Nutrients and Drugs Considerations after Bariatric Surgeries

Transcription

1 Nutrients and Drugs Considerations after Bariatric Surgeries Marwan Akel, Pharm D Clinical AssistantProfessor School of Pharmacy Lebanese International University

2 Overweight and Obesity Prevalence 2013 Institute for Health Metrics and Evaluation (IHME), 2013

3 Mtbli/B Metabolic/Bariatric iti Surgery Worldwide Obesity Surg (2013) 23:

4 Purely Restrictive ti Procedure Laparoscopic p Adjustable Gastric Banding (LAGB) Atlas of Metabolic and Weight Loss Syrgery, Jones et al. Cine Med, 2010.

5 Mil Mainly Restrictive ti Procedures Laparoscopic Sleeve Gastrectomy (SG) Roux en Y gastric bypass (RYGB) Atlas of Metabolic and Weight Loss Surgery, Jones et al. Cine Med, 2010.

6 Pi Primarily il Mlb Malabsorptive Procedure Biliopancreatic Diversion(BPD) Atlas of Metabolic and Weight Loss Syrgery, Jones et al. Cine Med, 2010.

7 Considerations Nutrients Drugs/Diseases

8 Clinical i l Scenario 1 Which of the following case scenarios require the administration of multivitamin/ multimineral supplements? A. Patients who received restrictive procedures B. Patients who received biliopancreatic diversion C. Patients who received gastric bypass D. All patients that have received bariatric procedures

9 2013 Guideline USA Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery 2014 Review Article Germany Review Article: the Nutritional and Pharmacological Consequences of Obesity Surgery Stein, J. et al. AP & T: Alimentary Pharmacology and Therapeutics. July 2014 Endocr Pract Mar Apr;19(2):

10 PROTEIN Low intake after all types of surgeries Weakness/ Decreased muscle mass/ Brittle hair/ Edema g/day Recommendation Dairy, Fish, Eggs and Meat Oral protein shakes

11 CALCIUM / VITAMIN D Low bone density/ Osteoporosis/ Spasms/ Pain/ Paresthesia/ Arthralgia/ Depression Recommendation Oral calcium citrate: mg/day Oral Vit D: 800 U/day Or U/ 3 6 months All types of surgeries

12 MAGNESIUM VITAMIN B1 Muscle contraction/ Neurologic / Psychiatric / Pain/ Spasm/ Osteoporosis Cardiac / Skeletal Recommendation Recommendation Oral Mg citrate:300 mg/day Standard multivitamin If vomiting: 100 mg/day for 7 14 days All types of surgeries All types of surgeries

13 ZINC VITAMIN A Alopecia/ Dermatitis / Compromised immunity Loss of nocturnal vision / Compromised immunity / Itching Severe deficiency: Severe deficiency: 8 15 mg elemental oral zinc Orally IU/day for + 1 mg copper 14 days BPD, RYGB BPD, RYGB

14 ANEMIA Copper Iron Folic Acid Vitamin B 12

15 IRON VITAMIN B12 Fatigue Performance Low meat diet Depression Dementia Tingling Oral ferrous sulfate: 300 mg 2 3 times/day IV iron in severe deficiency Oral: 1000 mcg/week OR mcg/day IM: 1000 mcg/month OR 3000 mcg/6 months BPD, RYGB BPD, RYGB

16 FOLIC ACID COPPER Palpitation Fatigue Neural tube defect Leukopenia Numbness Poor wound healing Women of childbearing age: 1 mg/day Standard multivitamin Oral copper gluconate, oxide or sulfate: 2 mg elemental copper All types of surgeries BPD, RYGB

17 CONSIDERATIONS Nutrients Drugs/Diseases

18 Where Are We? W? No standardized dose adjustment algorithms Rare case reports showing contradictory results Limited it trials ti on drugs after surgery Scarce data on pharmacokinetics after bariatric procedures Effect on drug absorption is poorly understood Overall effect on drug metabolism and transport is not clear

19 General lrules Liquid or crushable formulations Palatability and adherence May take up to 2 months for the patient to swallow a pill No enteric coated or extended release formulations Erratic absorption Suppositories should be avoided Diarrhea and dumping syndrome

20 Review ACCP Review 2012 Review 2013 Managementof Patients Receiving Bariatric Surgery Vitamin, Mineral, And Drug Absorption following Bariatric i Surgery TheImpact of Bariatric Surgery Procedures on Type 2 Diabetes, Hyperlipidemia andhypertension Chan, L. et al.psap. Curr Drug Metab Nov;13(9): Hellenic J Cardiol 2013; 54:

21 Controlled Trials on Drug Bioavailability

22 Controlled Trials on Drug Bioavailability

23 Diabetes Mellitus Type II (DM II) Bariatric surgery appears to offer a novel endpoint: COMPLETE REMISSION # of patients Type of FBG pre FBG post surgery surgery surgery Mortality 154 morbidly obese DM II RYB 187 mg/dl 140 mg/dl Decrease from 28% to 10 years of follow up 9%

24 Diabetes Mellitus Type II (DM II) Oral sulfonylureas and meglitinides Discontinue postoperatively ti Hypoglycemia Metformin Sf Safest oral drug postoperatively ti No fluctuations in blood glucose Euglycemia and normal insulin levels occur Euglycemia and normal insulin levels occur within days after surgery

25 Hyperlipidemia id i Ttl Total cholesterol, l low density lipoprotein i and triglycerides: decreased High density lipoprotein: increased At 2 and 10 years after bariatric surgery Type of surgery # of patients Outcome SG 80 Tot Chol normalized in 34 % of patients Triglycerides normalized in 78% RYGB % of patients resolved or improved Statin dose reduced according to panel

26 Hypertension Bariatric i surgery offers: RESOLUTION/ IMPROVEMENT Meta analysis # ofpatients Outcome 52 studies Systolic BP reduced from 139 to 124 mm Hg Diastolic BP reduced from 87 to 77 mmhg Diuretics are the first class to be withheld to limit fluid depletion

27 Antidepressants t Article 2013 The Effect of Gastric Bypass on the Pharmacokinetics i of Serotonin Reuptake Inhibitors Reduced bioavailability 1 month after surgery AUC values dropped to an average of 54% Close psychiatric i monitoring i

28 Gastric Ulcerations Use of non steroidal anti inflammatory drugs Use of salicylates: Risks and benefits of daily ASA therapy should be considered on an individual basis Use of oral bisphosphonates: Calcitonin, synthetic parathyroid hormone [teriparatide], raloxifene and HRT ASA: Aspirin; HRT: Hormone Replacement Therapy Pandolfino, J. et al. MedGenMed. 2004; 6(2): 15.

29 Clinical i l Scenario 2

30 Role of Pharmacist Facilitate t the transition of drugs from: Postoperative Perioperative Preoperative Assuresuitable suitable dosage form selection, dose conversion/adjustment, monitoring Work closely with medical doctors and clinical dietitians to ensure the optimal outcome