Help obese patients who underwent bariatric surgery adjust their medication

After ALL procedures, recommend using liquids, crushable tabs, or caps the patient can open for at least 4 weeks. Watch sweeteners in liquids.....
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

More obese patients will get BARIATRIC SURGERY and need help with their medications afterward. These procedures are becoming more accepted. They can lead to substantial weight loss, plus lower blood pressure, lipids, and glucose. Encourage patients to tell you about the type of surgery they had as different procedures affect drug therapy differently. Older procedures usually relied on BYPASS to limit absorption. Newer procedures RESTRICT food intake (gastric band, sleeve, etc) or are a COMBO of restriction and bypass (Roux-en-Y, etc).

          After ALL procedures, recommend using liquids, crushable tabs, or caps the patient can open for at least 4 weeks. Watch sweeteners in liquids, too much sugar, sorbitol, etc, can cause severe diarrhea. After healing, suggest using small pills or advise patients to split larger pills that could get stuck. After bypass surgery, recommend using immediate-release products and avoiding enteric-coated, delayed-release, or sustained-release products.

RECOMMENDATIONS
  • Hypertension, lipid, and diabetes medications. Suggest monitoring and adjusting doses as needed. Blood glucose often drops before weight loss.
  • Analgesics. Recommend acetaminophen. NSAIDs can cause ulcerations. Suggest adding a PPI if an NSAID is absolutely necessary.
  • Bisphosphonates. If needed, suggest IV Aclasta especially early after surgery. Save oral bisphosphonates (alendronate, etc) for patients without significant GI complications.
  • Contraceptives. Recommend nonoral contraceptives (Depo-Provera, etc) after bypass, but OCs are okay after restrictive-only procedures. Try to avoid using OCs with drospirenone or the Evra patch in obese women who are over 35 or smoke due to the higher clotting risk.
  • Warfarin. Doses often go DOWN after surgery then return to presurgery doses about 6 months later. Recommend monitoring INR more often until stable.
  • Vitamins and minerals. Emphasize the importance of daily supplements to prevent vitamin and mineral deficiencies.

REFERENCES

  • Chan L.N, Drug Therapy-Related Issues in Patients Who Received Bariatric Surgery (Part I). PRACTICAL GASTROENTEROLOGY (July 2010). Available at: https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/ChanArticle-July-2010.pdf

    Chan L.N, Drug Therapy-Related Issues in Patients Who Received Bariatric Surgery (Part II). PRACTICAL GASTROENTEROLOGY (August 2010). Available at: www.practicalgastro.com/pdf/August10/Chan_Part2_Article.pdf 

    Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis. 2013 Mar-Apr;9(2):159-91. Available at: https://pubmed.ncbi.nlm.nih.gov/23537696