson SL. Therapeutic drug monitoring of vancomycin in a morbidly obese patient. Ther Drug Monit. 1998;20:261–5.
Salazar DE, Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from estimated fat-free body mass. Am J Med. 1988;84(6):1053–60.
Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31–41.
Winter MA, Guhr KN, Berg GM. Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation. Pharmacotherapy. 2012;32(7):604–12. doi:10.1002/j.1875-9114.2012.01098.x.
Cho S-J, Yoon I-S, Kim D-D. Obesity-related physiological changes and their pharmacokinetic consequences. J Pharm Investig. 2013;43(3):161–9. doi:10.1007/s40005-013-0073-4.
McLeay SC, Morrish GA, Kirkpatrick CM, Green B. The relationship between drug clearance and body size: systematic review and meta-analysis of the literature published from 2000 to 2007. Clin Pharmacokinet. 2012;51(5):319–30. doi:10.2165/11598930-000000000-00000.
Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998;54:621–5.
Dvorchik BH, Damphousse D. The pharmacokinetics of daptomycin in moderately obese, morbidly obese, and matched nonobese subjects. J Clin Pharmacol. 2005;45:48–56. doi:10.1177/0091270004269562.
Pai MP, Norenberg JP, Anderson T, Goade DW, Rodvold KA, Telepak RA, et al. Influence of morbid obesity on the single-dose pharmacokinetics of daptomycin. Antimicrob Agents Chemother. 2007;51:2741–7. doi:10.1128/AAC.00059-07.
Yee JY, Duffull SB. The effect of body weight on dalteparin pharmacokinetics. A preliminary study. Eur J Clin Pharmacol. 2000;56:293–7.
Barras MA, Duffull SB, Atherton JJ, Green B. Modelling the occurrence and severity of enoxaparin-induced bleeding and bruising events. Br J Clin Pharmacol. 2009;68:700–11. doi:10.1111/j.1365-2125.2009.03518.x.
Willett KC, Alsharhan M, Durand C, Cooper MR. Dosing of enoxaparin for venous thromboembolism prophylaxis in obese patients. Ann Pharmacother. 2013;47:1717–20. doi:10.1177/1060028013507902.
Bauer LA, Wareing-Tran C, Edwards WA, Raisys V, Ferreri L, Jack R, et al. Cimetidine clearance in the obese. Clin Pharmacol Ther. 1985;37:425–30.
Abernethy DR, Greenblatt DJ, Matlis R, Gugler R. Cimetidine disposition in obesity. Am J Gastroenterol. 1984;79:91–4.
Chyka PA, Seger D, Krenzelok EP, Vale JA, AACT, EAPCCT. Position paper: single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61–87.
McNamara RM, Aaron CK, Gemborys M, Davidheiser S. Efficacy of charcoal cathartic versus ipecac in reducing serum acetaminophen in a simulated overdose. Ann Emerg Med. 1989;18(9):934–8.
Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol. 1999;37(6):731–51.
Krag E, Hojgaard L. Bile acid metabolism after intestinal bypass operations. Int J Obes. 1981;5(5):519–25.
Dunning K, Plymyer MR. Charcoal peritonitis causing chronic pelvic pain: a unique complication following bariatric surgery. Obes Surg. 2006;16(9):1238–42. doi:10.1381/096089206778392121.
Van Dinter Jr TG, John L, Guileyardo JM, John SF. Intestinal perforation caused by insertion of a nasogastric tube late after gastric bypass. Proc (Baylor Univ Med Cent). 2013;26(1):11–5.
Appelboam AV, Dargan PI, Knighton J. Fatal anaphylactoid reaction to N-acetylcysteine: caution in patients with asthma. Emerg Med J. 2002;19(6):594–5.
Prizont R. Medical officer review: acetadote. FDA Center for Drug Evaluation and Research: Office of Drug Evaluation. 2003. http://www.accessdata.fda.gov/drugsatfda_docs/nda/2004/21-539_Acetadote_Medr.pdf. Accessed 16 May 2015.
Duncan R, Cantlay G, Paterson B. New recommendation for N-acetylcystiene dosing may reduce incidence of adverse effects. Emerg Med J. 2006;23(7):584. doi:10.1136/emj.2005.031104.
Intralipid [package insert]. Deerfield: Baxter Healthare Corporation; 2007.
Methylene blue [package insert]. Lake Forest: Akorn, Inc.; 2008.
El-Solh A, Sikka P, Bozkanat E, Jaafar W, Davies J. Morbid obesity in the medical ICU. Chest. 2001;120(6):1989–97.
Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med. 2008;36(1):151–8. doi:10.1097/01.CCM.0000297885.60037.6E.
Bercault N, Boulain T, Kuteifan K, Wolf M, Runge I, Fleury JC. Obesity-related excess mortality rate in an adult intensive care unit: a risk-adjusted matched cohort study. Crit Care Med. 2004;32(4):998–1003.
Tremblay A, Bandi V. Impact of body mass index on outcomes following critical care. Chest. 2003;123(4):1202–7.
Funding
The authors have no funding to report in relation to this study.
Conflict of Interest
The authors declare that they have no competing interests.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Zuckerman, M., Greller, H.A. & Babu, K.M. A Review of the Toxicologic Implications of Obesity. J. Med. Toxicol. 11, 342–354 (2015). https://doi.org/10.1007/s13181-015-0488-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13181-015-0488-6