Recent Topics

Absorption issues. **PLEASE READ**

TweedleDum
on 5/21/10 2:36 pm, edited 11/16/10 11:52 am - Hattiesburg, MS
vitalady
on 5/21/10 10:34 pm - Puyallup, WA
RNY on 10/05/94
Generally, we don't take anything that is SR, XR and so on.

With something simple like vicodin, it's rx every 6 hrs and I get precisely 4.try to get that every 4 hrs.

yes, we do malabsorb meds. the timed release type more so, of course.

Welbutrin comes in an IR, immediate release. So, I take the mg my doc wants, but *I* am the timed release. Try this:


Vol. No: 30:02 Posted: 2/22/05

The Skinny on Gastric Bypass
What Pharmacists Need to Know
Sarah A. Fussy, PharmD Candidate,
BS Pharm Sci, minor Nutrition Sci,
North Dakota State University
Status: post Lap Roux-En-Y 6/03/03

US Pharm. 2005;2:HS-3-HS-12.

http://www.uspharmacist.com/index.asp?show=article&page=8_1438.htm

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To Print: Click your browser's PRINT button.

NOTE: To view the article with Web enhancements, go to:
http://www.medscape.com/viewarticle/548664


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Ask the Experts about Pharmacotherapy

>From Medscape Pharmacists



How Does Bariatric Surgery Affect the Absorption of Medications?

Question

I have a patient who underwent gastric bypass surgery recently. I know that the absorption of medications could be affected by many factors pertaining to the gastrointestinal system. How does bariatric surgery affect the absorption of medications?



Response from Brigette Nelson, MS, PharmD,BCNP Director, Clinical Pharmacy Services, MSC-Medical Services Company, Jacksonville, Florida







The number of bariatric surgical procedures performed in the United States has risen dramatically, from an estimated 16,000 procedures in the early 1990s to about 103,000 in 2003.[1] The surgery may involve a restrictive procedure (ie, vertical-banded gastroplasty or adjustable gastric banding), or a combination of restrictive and malabsorptive procedures (ie, biliopancreatic diversion or Roux-en-Y gastric bypass). Roux-en-Y gastric bypass is the most frequently performed variety in the United States, and it involves forming a small stomach pouch to restrict food intake and then reconnecting the small intestine to the pouch.

Bypassing a large portion of the stomach and small intestine puts these patients at risk for malabsorption, and it also changes the absorption of some medications. Patients are prone to deficiencies in the fat-soluble vitamins (A, D, E, and K) and in calcium.[2,3] Thus, appropriate supplementation with iron, vitamin B12, calcium, and folate is an important consideration.[2,3] In some cases, parenteral iron infusion may be necessary to avoid anemia, particularly in menstruating women.[3]

Due to changes in the acidic environment and the reduced surface area for drug absorption, changes in drug delivery route or dose may be necessary to assure adequate drug concentrations. Avoiding extended-release formulations is recommended, due to their long absorptive phase in the intestine.[2,4] Immediate-release formulations with a more frequent dosing schedule may be required. It may be useful to use a liquid formulation to eliminate the drug absorption phase where possible.[2] Other routes, such as intramuscular, transdermal, subcutaneous, and inhalation, may be considered. However, it is also important to keep in mind the impact obesity may have on these routes of administration.[2]

The salt form of medications may also require consideration.[2,4] For example, calcium citrate does not require stomach acid for absorption and would be a more reasonable choice than calcium carbonate, which requires a higher acid concentration.[2,4]

Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral bisphosphonates should be avoided in this population, since these patients are at increased risk for ulceration due to the reduced stomach size.[2] Consider using alternatives for pain relief, such as acetaminophen, tramadol, and/or opiates. Likewise, alternatives for osteoporosis prevention can be used.[2]

For gastric bypass patients, it is thus appropriate to regard these factors:
route of drug administration, salt formation, monitoring of medication blood levels to assure therapeutic concentrations, and appropriate nutrient and vitamin supplementation. As indicated, the impact of obesity and changes in lean body mass may also be important considerations when choosing drug form and dose.[2,5]



Posted 12/18/2006




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References
1.. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004:292:1724-1737. Abstract
2.. Miller AD, Smith KM. Medication and nutrient administration considerations after bariatric surgery. Am J Health-Syst Pharm.
2006;63:1852-1857.
3.. Virji A, Murr MM. Caring for patients after bariatric surgery.
Am Fam Physician. 2006;73:1403-1408. Abstract
4.. Fussy SA. The skinny on gastric bypass: what pharmacists need to know. US Pharm. 2005;2:HS-3-HS-12.
5.. Malone M. Altered drug disposition in obesity and after bariatric surgery. Nutr Clin Pract. 2003;18:131-135. Abstract
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Clinical Consultation
Medication and nutrient administration considerations after bariatric surgery
April D. Miller and Kelly M. Smith

American Journal of Health-System Pharmacy, Vol. 63, Issue 19,
1852-1857
Copyright © 2006 by American Society of Health-System Pharmacists

http://www.ajhp.org/cgi/content/full/63/19/1852



Great article for all to read about pill absorption -

~~~~~~~~~~~~~~~~
http://www.aboutmso.com/faq/faq.cfm

FROM ABOVE LINK How does the gastric bypass affect the absorption of medications?
Most medications absorb normally. The exceptions to this are birth control pills, hormone replacement medication, and certain sustained release (slow release) medications.


Michelle
RNY, distal, 10/5/94 

P.S.  My year + long absence has NOTHING to do with my WLS, or my type of WLS. See my profile.

Miss_Kitty
on 5/22/10 3:41 am - New Bedford, MA
Reading your post has probably answered my just recent post...............

Post Surgical Depression.

I have been post-op for 3 months.  How long did you go through spouts of depression and anxiety?  My psych doc wanted me to go on Klonopin also, but I told him no since I am already on Ativan and am afraid I may be developing a dependence for it. (which I am not happy about) I don't want to go the antidepressant route. I did that years ago and couldn't find one that I could really tolerate.  It's depressing that we try to do something positive for our bodies.......then have to struggle with this???  I have lots of aches and pains and the docs say everything is fine and normal.  I don't think so!  They just don't want to do the work!  Although I haven't gone through all you have been through, I have been going through my share of aches and pains and sufering and endless fighting with doctors who seem to not want to listen or believe me either!  I am allergic to Tylenol and and most other pain meds and I can't take Asprin or Motrin because I am on blood thinners. The only thing I really can take is Dilaudid, which is a narcotic and doctors won't prescribe that to me.  I don't want to "get high" eather.............I just want the pains to stop!

I feel your pain and hear your tears, sister!  Here is a hug(((((())))))  and I will say a prayer for you too.  

Take care and God bless.

Do you see the glass as half empty or half full? I say, what difference does it make--I paid for a full glass,so either way I am getting jipped!!!

TweedleDum
on 5/22/10 8:07 am - Hattiesburg, MS
Cicerogirl, The PhD
Version

on 5/23/10 12:10 pm - OH
Just a quick note that Lortab is available in a liquid form and I have not had any problem with absorption of that (whereas I *have* noticed that pain meds in pill form are not as effective since my RNY).

I think it really depends on where the drug is absorbed in the intestine because I ahve had trouble with pain meds and antidepressants not absorbing well but my synthroid and coumadin doses have not had to be changed.

Lora

 7 years out and maintaining 190 pounds lost!  

“You don't drown by falling in the water.  You drown by staying there.”

 

Wendy M.
on 5/25/10 10:41 am - South Milwaukee, WI
RNY on 02/28/05 with
I can't provide much help with the pain issues but I too suffer from depression and anxiety. I am 5 years post-op and have found that I have the best results using tablet forms of meds (not the capsules). Capsuls seem to go right through me and the meds never make it outside the capsule into my system. I tried liquid prozac but the taste was so awful I could not keep it down. So I am on the prozac tablets for depression (I give them a quick chew just before swallowing) and trazadone and xanax tablets for sleep & anxiety. If I have anxiety during the day, I just break off a small piece of the xanax to chew and swallow. My family doc will not prescribe the meds so I go to a psychiatrist form them.

Hope this helps.

Wendy

 
special kay
on 5/25/10 3:56 pm - Ladson, SC
I'm going thought a similar situation. I am on depression meds and they work for a while then they stop. My Dr decided to try liquids because we absorb liquids better. Since she did that, my iron is up, my CBC is up and I feel much better with my depression and anxiety. Like you, I started out of Prozac then tried several other depression meds and doctors and psychs just didn't believe me. I've tried several sleep meds and they work for a while then stop.

I am so happy that they thought thought of liquid Prozac. I am praying that it works better than pill form.
     ~*Kay*~
 
450/388/173/175   
http://s6.photobucket.com/albums/y217/Special-Kay/ <~~ Look!! 

Carol S.
on 5/26/10 9:08 pm - Milwaukee, WI
As an FYI, some people WLS or not who just cannot metabolize opiods.

If you never got any relief you may want to look into that.

As far as your back issues, I would think that they would want to do and MRI to find the cause of the pain and not just medicate it.

I hope you find answers.  That must be incredibly frustrating.
Desiree N.
on 6/28/10 1:03 pm - Marietta, GA
I am so glad I found your post. I have been experiencing similar issues and I almost 8 years out from my RNY.  I have a supersensitivity to many medications and it's like pulling teeth to get some of these doctors to believe you regarding meds.

I have had to be on antidepressants since this surgery due to all my hormonal changes.  I could never take the SSRIs,  surprisingly  Wellbutrin XL works well for me.  However, I have had some major stressors in my life and the Wellbutrin does raise my anxiety levels.  These doctors are so afraid  that you will sue them if you get addicted to the Xanax or other sedatives it's like pulling teeth to get pain pills or anti-anxiety meds.

I also have found that my serum iron levels are normal, but my ferritin is at such a low normal that I can barely function. I actually had a gatekeeping nurse at Emory's hematology department refuse to see me because she said my labs looked normal. The only reason I called them is because I had my RNY there.  However, i should of known better since Emory almost killed me during my gastric bypass. 

Since the surgery, I have struggled with low iron.  I have found some chewable irons, but the only thing that really helped me was iron injections when I was having plastic surgery but getting a regular PCP to help you out with that is slim to none as all they know to prescribe is ferrous sulfate which we don't really absorb and it is not kind to the intestin A hematologist is darn near impossible because they only seem to want to attend to their cancer patients. Lately, it feels like all these physicians think I'm a hysterical female.  Some have gotten annoyed because I am armed with information before I even enter the office.  I've been so frustrated which doesn't aid in my anxiety. 

I also do not show up as anything wrong on tests.  I do know the iron seems to be the connection with my anxiety, depression and pain symptoms.  I have had to employ a heavy vitamin regimen and have been starting to feel better on my own.  I have found that if I supplement bromelain, tender irons, vitamin c, e and fish oils in the morning my moods become more manageable. It also helps with the imflammation from my arthritis and tendonitis.   

I try to supplement calcium, magnesium and potassium in the evening before bed.  This was a result of chronic leg cramps that just would not stop.  The E, magnesium and tonic water started to ease this.  It also helps with the chronic constipation from the high protein and wellbutrin.   I  am starting to supplement tumeric and some other supplements for adrenal support.   You might want to start researching alternative healing therapies.  Many of these issues I have noticed seemed to reflect adrenal stress as well, and adrenal rarely show up in any test.  

I notice a great connection to the mineral/vitamin depletions in my moods and my pain issues.   I also since this surgery have never slept well.  I have had so many in addition to the RNY it really has taken a toll on me.  I have found that KAVA KAVA and melatonin have been a good source to take at night as well.  Many of these minerals do work in combination with each other.  Magnesium, calcium, melatonin and Kava Kava have sedating qualities.     

What is a real downer with this procedure is that docs don't tell you that your digestive system is the system that is your immune system.   WIth the altered absorption it really has a profound effect at least I think for me with regards to meds, diseases, and tolerances to infections.

I am at the point myself where I am ready to go to medical school.    The medical community offers these procedures yet follow-up care is irresponsible.  The disease model of health-care is yet another factor that is wrong with the current system.   The disease model doesn't work for a patient who no longer has obesity as the disease. 

Good luck. I hope this helps you.

Desiree Novajosky, Esq.
4/7/03 RNY

heritagerotts
on 11/1/14 1:07 pm

I have just joined this group and not sure why I didn't reach out way before now? But i had my surgery about 20 years ago so i am one of the beginners i guess you could say? I have had so many issues over the last 10 years such as iron issues and have had about 3 iron infusions over the last 4 or 5 years now. I have confusion and fatigue that is so depressing i don't leave my house. I am not on a anti depressant but am thinking i should be? I also have been reading some people have had a revision i am now asking if any one has had this done and how you are feeling? I am so tired of spending money on supplements that i don't really think i am absorbing and natro paths that help at first but then i start feeling crappy again a few months into treatment. Any advise would be greatly appreciated! I am in Michigan thanks Tammy

thathaway66
on 8/25/10 9:07 pm - Crestview, FL
Hi, I am 8 years post-op from an RNY Gastric Bypass surgery. I had my surgery done out-of-state, so I've never had follow-ups with the surgeon since I was released from the hospital. I've gone through a few internal specialists trying to find one that is up-to-date on the after-care of post-bariatric patients. I take B-12 supplements intravenously and I also take ferrous sulfate and a generic vitamin supplement.  I continue to be severely anemic and have even undergone a blood transfusion. I was also diagnosed with anxiety and have been on Celexa at the highest dosage (40mg/twice daily) for over 4 years.  I don't think my Celexa is working anymore due to the stress of my recent situation. Two months ago I started having severe back pain. An MRI showed a synovial cyst between L4-L5, a bulged disc, spinal stenosis and osteoarthritis. In the last 2 months the pain has progressed at an alarming rate, to the point of my BP averaging 170's/100's. Since the 12th of July I have received 30 Lortab5, 150 Lortab10 (60 given for surgery I had on my wrist on 15July), and 60 Percocet10/650. The Lortabs last for 2 hours max and the Percocets barely touched the pain. I am currently waiting to see a surgeon/pain specialist on 9Sept, however, I saw my PCP today. I asked to go back to the Lortab10. Even though they only last 2 hours, it was better than nothing at all. In addition, they drug tested me. My results were negative for any drugs, even the pain meds. I had taken my last percocet approx. 30 hours prior. My PCP is keeping me as a patient, given my unique situation, however his office manager told me that they could no longer prescribe me any pain meds because apparently I had taken too many and my urine showed I had none in my system. I was totally embarrassed and humiliated. I know I took my medicine and I know that the usual dosage is not effective for me, but I can't convince the doctor's office of that. Now granted, I live in FL where docs are being arrested all the time for prescribing pain meds, so I understand the office's position, but I feel that I am not being treated fairly because of my malabsorption problem is not being taken as a serious factor. I actually started crying hysterically at the docs office and couldn't stop crying for 2 hours. I have 3 children (1, 2, and 8 years old) that depend on me, and I am in so much pain I can barely stand/walk. Even sitting is painful for me. I whimper or cry out every time I roll over in my bed at night, because that sends radiating pain up my spine. So, right now I am at a complete loss as to what to do. I'm hoping when I see the pain specialist that they will be able to provide me with alternative treatments for my pain relief. I am open to any suggestions other than medicinal. However, from past experiences, steroid shots do not work on me either. Now I am worried that my docs office will contact the pain specialist and tell him about my pain med and drug test issues. So, when I go the specialist and tell him I don't want steroid injections, he's just going to think I am a pain meds seeker, which I am not, I am a seeker for pain relief, in whatever form works best. I'm going to call my bariatric surgeon tomorrow to explain my situation and try to get documentation/recommendations for my situation. My question is, are there any other sources I can turn to for help. It is not my fault that the pain meds they gave me were ineffective and I had to consume more than your average person. It is also not my fault that my drug test came up negative for any narcotics. I've been labeled as a drug seeker and distributor, when in fact I am not. Do you know of other post RNY patients experiencing similar problems? Are there any official/professional documentation supporting the facts about my current malabsorption dilemma? Is there anyone that can recommend what meds/doses are more efficient for me. I am at my wits end and ANY HELP and understanding I can get would be extremely appreciated. Thank You! Tabitha
Tabitha