NSAID question

There was a piece posted by a doc a few years ago, which I don't see anymore, that many took to be a specific recommendation of ASMBS (and by virtue of their publishing it might be considered a tacit recommendation,) that had some tables with advantages/disadvantages, basic supplement levels, etc. of the different procedures. It was fairly clear to those familiar with the DS that the author never consulted anyone in the DS world for by virtue of some of his "recommendations", beyond anything relating to the NSAID issue. That tainted the whole piece. Further, if he hadn't bothered to consult with the DS docs, he was also missing out on the most comprehensive experience as relates to the VSG, as the DS world is where that resides as they were the originators/early adopters of sleeve configuration.

What I do see on their site currently is:

Q: Which medications should I avoid after weight loss surgery?
A: Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the "Non-steroidal anti-inflammatory drugs" (NSAIDs), which can cause ulcers or stomach irritation in anyone but are especially linked to a kind of ulcer called "marginal ulcer" after gastric bypass. Marginal ulcers can bleed or perforate. Usually they are not fatal, but they can cause a lot of months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.

Some surgeons advise limiting the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary in some situations. Some long-acting, extended-release, or enteric coated medications may not be absorbed as well after bariatric surgery, so it is important that you work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is high enough. Finally, some prescription medications can be associated with weight gain, so you and your doctor can weigh the risk of weight gain versus the benefit of that medication. There may be alternative medications in some cases with less weight gain as a side effect.

https://asmbs.org/patients/life-after-bariatric-surgery

which is reflective of the general situation in the business today, and has long been the case in the DS/VSG world - NSAIDs big NO-NO for the RNY, and an okay/maybe/little no-no for the sleeve based procedures. This better reflects the physiology of the different procedures.

My VSG specializing surgeon stated unequivocally NO NSAIDs, and was adamant enough about it that he had me put it on my MedAlert bracelet. I believe this is the current guidance by the majority of VSG surgeons now.

Each case is unique, and ALL medical interventions are subject to a risk/benefit analysis.

My surgeon also specializes in VSGs and she is not AS concerned with NSAIDs with VSG as with RNY. Her standard instructions are no NSAIDs after either surgery. That's the default position of any physician that follows the guidelines.

However, they are GUIDELINES not hard and fast rules. My situation with the auto-immune requires occasional use of NSAIDs, and sometimes over long periods of time. She discussed the risks with me, told me the signs/symptoms of ulcers to be on the lookout for, said a PPI can reduce but not eliminate the risks, and gave me the following instructions: take them as little as possible, and for as short a period as possible, always with a PPI, and watch for evidence of an ulcer.

In my situation, in an emergency, it's more important to keep inflammation down than to avoid any risk of ulcer. So my medicalert says I have the auto-immune condition, and it also advises that I've had VSG. The docs can decide what's the priority in my case with that knowledge.

But that is MY specific situation. I would never advise someone to take NSAIDs after VSG unless their medical team has specifically said it's OK. The guidelines are there for a reason.

However, it's not malpractice for a doctor to decide NSAIDs are Ok for a particular patient given their medical profile, which is how it comes across sometimes from some posters.

Absolutely - it is not a black/white, yes/no, recommended/not recommended world, but one with shades of grey. Much of medicine involves choosing the "least bad" of several undesirable alternatives, and this is where these black and white "recommendations" fail us. We all have gotten into the WLS game not because it is so great, but that the alternative of continued morbid obesity is worse.

In this case with the NSAIDs, it is certainly a grey area, as these are serious drugs where even "normal" non-WLS people are being advised to avoid, or avoid over-using, them. The bypass has specific problems that stem from its basic Billroth II configuration that specifically contraindicates the use of such medications (it's basically an ulcer waiting to happen). The sleeve based procedures are more tolerant, even if we should still avoid their use - they are still an option when nothing else works, or other options are worse. It is this greater flexibility that has led many to choose the sleeve or DS over the RNY

The downside of the inappropriate blanket "no, never, not recommended" advice, beyond short circuiting the route of consulting your knowledgeable physicians is that it can encourage overuse of less effective "recommended" medications (see acetaminophen toxicity.)

I think every surgeon/doctor has a different stance on NSAIDs. My main doctor at our Bariatric clinic says they are okay. But only the smallest dose possible and for the shortest time (clear as mud) and only when also taking an acid prevention drug. I get migraines but not often enough for regular drugs and Tylenol just doesn't cut it. He told me to start with 1 pill instead of the 2 recommended and try to hold off in between doses. I had a sore throat and slight fever last week and tried many other things but 1 ibuprofen two separate times and I was feeling much better. Then I had my 6 month post surgery check up and the other doctor and one of the nurses flipped out because I had taken a NSAID. So even in one clinic you can get different stances.

Fellow migraineur here... It may be worth getting an as-needed script for one of the triptans if you can tolerate them. I am allowed NSAIDs but have also been cautioned to use them as little as possible. I used to try Excedrin for my migraines (the aspirin in it is an NSAID) and only if that failed take the triptan (I use Maxalt tablets that dissolve on the tongue - tastes like a dirty mint, but works SUPER fast) and my doc said it was better for me just to go to the triptan if I know it's a migraine and not a sinus/tension headache. (Sometimes it's hard to tell with the ones that creep up without an aura beforehand.)

Caffeine always helps whatever I take work better. I don't drink caffeine daily anymore (since surgery), and that has resulted in the caffeine working better for me when I do drink it.

I did suggest she get in touch with her Bariatric surgeon, however it's an emergency situation, and after hours... Plus the wife is a mess. I'm sure she'll talk to him at some point... But in the meantime, if rather be safe than sorry.

There should be someone in the practice who is "on call" after hours for just such situations. It may be one of the surgeons or an RN or PA (who can contact the surgeon if necessary) but they should be able to provide appropriate guidance - that's what they're there for! Our surgeon was on the horn to some ER docs in Nova Scotia (from SF) for a friend of ours who was suffering from (as it turned out) extreme electrolyte deficiency from food poisoning, but the doc was there to guide them through the possible implications of an unfamiliar (to them) surgery (a DS).

It's better to get it from the horse's mouth than depend upon blanket internet advice that may be inappropriate for the situation.

Update. Her wife did get in touch with her practice and was told no NSAIDS... that was this morning.

As of last night she had already requested them to stop, just in case.

I'm glad she did.

That's what you want to hear - considered medical advice from those who are familiar with her specific cir****tances rather than cookie cutter advice off the net. Other surgeons may have a different view, but this is the team that she has selected to work with.

One of the common failings of these forums is that we are often told to follow our doctor's directions or advice, unless it differs from my doctor's advice and since my doctor is better than your doctor you should follow his advice instead.