Info on meds after WLS and article links FYI

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.

1) Avoidance of Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral bisphosphonates (osteoporosis medications) should be avoided since RNYers are at increased risk for ulceration due to the reduced stomach size. Alternatives for pain relief, such as acetaminophen, tramadol, and/or opiates are recommended. Likewise, alternatives for osteoporosis prevention can be used.

What we talk about when we talk about drug class is NSAIDS. (NON_STEOIDAL_ANTI_INLFAMMATORY_DRUG_S) the reason NSAIDS are dangerous for us contrary to popular belief, it is not just that they are "pouch burners" it goes much deeper than that. According to an article published in the June 1999 New England Journal of Medicine, NSAIDS, once absorbed into the blood stream cause a chain of chemical reactions that affect the prostaglandins and this in turn reduces the production of mucus in the GI system. The mucus is what lines our GI system and protects our pouch and intestines from damage.

If the mucus production is reduced, this would allow ANYTHING, including eating something with too sharp of an edge or foods that are extremely spicy, to inadvertently begin a marginal ulcer. The best answer is to avoid NSAIDS at all cost. Taking an H2 receptor drug such as Pepcid or zantac or a Proton Pump inhibitor (PPI) such as Prilosec, Prevacid or Nexium is only a band-aid and no guarantee that it will protect you. You are at risk for marginal ulcers any time you take an anti-inflammatory medication. Not to mention the liver, kidney and cardiac issues we now know about w/NSAIDs in anyone! Not the safe drugs we once thought!!!

WARNINGS on most NSAID drugs are:
Gastrointestinal (GI) Effects - Risk of GI Ulceration, Bleeding, and Perforation:
Serious gastrointestinal toxicity, such as inflammation, bleeding, ulceration, and perforation of the stomach, small intestine or large intestine, can occur at any time, with or without warning symptoms, in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs).

Off-Limit Medication
REMEMBER after surgery Non-Steroidal Anti-inflammatory Drugs are no longer an option for use. DO NOT TAKE THEM. The chemical composition of this medication is very irritating to the esophagus and stomach lining. Chronic use will result in bleeding, ulceration of gastric lining, and eventually form scar tissue. Medications in this category are:
GENERIC BRAND
Flurbiprofen Ansaid
Fenoprofen Nalfon
Nabumetone Relafen
Ibuprofen Motrin, Advil, Nuprin
Ketoprofen Orudis, Oruvail
Piroxicam Feldene
Naproxen Naprosyn, Anaprox, Aleve
Indomethacin Indocin
Sulindac Clinoril
Tolmetin Tolmetin
Meclofenamate Meclomen
Etodolac Lodine
Ketorolac Toradol
Diclofenac Voltaren
Oxazoprin Daypro
Celecoxib Celebrex
Rofecoxib Vioxx

http://www.uclabariatrics.mednet.ucla.edu/recovery/recovery_discharge_offlimitmed.htm

~I would caution consideration of Alli (Xenical/Orlistat) as well due to its fatsoluable malabsortion effects on ADEK we already have this issue! Orlistat decreases the absorption of certain fat-soluble vitamins~
vitamins A, D and E. If you're taking Alli, you need to take a daily vitamin
supplement (at a time different from when you take Alli) to prevent potential
nutrient deficiencies. Besides the efficacy of the prescription strength was small that I worry the risk vs benefit of OTC form (smaller dose) would not be prudent!

ALSO in August-2009 warning on possible liver failure has surfaced!!! http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm179166.htm remember we already as obese people may have liver issues such as fatty liver etc and Wt loss is harsh rapidly on our livers!!!

Original Article:http://www.mayoclinic.com/health/alli/WT00030
Alli weight-loss pill: Does it work?
Donald Hensrud, M.D.
(snipped section on) Efficacy

Q: How much weight do patients lose with XENICAL treatment?
A: In clinical trials involving 1064 patients, 69% on XENICAL plus diet lost 3%
or more of initial body weight within 3 months, with a mean loss of 13 lbs.18 In
clinical trials, the overall mean weight loss from randomization to the end of 1
year in the intent-to-treat population was 13.4 lbs in patients treated with
XENICAL plus diet versus 5.8 lbs in placebo-treated patients.

2) 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.

~Malabsorption of nutrients due to bypassing some stomach and intestines. Postops are prone ESPECIALLY to nutritional deficiencies in things such as the fat-soluble vitamins (A, D, E, and K) but also in Zinc, Selenium, Copper, Magnesium, Potassium, B1, B6, B12, Folate, Phosphorus, Protein Calcium (men and women) Thus, appropriate lab monitoring of above and proper recommendation and guidance on supplementation with all of above as indicated is an important consideration that is ONGOING for life! (*I just developed vit D deficiency at 5 years postop! Everything had been fine until now! So a reminder we are never normal!). REMEMBER there are differences in forms of protein and bioavailability with whey having a preferential profile over other things such as Soy or milk protein. Different forms of vitamin and minerals are also a factor to consider. The salt form of medications may also require consideration.] 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 and most Rnyers do not have! Ferrous gluconate or fumarate may be better-tolerated and absorbed as well vs ferrous sulfate in a postop RNYer. Or using chelated iron or polysaccharide or carbonyl iron. At times iron infusions are needed for absorption!
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

~Birth control medications http://www.aboutmso.com/faq/faq.cfm
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.

My surgeon discussed this at length with me pre-op. he said I must go to my OB and discuss other options, as the pill cannot be a reliable form of birth control after surgery EVER. This is because if you take it there is no way of knowing how much you malabsorb (or get!) and if you happen to dump or vomit that day kiss that dose by by! Also Weight loss as rapidly as we are experiencing releases tons of estrogen into our bodies circulation making us fertile myrtles! Actually many people have this surgery as a way to get pregnant! As obesity can cause a lot of fertility issues. So with the increase in free-floating estrogen even if the pill was 100% absorbed it may not be enough! (Believe me I mourned this fact as I have been on the pill for 12 years!) But also any hormonal form of birth control may not be effective even Depo-provera shot, Lunelle shot, ortho-evra (the patch) or nuvaring (vaginal ring). Also barrier methods such as the cervical cap and the diaphram can not be relied on (as the rapid wt loss can cause you to not be fitted properly, and should be refitted every 15-20# or so! )
A word about the patch, it is ineffective/less-effective/contraindicated in any one over 198# (and well quite frankly that probably is many of us gastric bypass patients for a while at least!) The same with norplant (inplantable hormones good for 5 yrs or so),,,,,I am not saying abstinence is the only answer, but condoms are really the best option.

I opted for nuvaring though, despite the risk of the hormonal surges, it has been effective for me and is pretty hassle free. It is a vaginal ring that stays in the vagina for 3 weeks (no special placement it just needs to be in there), is removed for a week, then replaced...www.nuvaring.com After 4- mo it was irritating to self/DH so switched to patch, that had horrible s/e for me (breast tenderness so severe I could scream if I wore a loose tshirt!) so after 4 -5mo of that I got an IUD www.mirena.com it is WONDERFUL had it for 2 yrs so far so good, no hassle, is good for 5 yrs only payment was $20 office copay! I have never had kids so I didn't think an IUDwas doable but the new Mirena is (the coppper IUD can go in women who have had a preg, and some are good 10-12 yrs). I rarely get cramps or a period, I spot maybe 3-4x yr, have needed only 6 or less tampons this past yr, a panty liner usually works (sorry if TMI) but really prior since age 9 had horrid cramps/periods very heavy! So yes go to your obgyn, but go educated as many do not know our special needs (malabsorption/risk of vomiting/rapid wt loss etc).

ALSO BE AWARE OF THE RISK OF OSTEOPOROSIS w/ DEPO shot (not to mention many gain 50#+ on this and have a tough time losing even when they stop the med!!!) so after RNY we are already at risk for metabolic bone disease due to calcium malabsorbtion and wt loss!
http://www.medscape.com/viewarticle/522069_print
DMPA May Cause More Weight Gain Than Do Oral Contraceptives
Jan. 23, 2006 -- Depot medroxyprogesterone acetate (DMPA) is associated with significant weight gain compared with an oral contraceptive **** or no contraceptive, according to the results of a prospective study reported in the January issue of the Archives of Pediatrics & Adolescent Medicine.

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=291
New Warning on Depo-Provera Contraceptive Injection
FDA Patient Safety News: Show #36, February 2005
The FDA recently announced that a new black-box warning is being added to the labeling for Depo-Provera Contraceptive Injection. The warning alerts prescribers that prolonged use may result in loss of bone density. Pfizer, the drug's manufacturer, has also issued a Dear Doctor letter with the same information, and the new information also appears in the patient information sheet.
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SUGAR FREE cough syrups, cough drops etc may also lessen risk of dumping!

Here are a few articles I promised. 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

So if you made it through this long post I hope it helped understand there is not just a list to avoid, but many other things to consider! Be well.
Take Care,
Jamie Ellis RN MS NPP
Lap RNY 10/9/02 Dr. Singh
320/163/185 5'9'' (45# PREOP WT LOSS)
Plastics 6/9/04 & 11/11/2005 Dr. King
"Being happy doesn't mean everything's perfect, it just means you've
decided to see beyond the imperfections!"