Medical treatment after wls?

I've had some wierd upper respiratory virus this week and saw the doctor, but afterward it got me to thinking. I'm wondering if medical science has looked into how medications should be prescribed AFTER WLS? My doctor gave a prescription regime for what a person with NORMAL absorption would require. Even 2 1/2 years out -- I have found that most medications have a MORE RAPID onset, but also a shorter duration than before wls. So "I think" if the prescription reads "take 1 or 2 tablets every 8 hours" -- it would work better for ME to take 1 tablet every 4 hours instead. I'm still taking the medication within the prescribed parameters, BUT taking it so that maybe it's more effective with absorption. Does that make sense? Next time I see my dr, I'll ask - but my guess is the medical profession as a whole hasn't addressed that as a possible issue.

I have not seen much in the way of research in that direction. The only thing I *have* seen is anecdotal evidence on the boards from people who are on anti-depressants. Many of them have had to switch away from Extended Release and/or upped their dosage to get the same effect. BUT.......and this is a *BIG* very very important *BUT*...........I would NOT adjust any prescription without first discussing it with the doctor. Doubling a dosage could be extremely dangerous if you really ARE absorbing all of it. --BT

Yikes! I wouldn't imagine doubling a dose! I can see why people would need to move away from extended release too. I was wondering anything had been researched about spreading out administration of medications to using smaller & more frequent doses. I know it's a step backwards, considering we have a lot of medications available in 12hr or 24hr extend tabs now (as opposed to taking meds 3 or 4 times a day) - but if absorption would be better I would be willing to go back to that.

I cannot agree more - NEVER adjust your medications on your own. Work with your doctor.

Yes, you are correct for questioning the absorption levels of your meds. THere is a recent published article on just this subject - from one of the pharmacy journals I believe. Will have to get to work to get the exact reference - I printed one out to take with me when I go to the doctors- most primary care or even specialists don't take this into consideration as well. Most of my docs now are judging therapeutic doses for me specifically - in other words they increase the dose until they get the anticipated change they are looking for. Is very tricky in those meds that are coated to absorbed over time - most of those seem to pass before they do any good! But please don't play with your dosages - get your physician on board before regimens are changed - some drugs can be very harmful to the kidneys or liver if taken incorrectly. good luck B

I mentioned it to my surgeon, and he said once you hit 1 yr post op, your absorption of meds is the same. He is one of the top WLS surgeons in the country, but I disagree with him on this one. I had kidney stones last year and I was not a year out at the time, but the meds they gave me to help pass the stones just did not work, but he swore that even at 5 months post op, I should not have had the issues you mentioned, but I know that I know we do. I am now 14 months post op and I still have problems as I know pain meds go in quicker and don't last as long on me....had plastics last month, so I know they don't. Take care and I agree with you. We need capsules that have an easy to dissolve outer coating, like my bariatric vitamins. Deb

hi Deb ... congrats on your plastics (sorry bout the pain meds)! I agree with you ... some of these surgeons are NOT nutritionists, nor do they prescribe my meds, or follow-up with them, so I do question some of their opinions. I also know that I have probs with some meds (and from what I've read over the past 3 years here and on other boards, a lot of people seem to have probs with antibiotics, birth control pills, and some with pain meds ... others too I'm sure, but those are the ones with the most complaints as I recall). I posted an article written by a pharmacist who also had RNY (responding to another post in this thread), he does update it from time to time, but I found it rather interesting. Karyn

I think absorption is still an individual thing, but I have been seeing more about this. Here's an article written by a pharmacist who has had gastric bypass surgery himself (printed with his permission). --------------------------------- Medications and the Gastric Bypass Patient by Michael McEvoy Pharm.D. As a medication travels through the body, it undergoes four* distinct phases: ? Absorption ? Distribution ? Metabolism * Not all drugs are metabolized, some are excreted unchanged ? Excretion Patients with liver disease may have problems metabolizing medications; patients with kidney disease may have problems excreting drugs. Gastric bypass patients will have a variable absorption of medications, based on the chemical characteristics of the medication and on the physical properties of the dosage form (meaning: "the finished product" -- tablet, capsule, etc.) containing the active ingredient. First a chemistry lesson (it won't be too painful). Medications, like all chemicals can exist to two states: ionized and un-ionized. When you dissolve a teaspoonful of table salt in a glass of water, the sodium ions (represented by the chemical symbol Na+) separate from the chloride ions (represented by the chemical symbol Cl-). The Na+ and CI- are said to be 'ionized.' When you dissolve a teaspoon of sugar in a glass of water, no separation into electrically charged particles takes place. The sugar is in an un-ionized state. Salt and sugar serve as examples of what happens to medications. Medications are best absorbed by our bodies in the un-ionized state. Most medications can be described as the salts of weak acids or weak bases. By 'salt' we mean that one chemical combines with another chemical to make a new compound. The salt of a weak base and a strong acid, such as ranitidine HCI (Zantac ®) is un-ionized in the presence of a stronger base (like small intestine juices.) The salt of a weak acid and a strong base, such as sodium phenobarbital (Luminal ®) is un-ionized in the presence of a stronger acid (like stomach juices.) The small intestines are bathed in secretions which are basic (meaning alkaline, not acidic), so drugs that are salts of weak bases are best absorbed there. Gastric bypass patients should have no trouble absorbing these types of medications. A clue to whether a medication is the salt of a weak acid or base can be found in the generic name. Medications that are "sodium something", "potassium something", "calcium- or magnesium something" are salts of weak acids. Medications that are something-HCI (hydrogen chloride) or something-HBr (hydrogen bromide) are salts of weak bases. The "sodium or potassium-something" drugs present the most problems with absorption. They are best absorbed in the presence of stomach acid, which is in very short supply on our pouches. There will be some absorption in the ionized state in our small intestines. Fortunately, our small intestines are VERY LONG and have a large surface area to absorb the medication. Medications are absorbed in the small intestines by passive non-ionic diffusion. Think of the intestinal wall like a sponge that picks up the medication and transports it from one edge of the sponge to the other, delivering it to the bloodstream. The rate and extent of absorption in passive non-ionic diffusion will be erratic and may vary from one Gastric Bypass patient to another. A recent report in the April 27th 2006 issue of the New England Journal of Medicine again shows the importance of stomach acid in the absorption of certain medications. Patients who were on proton pump inhibitors (medications such as Prilosec ® (omeprazole) , Nexium ®, Protonix ®, and Prevacid ®) as part of the treatment of the ulcer causing bacteria Helicobacter pylori were found to have mal-absorption of the thyroid drug thyroxine sodium (Synthroid ®). The study stated "patients with impaired acid secretion require an increased dose of thyroxine, suggesting that normal gastric acid secretion is necessary for the effective absorption of oral thyroxine."5 Many patients who have had gastric bypass surgery also have other medical problems which require medication for their treatment. In the May-June 2005 issue of Psychosomatics, a study was published which looked at the dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model. It found that ten of twenty two psychiatric medication preparations had significantly less dissolution and two of twenty two medications had significantly greater dissolution in the post-RYGB environment, as compared with a control group. The medications were crushed in this study, which differs from clinical practice and that may account for the greater dissolution of the two medications. This study made no attempt to determine differences in absorbtion, however. Further study into the effects of RYGB surgery on serum blood levels is required.6 Some guidelines for your physician came from a review of this and other recent studies. Immediate release medications are preferred over time release medications. Monitor the levels of medications in the blood, if such monitoring exists (not all drugs can be monitored in this way). For drugs with a small volume of distribution (Vd) [this will mean something to your doctor, as a patient you need not worry about what this means], a lower maintenance dose may be required because of a decreased glomerular filtration rate which follows marked weight loss. Drugs such as lithium carbonate, valproic acid and oxcarbazine are common psychiatric medications with small Vd.7 The good news is that most patients after RYGB surgery require fewer medications, or at least reduced dosages of medications then they needed prior to the surgery.8 Other considerations: Enteric coated tablets are designed to pass through the stomach acid intact and be dissolved in the small intestines. They should present no problem to the Gastric Bypass patient. Controlled release dosage forms, however, may have erratic absorption as many (but not all) controlled release dosage forms depend on stomach acid to dissolve the coatings of the "tiny time pills". Suggest that your doctor prescribe immediate release preparations, even though this may mean that you have to take the medication multiple times a day instead of only once or twice a day. Medications that require stomach acid for activation are another matter. The ulcer medication sucralfate (Carafate ®) (which I hope none of you will need!) requires stomach acid to attach itself as a protective coating over the ulcer. More important to us is calcium carbonate. Calcium is largely absorbed from the duodenum by an active transport system, which is bypassed during Roux-En-Y surgery. Calcium carbonate (Tums®) is frequently recommended for calcium supplementation because it contains a higher percentage of calcium than other calcium salts. But Calcium carbonate is a less soluble salt, which requires stomach acid to get into solution, which makes it absorbable. Ionized or un¬ionized, the medication must be in solution to be of any use to you: if it is not in solution, it does you no good. Gastric bypass patients should take a more soluble form of calcium, such as calcium citrate (Citracal ®), or better yet, get your calcium from your diet (Got cheese?) Do not forget to take your vitamins. Because of impaired absorption, you should be taking at least two times the RDA of most vitamins. Don't worry about the water soluble vitamins; you body will discard those in excess of your body's need. You may find that the excess riboflavin colors your urine a bright yellow; this is normal. Fat soluble vitamins (A, D, E, and K) can accumulate if taken in great excess, but this will not be a problem, unless you take large doses. And these fat soluble vitamins are important. There can be visual problems in post RYGB patients who do not get enough vitamin A, such as dryness of the conjunctiva and cornea. The condition can even progress to night blindness with severe vitamin A deficiency.9 Roux-En-Y patients should get at least 7000 - 10,000 international units (IU) of vitamin A daily, 400 - 800 IU of vitamin D daily, and 400 - 800 IU of vitamin E daily. For duodenal switch patients, whose absorption is even more impaired, the recommendations are 1 ½ times the recommendations for RNY patients. Lap band patient do not suffer from malabsorbtion, but should consider supplementation at least to the recommended Daily Value, as indicated on the package label as 100% DV. Dosages of vitamin A greater than 10,000 - 15,000 IU of vitamin A can result in adverse affects to the liver, skin, hair, and can cause visual changes. Pregnant females should consult their obstetrician for guidance, as high intake of vitamin A can have risks to the fetus.11 Calcification of soft tissue or hypercalcemia can occur with vitamin D intake > 2000 IU per day. Doses of vitamin E up to 1000 IU per day are commonly prescribed in Alzheimer's patients, yet some gastrointestinal (GI) effects can occur, along with blood thinning" anti-platlet effects with daily intakes of greater than 800 IU per day. The %DV for vitamin K is approximately 75 mcg. Patients who are taking the blood thinner Coumadin ® (warfarin sodium) should only take vitamin K supplements as advised by your physician, as vitamin K opposes the effects of Coumadin®; indeed vitamin K is given as an "antidote" to patients whose blood has been overly thinned with Coumadin®. So take your vitamins! But don't over do the ADEKs. Vitamin B12 (cyanocobalamin) requires both stomach acid and a substance secreted by the stomach called "intrinsic factor" for absorption via the oral route. You should be using a sublingual ('under the tongue") tablet or spray as your B12 supplement, as this bypasses the absorption problem altogether. Iron, like calcium, is largely absorbed in the duodenum. Like calcium carbonate, ferrous sulfate is frequently recommended for iron supplementation because it contains a higher percentage of iron than other iron salts. Also like calcium carbonate, ferrous sulfate is a less soluble salt, which requires stomach acid to get into solution. Gastric bypass patients should take a more soluble form of iron, such as ferrous fumarate (Ferro Sequels ®, Femiron ®), ferrous gluconate (Fergon ®), or a polysaccharide iron complex (Niferex ®). Remember to separate your calcium and iron supplement by at least two hours. Some references for you and your doctor: 1. MacGregor AMC, Boggs L. Drug Distribution in Obesity and following Bariatric Surgery: A literature review. Obes Surg 6:17-27, 1996 2. Chaymol G. Clinical pharmacokinetics of drugs in obesity. Clin Pharmacokinet 25.103-114, 1993 3. Malone M. Altered Drug Disposition in Obesity and After Bariatric Surgery Nutr in Clin Practice 18:131-135, 2003 4. Fussy S. The skinny on gastric bypass: What pharmacists need to know US Pharmacist 30: HS-3-HS-12, 2005 5. Centanni, et al Thyroxine in Goiter, Helicobacter pylori Infection, and Chronic Gastritis. N Engl J Med. 2006;354:1787-95 6. Seaman, JS, et al Dissolution of Common Psychiatric Medications in a Roux-en-Y Gastric Bypass Model, Psychomatics 46:3, May-June 2005 7. McAlpine DE Current Psychiatry Vol 5 No 1, Jan 2006 8. Malone M and Alger-Mayer SA Medication Use Patterns after Gastric Bypass Surgery for Weight Management, Ann of Pharmacotherapy 39:637-42 April 2005 9. Lee WB et al Ocular Complications of Hypovitaminosis A after Bariatric Surgery J Optha 2005;112:1031-34 10. Evanston Northwestern Healthcare Bariatric Services. Long-term vitamin supplementation. June 2004 11. J. Canadian Med Assoc Vol 169 (1), 8 July 2003 ---------------------------------------------------------------------------

Thanks for the absortion information. I recently had PS and developed a staph infection. We finally have it under control. I worried about the absortion of anti-boitics. Not sure how, but after taking KFlex, Cipiro, Batrim and finally Levaquin it seems to be healed. Any thought on this?

Hi Karyn, thanks for sharing this article. If you come upon any other info. I'd appreciate it if you would share it with me......I'm bringing this to my PCP on Wednesday. Dana