MEDICATIONS After Bariatric Surgery. Bariatric surgery changes many aspects of one’s life, and medications are no exception. Most patients will be prescribed certain medications and supplements after their surgery, but the surgery can also affect what medications are safe to take for other reasons and how you take them. Because the Roux- en- Y operation bypasses the lower stomach and a majority of the small intestine, foods are slowly digested and only partially absorbed after this surgery. Some medications are not well absorbed, while others can irritate the small pouch and its connection to the Roux limb, causing marginal ulcers. Most importantly, patients are at risk for nutrient deficiencies, so appropriate supplementation is necessary. The duodenal switch produces even more malabsorption and requires strict post- operative supplementation. These patients are specifically prone to protein deficiency, and they should take supplemental protein as well as vitamins and minerals. Find out the dietary changes to expect with weight loss surgery. Learn the foods you can eat, foods to avoid, supplements, drinking, and follow-up tests. The number of bariatric surgical operations performed in the United States has been relatively stable for the last five years. It is estimated that 179,000 weight. Operations that restrict food intake without bypassing the bowel, such as gastric banding, sleeve gastrectomy and vertical banded gastroplasty, do not impair food absorption, so those patients do not require strict supplementation. They still need to take proton pump inhibitors (such as Nexium or Prilosec) to decrease reflux and protect the small gastric pouch. Surgery Overview. Restrictive operations like gastric sleeve surgery make the stomach smaller and help people lose weight. With a smaller stomach, you will feel full. The endoscopic sleeve gastroplasty; a new procedure for those who want the benefits of weight loss surgery but from a less invasive, reversible, non-surgical procedure. Liver biopsy is the biopsy (removal of a small sample of tissue) from the liver. It is a medical test that is done to aid diagnosis of liver disease, to assess the. Due to rapid weight loss, ursodiol (Actigall) is also recommended to prevent gallstone formation. Some medications are not recommended after bariatric surgery, but are not strictly prohibited for patients who have had restrictive operations (see table for details). Nutrient Supplementation. After gastric bypass, patients are prone to deficiencies of the fat- soluble vitamins (A, D, E and K) and calcium. They also have an increased risk of anemia due to inadequate amounts of iron, vitamin B1. Because of these deficits, all gastric bypass patients should take a daily multivitamin and calcium supplements, and additional supplementation with iron, vitamin B1. Making the stomach smaller through bariatric surgery decreases gastric acid production, which affects the absorption of calcium and can increase the patient’s risk of osteoporosis. Calcium carbonate requires acid to be absorbed, but calcium citrate, which we recommend for supplementation, does not. The duodenum is the primary site for absorption of iron and is bypassed in the Roux- en- Y procedure. Like calcium, iron requires acid to be absorbed, which is lacking in the small gastric pouch. Gastric bypass patients can take iron salts combined with ascorbic acid (vitamin C) to acidify the stomach and facilitate absorption. Vitamin B1. 2 absorption requires intrinsic factor, which is produced in the bypassed part of the stomach, as well as acid; a lack of these can lead to vitamin B1. Appropriate supplementation can be achieved by taking an oral formulation (1. Taking NSAIDs after gastric bypass surgery significantly increases the risk of developing marginal ulcers at the connection between the stomach pouch and the Roux limb. Thus, gastric bypass patients should avoid these medications. The same risk extends to the salicylates (i. Safer options for oral pain medications include acetaminophen and opioids (Percocet, Vicodin, Tylenol #3 and Tramadol). Oral biphosphonates are another type of medication that may produce marginal ulcers in gastric bypass patients. These drugs inhibit the loss of bone mass associated with bone diseases like osteoporosis and Paget’s disease; commonly used biphosphonates include Actonel, Aredia, Boniva, Didronel, Fosamax, Reclast, Skelid and Zometa. However, there are alternative treatment options available, such as calcitonin salmon nasal spray, synthetic parathyroid hormone and Raloxifene. Anti- acid medications (Nexium, Protonix or Prevacid) are prescribed to prevent ulcers in the gastric pouch. We recommend taking one of these for at least six months following any type of bariatric surgery. Reduced Medication Effectiveness. The shorter intestinal length after gastric bypass or duodenal switch surgery can make extended- release drug preparations less effective. Some extended- release drugs include antidepressants (Wellbutrin XL), anxiolytics and sleep medications (Xanax XR), and anti- hypertensives (Toprol XL, Verapamil XL). Because these formulations are intended to be absorbed over 2- 1. This same principle also applies to delayed- release and enteric- or film- coated pills, which are coated with a material that prevents the medication from being released until the pill moves through the stomach to the small intestine. Diarrhea, Constipation and Gallstones. Some patients experience mild gastrointestinal problems after surgery. Imodium AD is safe and effective for post- operative diarrhea, and mild gas pains can be treated with Gas- X. Since bariatric patients consume less food, smaller amounts of stool are formed, which can lead to constipation. Some people find that taking two or three tablespoons of milk of magnesia every few days helps. Drinking plenty of water is very important, and nothing works well for constipation if water intake is poor. It is not uncommon for bariatric patients to have a bowel movement every two to three days once it is regulated. Patients who continue to experience constipation can take a fiber supplement, like Metamucil or Fibercon, once they are on the pureed diet. Colace, a stool softener, is sometimes necessary for patients on pain medication to prevent constipation. Some patients are given Reglan and Zofran for nausea and to assist with bowel movements. Rapid weight loss after bariatric surgery predisposes patients to gallstones. If you still have your gallbladder and the pre- operative ultrasound did not show gallstones, you should take Actigall for six months post- operatively to prevent them from forming. Can I Resume My Diabetic and Water Pills? Patients are usually instructed to resume most of their pre- operative medications. Those who are on diabetic medications will need to monitor their blood sugar closely at home. Some patients’ blood sugar decreases very quickly after surgery (even before any weight loss), and they will need less of their diabetic medications. The same applies to insulin, which should be given when blood sugar is under strict control and under the supervision of an endocrinologist or primary care physician. Diuretics (water pills or Lasix) are frequently prescribed for patients with hypertension, edema and congestive heart failure. Many patients are instructed to hold off on resuming diuretics because it is important to avoid dehydration after gastric bypass surgery; this is usually decided on an individual basis. Other antihypertensive medications are safe to use after gastric bypass. Typically, the dose decreases as patients lose weight and their hypertension improves. Consult your doctor to discuss changing doses and types of medication. Should I Continue My Blood Thinner Medications? Some patients take oral blood thinners like Coumadin for atrial fibrillation, blood clots and other cardiovascular conditions. Coumadin is typically stopped before surgery and replaced with heparin injections. Following surgery, Coumadin is gradually resumed, with heparin given at the same time to “bridge? After this temporary period, patients should continue Coumadin therapy under strict control of INR. No major changes in Coumadin dosing are required after gastric bypass. My Pills Are Too Big! The opening produced by Roux- en- Y surgery is about 1. Some pills (such as calcium, multivitamins and iron) are quite big and cannot go through this small connection easily. We advise patients to take these pills one at a time throughout the day, if possible. Very large pills can be cut in half or crushed—but only if they are not time- release medications (i. Ask your doctors if the pills they prescribe can be safely crushed. NSAIDs. The following drugs are NSAIDs or include NSAIDs in their formula and should not be taken after weight loss surgery: Advil. Aleve. Amigesic. Anacin. Anaprox. Anaprox DSAnsaid. Arthrotec. Ascriptin. Aspirin. Azolid. Bextra. Bufferin. Butazolidin. Cataflam. Celebrex. Clinoril. Combunox. Darvon. Daypro. Disalcid. Dolobid. EC Naprosyn. Ecotrin. Equagesic. Excedrin. Excedrin IBFeldene. Ibuprofen. Indocin. Indocin SRIndo- Lemmon. Indomethagan. Lodine. Lodine XLMeclomen. Mictainin. Midol IBMobic. Motrin. Motrin IBNalfon. Nalfon 2. 00. Naprapac. Naprelan. Naprosyn. Nupin. Orudis. Oruvail. Pamprin IBPercodan. Ponstel. Relafen. Rexolate. Tab- Profen. Tandearil. Tolectin. Tolectin 6. 00. Tolectin DSToradol. Uracel. Vicoprofen. Voltaren. Medication Recommendations after Various Bariatric Surgeries Gastric Bypass. Gastric Banding. Sleeve Gastrectomy. Bilopancreatic Diversion DSNSAIDs. No. No. No. No. Baby Aspirin (8. YES, but consider individually. YESYESYES, but consider individually. Acetaminophen. YESYESYESYESOpiates. YESYESYESYESWater Pills (Lasix)NO, but consider individually. NO, but consider individually. NO, but consider individually. NO, but consider individually. Vitamins (B1. 2, C, D)YESNONOYESIron. YESNONOYESCalcium. YESNONOYESProtein Supplements. YESNONOYESAntacid. YESYESYESYESActigall (Anti- Gallstones)YESYESYESYESInsulin and Diabetes Pills. YES, under strict blood glucose control. YES, under strict blood glucose control. YES, under strict blood glucose control. YES, under strict blood glucose control. Hypertension Pills(other than Lasix)YES, under strict blood glucose control. YES, under strict blood glucose control. YES, under strict blood glucose control. YES, under strict blood glucose control. Antidepressants. YESYESYESYESExtended- Release (XL, XR), Coated Medications. NOYESYESNOTomasz Rogula, MD, Ph. D, a Staff Surgeon at the Bariatric and Metabolic Institute at Cleveland Clinic, has published frequently on the topics of bariatric and laparoscopic surgery. Philip Schauer, MD, FACS, the Director of Advanced Laparoscopic and Bariatric Surgery at Cleveland Clinic, has served as president of the American Society for Metabolic and Bariatric Surgery.
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