lipari malabsorptive syndromes

t/f: more than a third of adults in the US are obese and have significantly larger healthcare costs

true. 40.3% of adults are obese, $2k higher costs

whats a normal BMI

18.5-24.9

classify weight classes by BMI

underweight: <18.5

normal: 18.5-25

overweight : 25-30

obesity class 1: 30-35

obesity class 2: 35-40

obesity class 3: 40+

BMI equation

weight (kg) / height (m^2)

[ or lbs/inches * 703]

at what BMI may weight loss medications be considered

BMI >27

examples of obesity related complications remediable by weight loss

-T2DM, insulin resistance/ prediabetes

-dyslipidemia

-non-alcoholic fatty liver disease

-obstructive sleep apnea

-hypertension

-urinary stress incontinence

the most effective and sustainable intervention for obesity

bariatric surgery

3 indications for bariatric surgery

1. BMI >40 WITHOUT coexisting med problems

2. BMI >35 with >=1 med problem due to obesity

3. BMI 30-35 with T2DM and poor glycemic control despite optimal lifestyle and meds

is the following pt indicated for bariatric surgery:

pt AD has BMI of 33 with hypertension and dyslipidemia

no. BMI 30-35 must have T2DM with poor glycemic control

is the following pt indicated for bariatric surgery:

pt AD has BMI of 37 with hypertension and dyslipidemia

yes. bmi >35 with 1+ med problems that may be resolved w weight loss

is the following pt indicated for bariatric surgery:

pt AD has BMI of 37 with glaucoma and lupus

no. comorbidities must be weight loss related and resolved by weight loss. pt must have BMI>40 to get surgery if they dont have weight related conditions

4 types of bariatric surgeries

restrictive (reduce size of stomach)

1. laparoscopic adjustable gastric binding

2. laparoscopic sleeve gastrectomy

combo malabsorptive and restrictive:

3. roux-en-Y gastric bypass (RYGB)

4. biliopancreatic diversion with duodenal switch

laparoscopic adjustable gastric binding

describe:

projected weight loss:

- silicone band placed around upper stomach to limit food intake

- band is adjustable; can control food intake

20-25% weight loss from baseline

laparoscopic sleeve gastrectomy (70%)

describe:

projected weight loss:

- 70% of stomach is removed, leaving banana shaped tube

- irreversible; limited food intake

25-30% weight loss from baseline

roux-en-y gastric bypass (RYGB)

describe:

projected weight loss:

- SI is divided and connected to early part of stomach (so most of stomach and SI is bypassed)

- this both restricts food intake and causes malabsorption

30-35% weight loss

biliopancreatic diversion with duodenal switch

describe:

projected weight loss:

- portion of stomach removed (like LSG) AND lower SI is connected to stomach (malabsorption)

20-25% weight loss

which bariatric surgery is reversible

LAGB

Which restrictive weight loss surgery involves placing an adjustable silicone band around the stomach and is fully reversible?

a) Laparoscopic sleeve gastrectomy (LSG)

b) Roux-en-Y gastric bypass (RYGB)

c) Laparoscopic adjustable gastric banding (LAGB)

d) Biliopancreatic diversion with duodenal switch (BPD-DS

c) Laparoscopic adjustable gastric banding (LAGB)

Which procedure is both restrictive and malabsorptive, has a "Y"-shaped intestinal rearrangement, and is considered one of the most common bariatric surgeries?

a) Laparoscopic sleeve gastrectomy (LSG)

b) Roux-en-Y gastric bypass (RYGB)

c) Laparoscopic adjustable gastric banding (LAGB)

d) Biliopancreatic diversion with duodenal switch (BPD-DS)

b

t/f: while very helpful in quick weight loss, bariatric surgeries have a high risk of mortality

false. considered among the safest abdominal procedures

how is absorption affected in bariatric surgeries?

1. reduced stomach size= increased pH= bypasses 1st pass metabolism

2. increased pH= less acid dependent meds absorbed

3. less SA= less absorbed

4. SI bypassing= drugs needing bile salts not processed

bariatric surgeries can cause __________ in gastric pH, leading to

increased pH (less acidic)

- acid dependant drugs (ex: iron) less absorbed

in RYGB and BDDS, a portion of the SI is bypassed, impacting drugs that require bile salts. examples?

fenofibrate, cyclosporine, estrogen

increased gastric pH in bariatric surgeries may effect acid-dependant meds such as

ketoconazole, enalapril, iron, calcium carbonate, aspirin

how is distribution of drugs impacted post-bariatric surgery? examples?

- less adipose tissue= less lipophilic drug distribution

ex: tacrolimus, levothyroxine, propofol

how may bariatric surgery impact drug metabolism? examples?

- bypassing SI bypasses CYP3A4 enzymes

ex: verapamil, diltiazem, apixaban

monitor for decreased efficacy or toxicity!

how may bariatric surgery impact renal clearnace

may improve clearance, needing dose adjustments

which of the following drugs would be best for post-bariatric pts?

- IR, ER, or DR

- liquid or solid

- SQ or oral

-immediate release (avoid extended, delayed, or film)

- liquid/ crushable (over solid)

- SQ (use non-oral)

which meds should be initiated or discontinued pre-bariatric surgery?

1. discontinue estrogen therapy (to reduce risk of thromboembolism)

- stop oral birth control 1 cycle before

- stop hormone replacement 3 weeks before

2. take allopurinol for gout prophylaxis

3. stop smoking 6 weeks- 1 year beforehand

what kind of diet must be followed before bariatric surgery? which meds may have to be adjusted as a result?

- very low calorie diet of 800 or less

- induces ketosis (easier surgery, less complications)

- adjust diabetes meds (sulfonylureas, lantus, levemir)

vit D and calcium deficiency post surgery

sx:

monitoring:

sx: osteoporosis, tingling, leg cramping, tetany

monitor: DEXA scan every 2 years

proper calcium supplementation dosing post op

BPDDS: 1800-2400mg/day

LAGB, SG, RYGB: 1200-1500mg/day

proper VitD supplementation dosing post op

3000 IU daily until blood levels normal (>30ng/mL)

which forms of calcium are preferred post op? how must other be taken?

- calcium citrate preferred (does not need acid for absorption)

- if using calcium carbonate, must take with food (needs acid)

give in divided doses!! seperate from iron!!

pt AA has just received a LAGB. how much calcium and vitD would you recommend? how would you instruct to take it?

give 1200-1500mg calcium per day. citrate can take whenever, carbonate must be with food. divided doses!

give 3000IU VitD daily till levels are normal

thiamine (B1)

sx:

tx (preventative):

sx: neuropathy, lower extremity edema, wernicke-korsakoff syndrome

tx: AT LEAST 12mg thiamine (preferred B complex w 50-100mg)

cobalamin (b12)

sx:

tx:

sx: pernicious, megaloblastic anemias, fatigue, palpitations

tx:

-oral 350-1000microg daily

- nasal, see manufacturer

- IM/SQ: 1000 microg monthly

iron

sx:

tx:

sx: microcytic anemia, fatigue, palpitations

tx:

low risk= 18mg from multivitamin

rest= 45-60mg qd

give with VitC and away from calcium and acid reducers!!!!!

when giving iron, which supplements should you separate?

- separate calcium and acid reducers

- give with VitC

Vit A dosing post op

LAGB: 5000IU/day

RYGB, LSG: 5000-10,000 IU/day

BDDS: 10,000 IU/day

VitE dosing post op

15mg/d

VitK dosing post op

LAGB: 90-120 microg/day

RYGB, LSG: 90-120 microg/day

BDDS: 300 microg/day

Zinc dosing post op

Use multivitamin with minerals

BPD/DS: 200% RDA (16-22mg/d)

RYGB: 100-200% RDS (8-22mg/d)

SG, LAGB: 100% (8-11mg/d)

Ratio of 8-15mg zinc to 1mg copper

copper dosing post op

BPD/DS, RYGB: 200% RDA (2mg/d)

SG, LAGB: 100% RDA (1mg/d)

- Copper gluconate or sulfate recommended

- 1mg copper for every 8-15mg zinc

t/f: lifelong supplementation is necessary after bariatric surgery

true

what can you do as a pharmacist to increase supplementation adherence in post op pts

- lower frequency of administrations (ex: patch, injectables)

- powdered drinks, chewable tablets

- consider low cost OTC options

which medications should be separated from iron intake

Vampires Crave Blood Leaving Folks Tired

antiretroVirals

carbidopa/levodopa

bisphosphonates (alendronate)

Levothyroxine

Fluoroquinolones (ciprofloxacin)

Tetracyclines

which dosage forms are preferred post op and for how long

- liquid for 2 months

- avoid ER, DR, MR< and enteric coated

- see which tabs you may or may not crush

which meds are preferred for pain control in post op pts

- acetaminophen preferred

- AVOID NSAIDS! risk of ulcers

which meds and for how long post op are given to pts for anticoag effects

- first 4 weeks: IV anticoag therapy

- after 4 weeks: transition to warfarin or DOAC

which 3 classes of meds have a narrow therapeutic index and must be monitored in post op patients

- anti-epileptics

- immunosuppressants

- anticoags

how must diabetes meds be altered post op

- metformin bioavailability increases 50%-> must reduce dose

- reduce insulin dose 50-75% immediately post op

- avoid sulfonylureas

bisphosphonates and post op care

- oral bisphosphonates cause GI distress

- switch to IV: zoledronic acid, ibandronate

estrogen and post op care

- decreased absorption after SI bypass

- switch to topical

oral contraceptives and post op care

- surgery improves fertility and maternal outcomes

- avoid progesterone only pills and emergency contraception pills

dumping syndrome

sx:

tx:

- large carb load dumped straight into SI (like liquids w sugar)

- hypoglycemia, fluid shifts, fatigue

tx:

1. diet change: avoid rapidly absorbed carbs, increase fiber, separate food and liquids

2. meds: acarbose, octreotide

pt AD presents to pharmacy post op complaining that her estrogen meds have not been working. what is proper recommendation

a. fill estradiol script, follow up with doc

b. contact doc, recommend transdermal

c. recommend taking med with food

d. recommend probiotic to increase absorption

b