Townhall: Assisting Patients Post Bariatric Surgery · •Identify the common bariatric procedures...

Annual Meeting & ExpositionSeattle, Washington | March 22‐25

Townhall: Assisting Patients Post‐Bariatric SurgeryKatie McClendon, PharmD, BCPS, FCCPUniversity of Mississippi School of Pharmacy

• Dr. McClendon has nothing to disclose

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Disclosures

• Target Audience: Pharmacists• ACPE#: 0202‐0000‐19‐048‐L01‐P• Activity Type: Knowledge‐based

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CPE Information

At the completion of this knowledge‐based activity, participants will be able to:• Identify the common bariatric procedures being performed on obese patients

• Summarize the lifestyle changes that bariatric surgery patients must make

• Discuss the medications and supplements that bariatric surgery patients must take

• Discuss dosing and absorption challenges in patients post bariatric surgery

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Learning Objectives

1. Which type of surgery is considered the most effective for weight loss?A. Gastric bandB. SleeveC. Gastric bypassD. Electrical stimulation system

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Assessment Question

2. Which statement best describes life after bariatric surgery?A. A patient’s diet is very different—they need to be sure they eat proteinB. A female patient should avoid pregnancy indefinitelyC. A patient can continue to act the same as before; the surgery will be all that’s

needed to lose weightD. A patient needs close follow up in the weeks after surgery, but after 3‐6

months can follow up with primary care only

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Assessment Question

3. Which of the following vitamins is most likely to become deficient after bariatric surgery?

A. Vitamin KB. Vitamin B6C. Vitamin ED. Vitamin B12

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Assessment Question

4. Which of the following should be avoided post gastric bypass?A. contraceptivesB. antidepressantsC. multivitaminsD. NSAIDs

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Assessment Question

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Self‐Reported Obesity in the US (2017)

Overweight & Obesity. Centers for Disease Control and Prevention. 12 Sept. 2018, https://www.cdc.gov/obesity/data/prevalence‐maps.html.

• Surgery an option for:• Body mass index (BMI) > 40 kg/m2

• OR BMI > 35 kg/m2 with at least 1 obesity co‐morbidity, including: • Obstructive Sleep Apnea (OSA)• Type 2 diabetes mellitus (DM)• Hypertension (HTN)• Hyperlipidemia

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Qualifying for Surgery

Mechanick JI et al. Endocr Pract. 2013; 19: 337‐372.Jensen MD et al. 2013 AHA/ACC/TOS Guideline. Circulation 2014; 129: S102‐S138.

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Types of Surgery*

Image courtesy of PCORnet

*Additionally, FDA has approved electrical stimulation system, gastric balloons, and gastric emptying system for weight loss.

Roux‐en Y Gastric Bypass (RYGB)

Vertical Sleeve Gastrectomy (VSG)

Laproscopic Adjustable Gastric Band (LAGB)

• Restrictive procedures: LAGB and VSG• Restrictive and malabsorptive: RYGB and biliopancreatic diversion with duodenal switch (BPD‐DS)• RYGB: gastric capacity 15‐30 ml and bypass of proximal small intestine (100‐200 cm removed, leaving 4‐5 m)

• Malabsorptive: biliopancreatic diversion (BPD), jejunoileal bypass (JIB); rarely (or never) still done

• Weight loss of 20‐35% at 2‐3 years; 16% at 10 years

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Setting Expectations

Edwards A, Ensom MHH. Ann Pharmacother 2012; 46: 130‐6.Smith A et al. Am J Health‐Syst Pharm. 2011; 68: 2241‐7.Darwich AS et al. Br J Clin Pharmacol. 2012; 74: 774‐87.

Jensen MD et al. 2013 AHA/ACC/TOS Guideline. Circulation 2014; 129: S102‐S138.

• 2010 patients matched to 2037 usual control patients

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Sweedish Obese Subjects (SOS) Study

Benefits:• Reduced cardiovascular (CV) deaths (hazard ratio [HR] 0.47, p=0.002); first CV events (HR 0.67, P<0.001) at 14.7 years

• Improved: diabetes, cancer, overall mortality

Risks:• 13% had post‐op complications: bleeding, embolism/thrombosis, wound /infections

• 90 day post‐ op death: 0.25% (surgery) vs. 0.1% (control)Sjostrom L et al. N Engl J Med. 2004; 351: 2683‐93.Sjostrom L et al. N Engl J Med. 2007; 357: 741‐52.

Sjostrom L et al. JAMA. 2012; 307: 56‐65.

• Remember: this is elective surgery• Glucose control • Lipid management• Avoid estrogen 3‐4 weeks pre‐surgery to reduce venous thromboembolism (VTE) risk

• May need VTE prophylaxis

• Cardiology clearance process may indicate need for CV risk reduction• Smoking cessation at least 6 weeks pre‐surgery• May need gout prophylaxis if history of gout

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Pharmacist’s Role in Clearance

Mechanick JI et al. Endocr Pract. 2013; 19: 337‐372.

Pre‐Op Peri‐Op Post‐Op

• Medications, meals, habits must change for success• Ensure protein intake, avoid alcohol• Dumping Syndrome

• Pregnancy considerations• Typically avoid pregnancy for 2 years• RYGB: avoid oral contraception; intrauterine device (IUD) may be best

• Obesity‐related complications often improve• Generally need ½ the DM‐related meds initially

• Psychiatric care/support groups• Long‐term follow‐up with surgery team

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Life After Surgery

Mechanick JI et al. Endocr Pract. 2013; 19: 337‐372. Bland CM, et al. Am J Health‐Syst Pharm. 2016; 16: 1230‐1242.

• Slowed gastric emptying time: reduced rate of drug absorption• pH increased—less absorption of acidic drugs/increased with basic drugs• Small intestine transit time decreased: extended release• Gastrointestinal metabolizing enzymes: cytochrome P450 (CYP) 3A4 most common in gut

• Decreased surface area: decreased effective absorption• Efflux transporters in gut bypassed: increase bioavailability of some meds

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Changes in GI Physiology: Pharmacokinetic Principals in Bariatric Surgery

Edwards A, Ensom MHH. Ann Pharmacother 2012; 46: 130‐6.Smith A et al. Am J Health‐Syst Pharm. 2011; 68: 2241‐7.Darwich AS et al. Br J Clin Pharmacol. 2012; 74: 774‐87.

• Increased risk for ulceration• Nonsteroidal anti‐inflammatory (NSAIDs), aspirin• Small gastric pouch may affect bisphosphonates

• If need, intravenous (IV) may be safer

• Decreased intestinal length in RYGB• Extended‐ or delayed‐release• Enteric‐ or film‐coated

• Other routes of administration may be needed• Especially contraception, Vitamin B12

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Roux‐en‐Y Bypass (RYGB) Medication Consideration Principals

Miller AD, Smith KM. Am J Health‐Syst Pharm. 2006; 63: 1852‐7. Smith A et al. Am J Health‐Syst Pharm. 2011; 68: 2241‐7.

• Cohort of 6,235 bariatric surgery patients with Blue Cross/Blue Shield (2002‐2005) • Mean age 44 years, 82% women, 34% had diabetes

• At 3 months:• DM: 55% reduction• HTN: 34% for those with DM; 59% for those without• Lipid: 55% with DM; 52% without

• At 12 months:• DM: 76% reduction• HTN: 51% reduction• Lipid: 59% reduction• Minimal change: thyroid, antihistamine, antidepressant use 20

Fewer Chronic Medications

Segal JB et al. Obes Surg. 2009; 19: 1646‐56.

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Fewer Rx Meds, but…

• Common:• Vitamin B12 deficiency• Iron deficiency• Thiamin deficiency

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Nutritional Complications in RYGB

• Less common: • Severe malnutrition • Fat malabsorption • Folate deficiency• Fat‐soluble vitamin deficiency

• Calcium deficiency

Malinowski S. Am J Med Sci. 2006; 331 (4): 219‐225.

Monitoring• Insufficient evidence to monitor: essential fatty acid, vitamin E, vitamin K•Monitor with all surgeries: iron, vitamin B12• RYGB: folic acid, iron studies, 25‐vitamin D, parathyroid monitoring

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Nutritional Supplementation


• RYGB/LSG patients should receive 2 multivitamins (MV) with iron, folic acid, and thiamine; 1 MV/day for LAGB• Chewable MV for first 3‐6 months• RYGB/LSG patients need total iron intake from all sources of 45‐60 mg/day

• Increased risk for osteoporosis: ensure calcium/Vit D (minimum of 1200‐1500 mg calcium/3000 international units vitamin D); monitor dual x‐ray absorptiometry (DXA)• Calcium citrate recommended• Treatment goal of 25‐hydroxyvitamin D levels >30 ng/ml

• Start with oral, but may need intranasal or parenteral B12

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Nutritional Supplementation


LAGB LSG RYGB

Multivitamin with Minerals(including iron, folic acid, thiamine)

1 daily 2 daily 2 daily

Calcium citrate 1200‐1500 mg/day divided doses

1200‐1500 mg/day divided doses

1200‐1500 mg/day divided doses

Vitamin D >3000 international units/day to therapeutic levels

>3000 international units/day to therapeutic levels

>3000 international units/day to therapeutic levels

Vitamin B12 As needed to normal range

As needed to normal range

As needed to normal range

Iron No recommendation Total daily dose 45‐60 mg Total daily dose 45‐60 mg

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Supplementation Comparison


• Patient reports to free clinic for med refills. She had gastric bypass about 15 years ago. Patient currently takes the following meds:• Venlafaxine XR 150 mg by mouth (PO) daily• Vitamin D (unknown regimen)• Hydrochlorothiazide 25 mg PO daily• Vitamin B12 intramuscularly (IM) monthly (1000 mcg?)The team is medicine students and they don’t know much about gastric bypass and need guidance. What should they do with her meds? What labs should be checked today?

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Minicase

• What medication changes are needed?• poll.ev.com/katiemcclend457

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• What surgery did the patient have? • Likely RnY given time of surgery and vitamin regimen

• Does the patient have Vitamin B12 deficiency? Or is this a prophylaxis dose?

• How is her mood? Is her depression/anxiety well controlled?• Is she taking anything else?• How does she feel after eating/taking medications?• What’s her blood pressure today?

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Questions to ask

• While venlafaxine XR is not likely actually extended release, since well controlled, don’t change

• Since had Vitamin B12 deficiency, continue IM B12 with regular monitoring

• Start a multivitamin with minerals 2 daily • Ensure adequate Vitamin D (3000 units) and calcium (1500 mg) supplementation

• Monitor blood pressure• Labs: Vitamin B12, folate, iron studies, 25‐vitamin D, intact parathyroid hormone (iPTH), complete blood count (CBC), complete metabolic panel (CMP), lipid panel, 24‐hour urinary calcium excretion

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My recommendations

• Identify the common bariatric procedures being performed on obese patients• RYGB, VSG, LAGB

• Summarize the lifestyle changes that bariatric surgery patients must make• Long‐term follow‐up and monitoring, dietary changes, pregnancy, mental health/support

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Learning Objectives Review

• Discuss the medications and supplements that bariatric surgery patients must take• Depends on surgery. Minimally: MV, calcium/Vit D. May need additional iron, Vitamin B12

• Discuss dosing and absorption challenges in patients post bariatric surgery• Extended release, pouch size, contraception, gastric pH changes

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Learning Objectives Review

• Important to have a team approach to bariatric surgery • May provide care and expertise:

• Some medications may need to be changed after surgery• Nutritional supplement needs will change

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Closing Remarks/Conclusions

Pre‐Op Peri‐Op Post‐Op


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Annual Meeting & ExpositionSeattle, Washington | March 22‐25

Townhall: Assisting Patients Post‐Bariatric SurgeryKatie McClendon, PharmD, BCPS, FCCPUniversity of Mississippi School of Pharmacy

Townhall: Assisting Patients Post Bariatric Surgery · •Identify the common bariatric procedures...

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