Townhall: Assisting Patients Post Bariatric Surgery Katie McClendon, PharmD, BCPS, FCCP University of Mississippi School of Pharmacy

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1 Townhall: Assisting Patients Post Bariatric Surgery Katie McClendon, PharmD, BCPS, FCCP University of Mississippi School of Pharmacy Annual Meeting & Exposition Seattle, Washington March 22 25

2 Disclosures Dr. McClendon has nothing to disclose 2

3 CPE Information Target Audience: Pharmacists ACPE#: L01 P Activity Type: Knowledge based 3

4 Learning Objectives 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 4

5 Assessment Question 1. Which type of surgery is considered the most effective for weight loss? A. Gastric band B. Sleeve C. Gastric bypass D. Electrical stimulation system 5

6 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 protein B. A female patient should avoid pregnancy indefinitely C. A patient can continue to act the same as before; the surgery will be all that s needed to lose weight D. A patient needs close follow up in the weeks after surgery, but after 3 6 months can follow up with primary care only 6

7 Assessment Question 3. Which of the following vitamins is most likely to become deficient after bariatric surgery? A. Vitamin K B. Vitamin B6 C. Vitamin E D. Vitamin B12 7

8 Assessment Question 4. Which of the following should be avoided post gastric bypass? A. contraceptives B. antidepressants C. multivitamins D. NSAIDs 8

9 Self Reported Obesity in the US (2017) Overweight & Obesity. Centers for Disease Control and Prevention. 12 Sept. 2018, 9

10 10

11 Qualifying for Surgery Surgery an option for: Body mass index (BMI) >40 kg/m 2 OR BMI >35 kg/m 2 with at least 1 obesity comorbidity, including: Obstructive Sleep Apnea (OSA) Type 2 diabetes mellitus (DM) Hypertension (HTN) Hyperlipidemia Mechanick JI et al. Endocr Pract. 2013; 19: Jensen MD et al AHA/ACC/TOS Guideline. Circulation 2014; 129: S102 S

12 Types of Surgery* *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) 12 Image courtesy of PCORnet

13 Setting Expectations Restrictive procedures: LAGB and VSG Restrictive and malabsorptive: RYGB and biliopancreatic diversion with duodenal switch (BPD DS) RYGB: gastric capacity ml and bypass of proximal small intestine ( 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 Edwards A, Ensom MHH. Ann Pharmacother 2012; 46: Smith A et al. Am J Health Syst Pharm. 2011; 68: Darwich AS et al. Br J Clin Pharmacol. 2012; 74: Jensen MD et al AHA/ACC/TOS Guideline. Circulation 2014; 129: S102 S

14 Sweedish Obese Subjects (SOS) Study 2010 patients matched to 2037 usual control patients 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: Sjostrom L et al. N Engl J Med. 2007; 357: Sjostrom L et al. JAMA. 2012; 307:

15 Pharmacist s Role in Clearance Pre Op Peri Op Post Op 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 Mechanick JI et al. Endocr Pract. 2013; 19:

16 16

17 Life After Surgery 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 Mechanick JI et al. Endocr Pract. 2013; 19: Bland CM, et al. Am J Health Syst Pharm. 2016; 16:

18 Changes in GI Physiology: Pharmacokinetic Principals in Bariatric Surgery 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 Edwards A, Ensom MHH. Ann Pharmacother 2012; 46: Smith A et al. Am J Health Syst Pharm. 2011; 68: Darwich AS et al. Br J Clin Pharmacol. 2012; 74:

19 Roux en Y Bypass (RYGB) Medication Consideration Principals 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 Miller AD, Smith KM. Am J Health Syst Pharm. 2006; 63: Smith A et al. Am J Health Syst Pharm. 2011; 68:

20 Fewer Chronic Medications Cohort of 6,235 bariatric surgery patients with Blue Cross/Blue Shield ( ) 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 Segal JB et al. Obes Surg. 2009; 19:

21 Fewer Rx Meds, but 21

22 Nutritional Complications in RYGB Common: Vitamin B12 deficiency Iron deficiency Thiamin deficiency Less common: Severe malnutrition Fat malabsorption Folate deficiency Fat soluble vitamin deficiency Calcium deficiency Malinowski S. Am J Med Sci. 2006; 331 (4):

23 Nutritional Supplementation Monitoring Insufficient evidence to monitor: essential fatty acid, vitamin E, vitamin K Monitor with all surgeries: iron, vitamin B 12 RYGB: folic acid, iron studies, 25 vitamin D, parathyroid monitoring Mechanick JI et al. Endocr Pract. 2013; 19:

24 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 mg/day Increased risk for osteoporosis: ensure calcium/vit D (minimum of 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 B Mechanick JI et al. Endocr Pract. 2013; 19:

25 Supplementation Comparison Multivitamin with Minerals (including iron, folic acid, thiamine) Calcium citrate LAGB LSG RYGB 1 daily 2 daily 2 daily mg/day divided doses mg/day divided doses 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 mg Total daily dose mg Mechanick JI et al. Endocr Pract. 2013; 19:

26 Minicase 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? 26

27 What medication changes are needed? poll.ev.com/katiemcclend457 27

28 Questions to ask 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? 28

29 My recommendations 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 29

30 Learning Objectives Review 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 30

31 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 31

32 Closing Remarks/Conclusions Important to have a team approach to bariatric surgery May provide care and expertise: Pre Op Peri Op Post Op Some medications may need to be changed after surgery Nutritional supplement needs will change 32

33 Assessment Question 1. Which type of surgery is considered the most effective for weight loss? A. Gastric band B. Sleeve C. Gastric bypass D. Electrical stimulation system 33

34 Assessment Question 1. Which type of surgery is considered the most effective for weight loss? A. Gastric band B. Sleeve C. Gastric bypass D. Electrical stimulation system 34

35 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 protein B. A female patient should avoid pregnancy indefinitely C. A patient can continue to act the same as before; the surgery will be all that s needed to lose weight D. A patient needs close follow up in the weeks after surgery, but after 3 6 months can follow up with primary care only 35

36 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 protein B. A female patient should avoid pregnancy indefinitely C. A patient can continue to act the same as before; the surgery will be all that s needed to lose weight D. A patient needs close follow up in the weeks after surgery, but after 3 6 months can follow up with primary care only 36

37 Assessment Question 3. Which of the following vitamins is most likely to become deficient after bariatric surgery? A. Vitamin K B. Vitamin B6 C. Vitamin E D. Vitamin B12 37

38 Assessment Question 3. Which of the following vitamins is most likely to become deficient after bariatric surgery? A. Vitamin K B. Vitamin B6 C. Vitamin E D. Vitamin B12 38

39 Assessment Question 4. Which of the following should be avoided post gastric bypass? A. contraceptives B. antidepressants C. multivitamins D. NSAIDs 39

40 Assessment Question 4. Which of the following should be avoided post gastric bypass? A. contraceptives B. antidepressants C. multivitamins D. NSAIDs 40

41 Townhall: Assisting Patients Post Bariatric Surgery Katie McClendon, PharmD, BCPS, FCCP University of Mississippi School of Pharmacy Annual Meeting & Exposition Seattle, Washington March 22 25

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