Need some advice

My daughter who had WLS in March of 2007 has asked me to make her an appointment to go to the PCP to see about being put back on anti-depressants.   She had been on them a few years ago but went off them at least a year prior to her surgery.  What I am wondering is which anti-depressent works well for WLS patients.   She was on Effexor XR before and I am not sure that is an option again, beside that it caused horrible weight gain and that is that last thing that she needs.  She hasn't been able to reach goal and has been loosing very slowly and I think that is also part of the depression issue.     I sure would appreciate any suggesting of what seems to work for everyone.  She has an appointment tomorrow morning.  Sorry about the short notice.  Thanks Sally

you would really want to check with the weight loss surgeon as well to make sure it wont hinder that process as well , just a thought

Hi. I was on Effexor XR prior to surgery but switched to the non-time released version two weeks prior to surgery.  I've been taking Effexor and Wellbutrin for several years without a weight gain issue.  There are plenty of othe alternatives if her and her doctor doesn't feel this is the right option. I wish her the best. Depression has to be the worsed feeling ever. Dominique

Sally:

Hello, welcome and thanks for bringing this up for the board. It is a great topic and reminder for long-term postops and great for newbies and preops as well!
There are several things to consider and one list is not really possible. I will include in this post several articles to further support furthering understanding for those interested in this area.


FIRST has she had a full set of labs with al her vitamin and mineral levels?

Does she exercise? This is the safest andtidepressant any of us can naturally get!

Especially look for: Vit D, B12, Folate, anemia's & Thiamine deficiencies (is she taking a good multivitamin? Sublingual B12 or IM B12? oral is not absorbed due to bypass) a B complex? Calcium citrate? Iron (ferrous gluconate, ferrous fumarate, polysaccharide iron, carbonyl iron are more tolerated better absorbed usually)

Here is a typical lab slip we get each 3, 6, 12 months as indicated!
COMPREHENSIVE METABOLIC PROFILE
LIPID PROFILE
GGT, LDH, Prealbumin
PHOSPHORUS - INORGANIC, URIC ACID
CBC w/ diff
B-12 & FOLATE, B-6 & Thiamine (B-1)
IRON, TIBC, % SAT, FERRITIN
VITAMIN A, E & D (25-hydroxy)
THYROID PANEL (T3, T4, TSH)*only initially unless suspect.
ZINC, MAGNESIUM, Selenium, Copper
SERUM INTACT PTH
Homocystine, MMA *to assist if needed in B12 deficiency
HGB A1C (only if diabetic or suspected)
DEXA SCAN every 1-2 years depends on results!
Diagnosis:
579.3 post-surgical malabsorption
268 vitamin D deficiency
269.2 hypovitaminosis
268.2 metabolic bone disease
244.9 hypothyroidism

Effexor in many leads to wt loss more so than gain, but some can gain on it in my personal prescribing experience.

Absorption of medications and nutrition due to bypassing stomach and intestines to some extent affects many things. This is not necessarily about what to avoid more than what will be absorbed.

~So sustained release medications are of concern potentially. Sustained released meds can not be broken, opened, crushed as they can lose the effectiveness if broken, cut or crushed, so either do not cut it or skip it, because really by cutting it you are skipping it or it could be harmful! Additionally; sustained release medications may not be as effective or effective at all after gastric bypass, as they are meant to need acid (which we do not have to any extent in our tiny tummies) to break them down and to be absorbed lower in the intestines (which we have around 3-4 feet bypassed). Unfortunately, there is not enough literature out or research in this area to know exactness, it is purely anecdotal. 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.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. 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. When available/indicated monitoring of medication blood levels to assure therapeutic concentrations can be helpful.

Here are a few articles on Wls and med articles absorption
#1 Clinical Consultation
Medication and nutrient administration considerations after bariatric surgery by 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

#2 Ask the Experts about Pharmacotherapy
From Medscape Pharmacists
How Does Bariatric Surgery Affect the Absorption of Medications?
*you will need to register for free to use this site
http://www.medscape.com/viewarticle/548664

#3 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

~~~~~~~~~~~~~~
I try and prepare patients ahead of time (when doing preop psych evals) NOT to go off their antidepressants for at least a year postop. This is due to a few factors. Depression is quite common believe it or not postop (whether or not preop one was diagnosed!). First of all due to the loss of food and the grieving process we go through, however different for all of us, it is a stressful time as we learn alternative coping skills to deal with emotions where we once used food as a solution. Secondly it is a time of HUGE change and not a good time to go off an antidepressant. Thirdly the hormonal imbalances/changes with rapid wt loss can cause a sever case of PMS/depression as estrogen is surged into the blood from the fat it was once stored it!

As for the formulation. Many antidepressants (AD) come in extended release form or controlled release...
These meds are not what I would prescribe to a bypass patient as we need acid in our stomachs to break down this type of med (whether an antidepressant or a blood pressure med for that matter!) and it needs a long transit time in the small intestines for absorption. We do not have either and this type of med may be less effective or ineffective...BUT the good news is many XR meds have plain formulations! Not enough research is done on SR/XR meds but if you are on one and it isn't effective changing formulation may help...I haven't come across a pt who needed a higher dose of a AD due to the bypass but it may be possible!

Depression is not a pleasant disease....
So go armed with this info and see what the provider suggests, be frank about your concerns with side-effects esp. the wt gain and about XR meds...
For example Wellbutrin XL and SR is available as a plain Wellbutrin but instead of a once a day or twice a day pill it is needed to be dosed 3x a day....

Effexor XR is a 1-2x a day med but there is the plain effexor but it needs 2-3x a day dosing...
Paxil CR is available as is plain paxil, both are once a day.
Zoloft is only plain, celexa & prozac are only plain and lexapro the newest AD out is only plain release.
Remeron is only plain (once a day dosing) and serzone is only plain (but usually is 2x a day dosing).

CR, XR, XL OR SR forms are usually the same med, just packaged differently for better tolerability and increased compliance (as the dosing is usually less) all of the above even in different preparations have the EXACT same drug formulation!

These are the most commonly used AD... There are others (older tricyclics such as elavil, imipramine, doxepin etc and the MAOI's parnate and nardil)
we tend to use these last as the SSRIS (selective serotonin reuptake inhibitors) (prozac, paxil, celexa, zoloft, lexapro are much safer and tolerated better....
Serzone, remeron and wellbutrin are newer but not SSRIs...

I would recommend AVOIDING any Sustained release meds if at all possible due to the small stomach (30cc) that has little/no acid in it to break down pills, no pyloric valve to keep it in stomach, and bypassing of differing amounts of small intestines. (*see below for limb definitions/amounts bypassed)

I avoid Paxil CR (paroxetine Controlled release), Wellbutrin XL (buproprion XL), Wellbutrin SR (buproprion SR) is helpful to some, others need the Wellbutrin IR (buproprion immediate release) dosed 2-3x day. I also am careful with Effexor XR (venlafaxine SR) some are okay, others need the plain effexor (venlafaxine) dosed 2-3x day.

I also am careful with SSRI's with these patients due to the risk of bleeding/especially GI bleeding. In their small newly created pouch (stomach) and newly created anastomoses it could potentially add to ulcers so a Proton Pump Inhibitor or H2 blocker may help/be indicated.

(2 links to articles on bleeding w/ SSRIS)
SSRIs May Increase Risk of Gastrointestinal Bleeding
http://www.medscape.com/viewarticle/448068
Selective Serotonin Reuptake Inhibitors May Increase Risk of Abnormal Bleeding
http://www.medscape.com/viewarticle/494691_print


http://www.aboutmso.com/pp/pp-gastricbypass.cfm
a good link for explaining and pictures of the RNY bypass proximal an distal surgeries.

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.

MEDSCAPE articles require a free registration to their site to view!