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Kingma JS, Peeters NWL, Knibbe CAJ, Agterof MJ, Derksen WJM, Burgers DMT, van den Broek MPH. Clinical Guidance for Dosing and Monitoring Oral Antihormonal Drugs in Patients with Breast Cancer After Roux-en-Y Gastric Bypass. Ther Drug Monit 2024; 46:404-409. [PMID: 38018850 DOI: 10.1097/ftd.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/08/2023] [Indexed: 11/30/2023]
Abstract
ABSTRACT Obesity is associated with an increased risk of cancers, such as breast cancer. Roux-en-Y gastric bypass (RYGB) is a common surgical intervention used to induce weight loss, reduce comorbidities, and improve overall survival. Due to alterations in the gastrointestinal tract, RYGB is associated with changes in oral drug disposition, which can affect treatment outcomes. Oral antihormonal agents were monitored in 9 patients who previously underwent RYGB. The results of therapeutic drug monitoring and estradiol concentrations were analyzed, and a review of the relevant literature was performed. As only 1 of the 6 patients prescribed tamoxifen achieved a therapeutic endoxifen concentration with the standard dose of 20 mg/d, a higher starting dose of 40 mg/d was recommended to increase the probability of attaining a therapeutic plasma concentration. All patients with decreased CYP2D6 metabolic activity could not achieve therapeutic plasma concentrations; therefore, CYP2D6 genotyping was recommended before the initiation of tamoxifen therapy to identify patients who should be switched to aromatase inhibitors. Anastrozole and letrozole exposure in patients who underwent RYGB patients appeared sufficient, with no dose adjustment required. However, until more data become available, monitoring aromatase inhibitor efficacy is recommended. Monitoring the drug concentrations is a viable option; however, only indicative data on therapeutic drug monitoring are available. Therefore, estradiol concentrations should be measured.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
| | - Niels W L Peeters
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
- Division of Systems Pharmacology & Pharmacy, Leiden Academic Center for Drug Research, Leiden University, Leiden, the Netherlands
| | - Mariette J Agterof
- Department of Internal Medicine, St. Antonius Hospital, Utrecht, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; and
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
| | - Marcel P H van den Broek
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, the Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, the Netherlands
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Kvitne KE, Hjelmesæth J, Hovd M, Sandbu R, Johnson LK, Andersson S, Karlsson C, Christensen H, Jansson-Löfmark R, Åsberg A, Robertsen I. Oral Drug Dosing After Gastric Bypass and Diet-Induced Weight Loss: Simpler Than We Think? Lessons Learned From the COCKTAIL Study. Clin Pharmacol Ther 2024. [PMID: 38771070 DOI: 10.1002/cpt.3307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
This article summarizes the lessons learned from the COCKTAIL study: an open, three-armed, single-center study including patients with obesity scheduled for treatment with Roux-en-Y gastric bypass (RYGB) or nonsurgical calorie restriction, and a normal- to overweight control group. The clinical implications of the results from multiple peer-reviewed articles describing the effects of RYGB, severe caloric restriction, weight loss, and type 2 diabetes on the in vivo activity and protein expression of drug-metabolizing enzymes (cytochrome P450 (CYP) 1A2, 2C9, 2C19, and 3A) and transporters (DMETs; organic anion-transporting polypeptide (OATP) 1B1 and P-glycoprotein (P-gp)) are discussed in the perspective of three clinically relevant questions: (1) How should clinicians get the dose right in patients after RYGB? (2) Will drug disposition in patients with obesity be normalized after successful weight loss? (3) Are dose adjustments needed according to obesity and diabetes status? Overall, RYGB seems to have a lower impact on drug disposition than previously assumed, but clinicians should pay close attention to drugs with a narrow therapeutic range or where a high maximum drug concentration may be problematic. Whether obesity-related alterations of DMETs normalize with substantial weight loss depends on the DMET in question. Obesity and diabetes downregulate the in vivo activity of CYP2C19 and CYP3A (only obesity) but whether substrate drugs should be dose adjusted is also dependent on other factors that influence clearance, that is, liver blood flow and protein binding. Finally, we recommend frequent and individualized follow-up due to high inter- and intraindividual variability in these patients, particularly following RYGB.
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Affiliation(s)
| | - Jøran Hjelmesæth
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus Hovd
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Rune Sandbu
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
| | - Line Kristin Johnson
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
| | - Shalini Andersson
- Oligonucleotide Discovery, Discovery Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Cecilia Karlsson
- Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Rasmus Jansson-Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anders Åsberg
- Department of Pharmacy, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ida Robertsen
- Department of Pharmacy, University of Oslo, Oslo, Norway
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Kingma JS, Brenkman IAM, van den Broek MPH, van den Bemt PMLA, Janssen K, Knibbe CAJ, Burgers DMT. Documentation of the Patient Characteristics Morbid Obesity and Bariatric Surgery in the Hospital Information System and the Influence on the Number of Medication-Related Problems. Ann Pharmacother 2024:10600280231226243. [PMID: 38268179 DOI: 10.1177/10600280231226243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND As a result of pharmacokinetic changes, individuals with morbid obesity and/or with bariatric surgery may require dose adjustments, additional monitoring or medication should be avoided. Clinical decision support (CDS) may provide automated alerts enabling correct prescribing but requires documentation of these patient characteristics in the Hospital Information System (HIS) to prevent medication-related problems (MRPs). OBJECTIVE The primary objective is to determine the proportion of patients with documentation of the patient characteristics morbid obesity and bariatric surgery in the HIS. The secondary objective is to compare the proportion of patients with an MRP in the group with versus without documentation. Also, the type and severity of MRPs and the medication involved are determined. METHODS A prospective cohort study was performed. Patients admitted to the hospital were identified as morbidly obese and/or with bariatric surgery. In the identified patients, the proportion of patients with documentation of the patient characteristics in the HIS was evaluated as primary outcome. Subsequently, patient records were reviewed for MRPs, which were categorized and associated medication was registered. For the primary objective, descriptive statistics was used. For the secondary outcome, the Fisher's exact test was used. RESULTS In 43 (21.4%, 95% confidence interval [CI]: 15.7%-27.1%) of 201 included patient (113 morbid obesity, 70 bariatric surgery and 18 both), the patient characteristics were documented. An MRP occurred in 2.3% versus 13.9% (P = 0.032) of patients with and without documentation, respectively. The most common MRP was underdosing in morbid obesity, while in patients with bariatric surgery it was prescription of contra-indicated medication. CONCLUSION AND RELEVANCE The proportion of patients with documentation of the patient characteristics bariatric surgery and/or morbid obesity in the HIS is low, which appears to be associated with more MRPs. To improve medication safety, it is important to document these patient characteristics.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Iris A M Brenkman
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Marcel P H van den Broek
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pharmaceutics, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karin Janssen
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
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Konstantinidou SK, Argyrakopoulou G, Dalamaga M, Kokkinos A. The Effects of Bariatric Surgery on Pharmacokinetics of Drugs: a Review of Current Evidence. Curr Nutr Rep 2023; 12:695-708. [PMID: 37857987 PMCID: PMC10766679 DOI: 10.1007/s13668-023-00498-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Obesity constitutes a major public health concern and has been recognized as an epidemic. To date, bariatric surgery remains the most effective way for substantial long-lasting weight loss in severe obesity. The purpose of this review is to summarize how the pharmacokinetics of drugs are affected by the most common types of bariatric surgery, i.e., Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). RECENT FINDINGS Limited data are available regarding the changes in pharmacokinetics of drugs after bariatric surgery. The lack of existing guidelines may lead patients to experience drug toxicity or therapeutic undertreatment. Pharmacokinetic parameters that need to be taken into consideration postoperatively include gastric motility, gastric volume, pH, surface area, bile secretions, carrier proteins, and first-pass metabolism. For drugs with a narrow therapeutic index, other factors need to be monitored closely, including plasma drug levels, patients' clinical outcomes, and laboratory markers. Patients should be followed up frequently and treated in accordance with their response to the drug therapy. Bariatric surgery may affect the pharmacokinetics of various drugs, due to the resultant anatomical changes and the substantial weight loss. Therefore, there is a need to identify those potential changes and adjust patients' medication doses in order to achieve higher efficacy and avoid toxicity.
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Affiliation(s)
- Sofia K Konstantinidou
- First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | | | - Maria Dalamaga
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Alexander Kokkinos
- First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Böhm DTMM, Berghuis K, Said M, Kerskes MCHM, Deenen MJ, Bastiaans DET. Identification of Medication-Related Risks in Bariatric Surgery Patients by Performing Structured Medication Reviews. Obes Surg 2023; 33:3932-3937. [PMID: 37882989 DOI: 10.1007/s11695-023-06889-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE More medication-related issues are seen with the growing demand for bariatric surgery, because of possible altered pharmacokinetics after surgery. Collaboration with a pharmacist could improve the short- and long-term safety and efficacy of pharmacotherapy in patients undergoing bariatric surgery. The aim of this study was to evaluate the impact of a structured medication review to identify medication-related risks before bariatric surgery. MATERIALS AND METHODS The impact on pharmacy-led interventions of introducing a structured medication review was evaluated in a historically controlled study. In the retrospective part, we evaluated patient characteristics, medication use, and number of pre-surgery consultations with a pharmacist before the introduction of medication reviews. A flowchart was developed to detect the use of medicines with risks associated with bariatric surgery. In the prospective part, we evaluated pharmacy-led interventions after the introduction of structured medication reviews using the flowchart. Outcome effectiveness was measured through the number of pre-surgery pharmacy-led interventions. RESULTS Before using the flowchart for screening on risk medicines, 40 (2.6%) pharmacy-led interventions were identified in 1536 patients. In the prospective group, 195 patients were included and 88 (45%) interventions were identified (p < 0.001). CONCLUSION A structured medication review before bariatric surgery significantly increased the number of pharmacy-led interventions in bariatric surgery patients. This procedure will shift interventions to pre-surgery instead of post-surgery, contributing to the optimization of pharmacotherapy at an early stage.
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Affiliation(s)
- Doortje T M M Böhm
- Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Kim Berghuis
- Obesity Center, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Mohammed Said
- Obesity Center, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Marieke C H M Kerskes
- Department of Clinical Pharmacy, Catharina Ziekenhuis, Michelangelolaan 2, 5623, EJ, Eindhoven, The Netherlands
| | - Maarten J Deenen
- Department of Clinical Pharmacy, Catharina Ziekenhuis, Michelangelolaan 2, 5623, EJ, Eindhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Diane E T Bastiaans
- Department of Clinical Pharmacy, Catharina Ziekenhuis, Michelangelolaan 2, 5623, EJ, Eindhoven, The Netherlands.
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Greenblatt DJ, Bruno CD, Harmatz JS, Dawson-Hughes B, Zhang Q, Li C, Chow CR. Estimation of Absolute and Relative Body Fat Content Using Noninvasive Surrogates: Can DXA Be Bypassed? J Clin Pharmacol 2023; 63 Suppl 2:S35-S47. [PMID: 37942909 PMCID: PMC10651165 DOI: 10.1002/jcph.2306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/01/2023] [Indexed: 11/10/2023]
Abstract
Dual-energy x-ray absorptiometry (DXA) scanning is used for objective determination of body composition, but instrumentation is expensive and not generally available in customary clinical practice. Anthropometric surrogates are often substituted as anticipated correlates of absolute and relative body fat content in the clinical management of obesity and its associated medical risks. DXA and anthropometric data from a cohort of 9230 randomly selected American subjects, available through the ongoing National Health and Nutrition Examination Survey, was used to evaluate combinations of surrogates (age, height, total weight, waist circumference) as predictors of DXA-determined absolute and relative body fat content. Multiple regression analysis yielded linear combinations of the 4 surrogates that were closely predictive of DXA-determined absolute fat content (R2 = 0.93 and 0.96 for male and female subjects). Accuracy of the new algorithm was improved over customary surrogate-based predictors such as body mass index. However prediction of relative body fat was less robust (R2 less than 0.75), probably due to the nonlinear relation between degree of obesity (based on body mass index) and relative body fat. The paradigm was validated using an independent cohort from the National Health and Nutrition Examination Survey, as well as two independent external subject groups. The described regression-based algorithm is likely to be a sufficiently accurate predictor of absolute body fat (but not relative body fat) to substitute for DXA scanning in many clinical situations. Further work is needed to assess algorithm validity for subgroups of individuals with "atypical" body construction.
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Affiliation(s)
- David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
- Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
| | - Christopher D Bruno
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
- Emerald Lake Safety, LLC, Newport Beach, CA, USA
| | - Jerold S Harmatz
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
| | - Bess Dawson-Hughes
- Jean Mayer Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | - Qingchen Zhang
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
| | - Chunhui Li
- Program in Pharmacology and Drug Development, Tufts University School of Medicine, Boston, MA, USA
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Wuyts SCM, Torensma B, Schellekens AFA, Kramers CK. Opioid Analgesics after Bariatric Surgery: A Scoping Review to Evaluate Physiological Risk Factors for Opioid-Related Harm. J Clin Med 2023; 12:4296. [PMID: 37445331 DOI: 10.3390/jcm12134296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.
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Affiliation(s)
- Stephanie C M Wuyts
- Pharmacy Department, Universitair Ziekenhuis Brussel (UZ Brussel), 1090 Brussels, Belgium
- Research Group Clinical Pharmacology and Clinical Pharmacy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Bart Torensma
- Department of Anesthesiology, Leiden University Medical Center (LUMC), 2333 ZA Leiden, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Cornelis Kees Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Nijmegen Medical Center, 6525 GA Nijmegen, The Netherlands
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Pasi P, Kröll D, Siegfried A, Sykora M, Wildisen A, Milone C, Milos G, Horka L, Fischli S, Henzen C. Plasma concentrations of SSRI/SNRI after bariatric surgery and the effects on depressive symptoms. Front Psychiatry 2023; 14:1132112. [PMID: 37181889 PMCID: PMC10166804 DOI: 10.3389/fpsyt.2023.1132112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/29/2023] [Indexed: 05/16/2023] Open
Abstract
Background Depression and treatment with antidepressants SSRI/SNRI are common in people with morbid obesity who are candidates for bariatric surgery. There is few and inconsistent data about the postoperative plasma concentrations of SSRI/SNRI. The aims of our study were to provide comprehensive data about the postoperative bioavailability of SSRI/SNRI, and the clinical effects on depressive symptoms. Methods Prospective multicenter study including 63 patients with morbid obesity and therapy with fixed doses of SSRI/SNRI: participants filled the Beck Depression Inventory (BDI) questionnaire, and plasma levels of SSRI/SNRI were measured by HPLC, preoperatively (T0), and 4 weeks (T1) and 6 months (T2) postoperatively. Results The plasma concentrations of SSRI/SNRI dropped significantly in the bariatric surgery group from T0 to T2 by 24.7% (95% confidence interval [CI], -36.8 to -16.6, p = 0.0027): from T0 to T1 by 10.5% (95% 17 CI, -22.7 to -2.3; p = 0.016), and from T1 to T2 by 12.8% (95% CI, -29.3 to 3.5, p = 0.123), respectively.There was no significant change in the BDI score during follow-up (-2.9, 95% CI, -7.4 to 1.0; p = 0.13).The clinical outcome with respect to SSRI/SNRI plasma concentrations, weight change, and change of BDI score were similar in the subgroups undergoing gastric bypass surgery and sleeve gastrectomy, respectively. In the conservative group the plasma concentrations of SSRI/SNRI remained unchanged throughout the 6 months follow-up (-14.7, 95% CI, -32.6 to 1.7; p = 0.076). Conclusion In patients undergoing bariatric surgery plasma concentrations of SSRI/SNRI decrease significantly by about 25% mainly during the first 4 weeks postoperatively with wide individual variation, but without correlation to the severity of depression or weight loss.
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Affiliation(s)
- Patrick Pasi
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Dino Kröll
- Division of Visceral Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Alena Siegfried
- Department of Surgery, Division of Visceral Surgery, Cantonal Hospital, Lucerne, Switzerland
| | - Martin Sykora
- Department of Surgery, Division of Visceral Surgery, Cantonal Hospital, Lucerne, Switzerland
| | - Alessandro Wildisen
- Department of Surgery, Division of Visceral Surgery, Cantonal Hospital, Lucerne, Switzerland
| | - Cristiana Milone
- Department of Surgery, Division of Visceral Surgery, Cantonal Hospital, Lucerne, Switzerland
| | - Gabriella Milos
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Laura Horka
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Stefan Fischli
- Department of Internal Medicine, Division of Endocrinology, Cantonal Hospital, Lucerne, Switzerland
| | - Christoph Henzen
- Department of Internal Medicine, Division of Endocrinology, Cantonal Hospital, Lucerne, Switzerland
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Kuzin M, Schoretsanitis G, Gardin F, Markus G, Kawohl W, Xepapadakos F. Switching From Aripiprazole Tablets to Oral Suspension in a Patient With Roux-en-Y Gastric Bypass: A Case Report. J Clin Psychopharmacol 2023; 43:300-302. [PMID: 37068029 DOI: 10.1097/jcp.0000000000001685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
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10
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Greenblatt DJ, Bruno CD, Harmatz JS, Zhang Q, Chow CR. Drug Disposition in Subjects with Obesity: The Research Work of Darrell R. Abernethy. J Clin Pharmacol 2022; 62:1350-1363. [PMID: 35661375 DOI: 10.1002/jcph.2093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/27/2022] [Indexed: 11/10/2022]
Abstract
In 1979, the late Dr. Darrell R. Abernethy and colleagues began a series of clinical studies aimed at understanding the pertinent determinants of drug distribution, elimination, and clearance in obesity, and how those variables are interconnected. The studies confirmed that volume of distribution (Vd) and clearance are the principal independent biological variables, which conjointly determine elimination half-life as a dependent variable. For drugs distributed by passive diffusion, their pharmacokinetic Vd - after correcting for plasma protein binding - was increased in obesity, depending in part on the physicochemical lipophilicity of the individual drugs, and the quantitative extent of obesity in overweight individuals. Across all studies, the ratio of mean clearance in obese divided by control groups had an overall median value of 1.21 (range: 0.75 to 3.11), indicating a small and variable effect of obesity on clearance, without clear directionality. Since drug clearance was not clearly related to lipophilicity or degree of obesity, the prolonged half-life of lipophilic drugs in obese patients was largely explained by the increased Vd. Dr. Abernethy further identified delayed attainment of steady-state after initiation of multiple-dose treatment, and delayed washout after termination of dosage, as potential clinical consequences of the extended half-life in obese persons. These consequences for specific drugs have been recently emphasized in contemporary studies of chronic dosage in subjects with obesity. Without data identifying an obesity-related change in clearance for a specific drug, maintenance doses (in milligrams) should be based on ideal weight rather than adjusted upward based on total weight. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- David J Greenblatt
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA.,the Clinical and Translational Sciences Institute, Tufts Medical Center, Boston, MA
| | - Christopher D Bruno
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA.,Emerald Lake Safety LLC, Newport Beach, CA
| | - Jerold S Harmatz
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA
| | - Qingchen Zhang
- Program in Pharmacology and Drug Development, Tufts University School of Medicine and Graduate School of Biomedical Sciences, Boston, MA
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Coughlin JW, Steffen KJ, Sockalingam S, Mitchell JE. Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations. Curr Psychiatry Rep 2022; 24:89-98. [PMID: 35076886 DOI: 10.1007/s11920-022-01317-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, MD, 21224, Baltimore, USA.
| | - Kristine J Steffen
- North Dakota State University, College of Health Professions, ND, 58103, Fargo, USA.,Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA
| | - Sanjeev Sockalingam
- University Health Network Bariatric Surgery Program Centre for Addiction and Mental Health University of Toronto, ON, M6J 1H4, Toronto, Canada
| | - James E Mitchell
- Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA.,University of North Dakota School of Medicine and Health Sciences, ND, 58103, Fargo, USA
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12
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Optimized In Silico Modeling of Drug Absorption after Gastric Bypass: The Case of Metformin. Pharmaceutics 2021; 13:pharmaceutics13111873. [PMID: 34834288 PMCID: PMC8624529 DOI: 10.3390/pharmaceutics13111873] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
Bariatric surgery is an effective treatment for severe obesity and related comorbidities, such as type II diabetes. Gastric bypass surgery shortens the length of the intestine, possibly leading to altered drug absorption. Metformin, a first-line treatment for type II diabetes, has permeability-dependent drug absorption, which may be sensitive to intestinal anatomic changes during bypass surgery, including Roux-en-Y gastric bypass (RYGB). Previous computer simulation data indicate increased metformin absorption after RYGB. In this study, we experimentally determined the region-dependent permeability of metformin, using the rat single-pass intestinal perfusion method (SPIP), which we then implemented into GastroPlusTM to assess the contribution of our SPIP data to post-RYGB metformin absorption modeling. Previous simulations allowed a good fit with in vivo literature data on healthy and obese control subjects. However, it was revealed that for post-RYGB drug absorption predictions, simply excluding the duodenum/jejunum is insufficient, as the software underestimates the observed plasma concentrations post-RYGB. By implementing experimentally determined segmental-dependent permeabilities for metformin in the remaining segments post-surgery, GastroPlusTM proved to fit the observed plasma concentration profile, making it a useful tool for predicting drug absorption after gastric bypass. Reliable evaluation of the parameters dictating drug absorption is required for the accurate prediction of overall absorption after bariatric surgery.
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13
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Chen K, Lin Y, Luo P, Yang N, Yang G, Zhu L, Pei Q. Effect of laparoscopic sleeve gastrectomy on drug pharmacokinetics. Expert Rev Clin Pharmacol 2021; 14:1481-1495. [PMID: 34694169 DOI: 10.1080/17512433.2021.1997585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Given its feasibility and efficacy, laparoscopic sleeve gastrectomy (LSG) has become a widely accepted bariatric surgery for patients with clinically diagnosed severe obesity. LSG induces anatomical changes and subsequent weight loss which may affect drug pharmacokinetics (PK) and consequently impact dosing regimens. This review aims to examine the effect of LSG on drug PK and identify relevant gastrointestinal physiological alterations. AREAS COVERED PubMed, Embase, Scopus, and the Cochrane Library were searched for articles related to drug PK and LSG from inception to July 2021. Moreover, literature concerning postoperative physiological conditions in the gastrointestinal tract, such as gastric pH, gastric emptying, and small bowel transit time, etc., which may affect the PK profile of drug products was also reviewed. EXPERT OPINION Although LSG is classified as having restrictive property without malabsorptive bypass, postoperative changes in gastrointestinal physiology and subsequent weight loss may also lead to increased, decreased or unaltered drug exposure levels. General monitoring on drug efficacy or safety using biomarkers is proposed. In addition, therapeutic drug monitoring for those drugs when it is applicable and available is recommended to ensure efficient drug dosing and avoid adverse effects. Further research into many individual drugs are warranted.
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Affiliation(s)
- Kaifeng Chen
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.,Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yaqi Lin
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China.,Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ping Luo
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Nan Yang
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guoping Yang
- Center of Clinical Pharmacology, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Liyong Zhu
- Department of General Surgery, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qi Pei
- Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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14
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Srivastava K, Patel N, Tabbara M, Liew A, Zaghloul I, Migliore MM, Mekary RA. Thromboembolism, Bleeding, and Mortality Incidence of Direct Oral Anticoagulants Versus Warfarin Postbariatric Surgery. Am J Med 2021; 134:1403-1412.e2. [PMID: 34273283 DOI: 10.1016/j.amjmed.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no randomized controlled trial comparing direct oral anticoagulants (DOACs) and warfarin following bariatric surgery to date. The mortality, thromboembolism, and bleeding risk of DOACs in comparison with warfarin following bariatric surgery remains unclear. We aimed to provide a clinical comparison between DOACs and warfarin for these 3 prespecified outcomes. METHODS A systematic literature search was performed on November 10, 2019, using PubMed, Embase, clinicaltrial.gov, and Cochrane databases. Studies with adult patients who were on either warfarin or DOACs following bariatric surgery and reported the incidence of thromboembolism, bleeding, or mortality were included. Pooled incidence for these prespecified outcomes and its 95% confidence interval (CI) were calculated for each drug separately using the random-effects model, along with a nonadjusted P value comparing the 2 subgroups. RESULTS A total of 11 studies (805 patients) were included. Comparing DOACs to warfarin, the following pooled incidences were observed for mortality (DOACs: 3.0%; 95% CI 0.4%-18.6% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value comparing the 2 subgroups = .38), thromboembolism (DOACs: 4.9%; 95% CI 1%-21.1% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value = .18), and bleeding (DOACs: 3.9%; 95% CI 0.7%-18.2% versus warfarin: 11.3%; 95% CI 5.7%-21.4%; P value = .23). CONCLUSION The results of our meta-analysis remain hypothesis-generating, providing rationale for future randomized controlled trial design or well-designed comparative observational studies. Currently, it does not support the change in the current recommendation from warfarin to DOACs following bariatric surgery.
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Affiliation(s)
- Krutika Srivastava
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Neil Patel
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Malek Tabbara
- Department of Surgery, Maniwaki Hospital, McGill University, Montreal, Canada
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway, Galway, Ireland
| | - Iman Zaghloul
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Mattia M Migliore
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Rania A Mekary
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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15
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Braun A, Bruxner G. "Little more than a gut feeling?"-considerations when prescribing psychotropic medications to patients undergoing bariatric surgery. Australas Psychiatry 2021; 29:272-274. [PMID: 32961098 DOI: 10.1177/1039856220956468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Bariatric surgical procedures are being commonly performed increasingly, and many surgical candidates are concomitantly taking psychotropic medication. This paper aims to elucidate issues when prescribing psychiatric medication in this setting of substantial anatomical and physiological change. METHOD A hand search of the literature to assess the current understanding of effects of various bariatric procedures on the bioavailability of psychotropic medication. RESULTS Predominantly malabsorptive bariatric procedures may reduce bioavailability of some but not all commonly used psychiatric medications. There is minimal information about the effects of the most commonly performed surgery, vertical sleeve gastrectomy. Lithium prescription and monitoring requires caution. CONCLUSIONS There is limited guidance for prescription for psychotropic medication in the bariatric surgery patient group, and vigilance for unexpected adverse effects or altered efficacy is warranted.
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Affiliation(s)
- Anastasia Braun
- Royal Brisbane and Woman's Hospital Health Service District, Australia
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16
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Brown CS, Rabinstein AA, Nystrom EM, Britton JW, Singh TD. Antiseizure Medication use in Gastric Bypass Patients and Other Post-Surgical Malabsorptive States. Epilepsy Behav Rep 2021; 16:100439. [PMID: 33997757 PMCID: PMC8093413 DOI: 10.1016/j.ebr.2021.100439] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 11/02/2022] Open
Abstract
Healthcare professionals are encountering an increasing number of patients who have undergone bariatric surgeries. Antiseizure medications (ASM) have a narrow therapeutic window, and patients with malabsorptive states receiving ASM present a complex situation as the pharmacokinetics of these drugs have only been studied in patients with a normal functioning gastrointestinal tract. Patients with malabsorptive states may have altered pharmacokinetics, and there is limited literature to guide drug selection and dosage adjustment in patients with malabsorptive states. This review highlights pharmacokinetic parameters of common ASM, and considerations when managing patients on them. The effect of pH, lipophilicity, absorption, and metabolism should be taken into account when selecting and managing ASMs in this patient population. Based on these parameters, levetiracetam, and topiramate have fewer issues referable to absorption related to bariatric surgery while oral formulations of phenytoin, carbamazepine, oxcarbamazepine and valproic acid have reduced absorption due to effects of bariatric surgery based on the pharmacokinetic properties of these medications. Extended formulations should be avoided and ASM serum concentrations should be checked before and after surgery. The care of patients with epilepsy who are scheduled to undergo bariatric surgery should be guided by a multidisciplinary team including a pharmacist and a neurologist who should be involved in the adjustment of the ASMs throughout the pre-surgical and post-surgical periods.
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Affiliation(s)
- Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States
| | | | - Erin M Nystrom
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States
| | | | - Tarun D Singh
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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17
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Rössler F, Hübel K, Di Natale S, Oberkofler C, Gerber P, Bueter M, de Rougemont O. Sleeve gastrectomy enables simultaneous pancreas and kidney transplantation in severely obese recipients. Clin Transplant 2020; 35:e14197. [PMID: 33340422 DOI: 10.1111/ctr.14197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obesity adversely affects wait-listing and precludes patients with concomitant end-stage renal disease and type 1 diabetes mellitus from getting a simultaneous pancreas and kidney transplantation (SPK). OBJECTIVE To analyze safety and efficacy of laparoscopic sleeve gastrectomy (LSG) before SPK in severely obese type I diabetics. METHODS We assessed weight curve, complications, and graft function of three patients who underwent LSG before SPK. RESULTS LSG was uneventful in all patients. Body mass index dropped from 38.4 (range 35.7 - 39.9) before LSG to 28.5 (26.8 - 30.9) until SPK, with a mean loss of 25.8% (22.4 - 32.3). Interval between LSG and SPK was 364.3 (173 - 587) days. Pancreas and kidney graft function was excellent, with 100% insulin-free and dialysis-free survival over a mean follow-up of 3.6 (2.9 - 4.5) years. A1C dropped from 7% (6.3 - 8.2) before LSG to 4.9% (4.7 - 5.3) and 4.8% (4.5 - 5.1) 1 and 2 years after SPK, respectively. CONCLUSION LSG before SPK is safe and effective to enable severely obese type I diabetics to receive a lifesaving transplant. This is the first study analyzing the role of bariatric surgery before simultaneous pancreas and kidney transplantation.
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Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Samuela Di Natale
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Gerber
- Department of Endocrinology, University Hospital Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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18
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Leven C, Hoffmann C, Roche C, Couturaud F, Thereaux J, Lacut K. Impact of bariatric surgery on oral anticoagulants pharmacology, and consequences for clinical practice: a narrative review. Fundam Clin Pharmacol 2020; 35:53-61. [PMID: 32621292 DOI: 10.1111/fcp.12587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/11/2020] [Accepted: 06/28/2020] [Indexed: 11/27/2022]
Abstract
The prevalence of obesity has been steadily increasing in recent years worldwide. At the same time bariatric surgery, the best therapeutic strategy to date in terms of sustainable weight loss and improvement of associated comorbidities has been also increasing. However, these surgeries, whether primarily restrictive or malabsorptive, raise questions about the pharmacology of oral drugs. Among widely used drugs, anticoagulants are the referent therapy to treat some cardiovascular diseases such as atrial fibrillation and venous thromboembolism. How bariatric surgery may impact pharmacological properties of oral anticoagulants, and more specifically, direct oral anticoagulants (DOACs) are difficult to anticipate. In this review, we describe available data concerning the potential impact of bariatric surgery on the pharmacology of oral anticoagulants. The vitamin K antagonists (VKAs) requirements for the same international normalized ratio target are reduced after bariatric surgery. Limited data available for dabigatran 150 mg twice daily indicate a risk of insufficient efficacy in atrial fibrillation after gastric bypass due to probable impaired absorption. Data for rivaroxaban at the prophylactic dose of 10 mg per day suggest no impact of bariatric surgery from 3 days to 8 months post-surgery. However, no conclusive data are available for other anticoagulants or the use of DOACs at therapeutic doses. To date, DOACs are not recommended in patients who have undergone bariatric surgery, because of limited available data. Pending new studies to confirm the predictable pharmacokinetics and safety of DOACs in this population, especially at therapeutic doses, VKAs remain the first option for chronic anticoagulation.
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Affiliation(s)
- Cyril Leven
- Département de Biochimie et Pharmaco-toxicologie, Hôpital de la Cavale Blanche, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France.,Université de Bretagne Occidentale, Brest, EA3878, France
| | - Clément Hoffmann
- Université de Bretagne Occidentale, Brest, EA3878, France.,Département de Médecine Interne, Médecine vasculaire et pneumologie, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France
| | - Charles Roche
- Service de chirurgie viscérale, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France
| | - Francis Couturaud
- Université de Bretagne Occidentale, Brest, EA3878, France.,Département de Médecine Interne, Médecine vasculaire et pneumologie, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France
| | - Jérémie Thereaux
- Université de Bretagne Occidentale, Brest, EA3878, France.,Service de chirurgie viscérale, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France
| | - Karine Lacut
- Université de Bretagne Occidentale, Brest, EA3878, France.,Département de Médecine Interne, Médecine vasculaire et pneumologie, CHU Brest, Bd Tanguy Prigent, Brest Cedex, F-29609, France
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19
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Porat D, Dahan A. Medication Management after Bariatric Surgery: Providing Optimal Patient Care. J Clin Med 2020; 9:jcm9051511. [PMID: 32429592 PMCID: PMC7290848 DOI: 10.3390/jcm9051511] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022] Open
Abstract
Substantially altered gastrointestinal anatomy/physiology after bariatric surgery presents new challenges for the proper medication management of these patients; drug absorption and bioavailability may increase, decrease, or remain unchanged post surgery, depending on the specific drug in question and the type of bariatric procedure. In this article, we offer a concise overview of the various aspects of this clinically significant issue, aiming to provide readers with a clear understanding as well as practical tools to handle drug management post bariatric surgery. Realizing the potentially altered pharmacokinetics of various drugs after bariatric surgery is essential for providing optimal pharmacological therapy and overall patient care.
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Affiliation(s)
| | - Arik Dahan
- Correspondence: ; Tel.: +972-8-6479483; Fax: +972-8-6479303
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20
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Yska JP, Wanders JTM, Odigie B, Apers JA, Emous M, Totté ERE, Boerma EC, Ubels FL, Woerdenbag HJ, Frijlink HW, Wilffert B, van Roon EN. Effect of Roux-en-Y gastric bypass on the bioavailability of metoprolol from immediate and controlled release tablets: a single oral dose study before and after surgery. Eur J Hosp Pharm 2020; 27:e19-e24. [PMID: 32296500 DOI: 10.1136/ejhpharm-2018-001804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 11/04/2022] Open
Abstract
Objective Roux-en-Y gastric bypass (RYGB) surgery induces major changes in the gastrointestinal tract that may alter the pharmacokinetics of orally administered drugs. Results from pharmacokinetic studies are sparse. This study aimed to investigate the effect of RYGB on the bioavailability of metoprolol from immediate release (IR) and controlled release (CR) tablets in female patient volunteers before and after surgery. Methods An explorative, two-phase, single oral dose pharmacokinetic study of metoprolol in female patients undergoing RYGB was carried out. The dose was administered twice in each patient, 1 month before and 6 months after surgery. After intake of either 100 mg of metoprolol IR or CR tablet serum concentration-time profiles of metoprolol were determined. The endpoint was the ratio of AUCafter/AUCbefore of metoprolol. Results Twelve patients were included in the study (metoprolol IR: 7; metoprolol CR: 5). After intake of a metoprolol IR tablet major intraindividual and interindividual differences for area under the serum concentration versus time curve (AUC) of metoprolol before and after surgery were observed (range ratio AUC0-10 hours after/AUC0-10 hours before: 0.74-1.98). For metoprolol CR tablets a significant reduction in bioavailability of metoprolol was observed after surgery (range ratio AUC0-24 hours after/AUC0-24 hours before: 0.43-0.77). Conclusion RYGB may influence the bioavailability of metoprolol from an IR tablet. The magnitude of changes in bioavailability after RYGB requires close monitoring of patients using metoprolol IR tablets and dose adjustment if deemed necessary. RYGB clearly reduces the bioavailability of metoprolol from a CR tablet. After RYGB clinicians may consider to increase the dose according to clinical response.
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Affiliation(s)
- Jan Peter Yska
- Department of Clinical Pharmacy and Clinical Pharmacology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Jacquelien T M Wanders
- Department of Clinical Pharmacy and Clinical Pharmacology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Blessing Odigie
- Department of Clinical Pharmacy and Clinical Pharmacology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Jan A Apers
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Marloes Emous
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Erik R E Totté
- Department of Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Froukje L Ubels
- Department of Internal Medicine, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Herman J Woerdenbag
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Groningen, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Groningen, The Netherlands
| | - Bob Wilffert
- Unit of Pharmacotherapy, Pharmacoepidemiology and Pharmacoeconomics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Eric N van Roon
- Department of Clinical Pharmacy and Clinical Pharmacology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands.,Unit of Pharmacotherapy, Pharmacoepidemiology and Pharmacoeconomics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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21
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McGrane IR, Salyers LA, Molinaro JR, Munjal RC. Roux-en-Y Gastric Bypass and Antipsychotic Therapeutic Drug Monitoring: Two Cases. J Pharm Pract 2020; 34:503-506. [PMID: 32067562 DOI: 10.1177/0897190020905467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many patients with psychiatric conditions undergo bariatric surgery. The Roux-en-Y gastric bypass (RYGB) procedure alters medication pharmacokinetic properties and may have significant impact on drug response. Our report is the first to describe atypical antipsychotic therapeutic drug monitoring in patients who have undergone RYGB. The first patient is a 53-year-old female with a stable psychiatric condition undergoing a laparoscopic RYGB. Her medications prior and following the procedure include bupropion, fluvoxamine, lurasidone, methylphenidate, oxcarbazepine, and verapamil. A concentration steady-state lurasidone concentration obtained prior to the procedure was 20 ng/mL and returned at 8.1 ng/mL, 29 days after surgery. The second patient is a 42-year-old female psychiatric inpatient who had previously undergone an RYGB procedure. Medications on admission included phenytoin, oxcarbazepine, risperidone, and venlafaxine. The patient was believed to be a good candidate for a long-acting antipsychotic and paliperidone was chosen. After concentration-steady-state on 6 mg oral paliperidone, a 23.5-hour trough level was drawn. The patient was noted to be improved on the oral paliperidone, the paliperidone long-acting injection was given, and the patient was discharged. After discharge, the paliperidone concentration returned very low at 1.1 ng/mL. We describe the contributions of drug-drug interactions, medication release mechanisms, and food coadministration that may have affected our therapeutic drug monitoring. Our therapeutic drug monitoring results need to be replicated prior to use in the general population but suggest that oral extended-release drug formulations are particularly poor choices and that nonoral antipsychotic formulations may be preferred in some patients who have undergone RYBG.
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Affiliation(s)
- Ian R McGrane
- Skaggs School of Pharmacy, College of Health Professions & Biomedical Sciences, 307078University of Montana, Missoula, MT, USA
| | - Laura A Salyers
- Department of Psychiatry, 3279Providence St. Patrick Hospital, Missoula, MT, USA
| | - Jason R Molinaro
- Department of Psychiatry, 3279Providence St. Patrick Hospital, Missoula, MT, USA
| | - Robert C Munjal
- Department of Psychiatry, 3279Providence St. Patrick Hospital, Missoula, MT, USA
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22
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Simoni AH, Ladebo L, Christrup LL, Drewes AM, Johnsen SP, Olesen AE. Chronic abdominal pain and persistent opioid use after bariatric surgery. Scand J Pain 2019; 20:239-251. [DOI: 10.1515/sjpain-2019-0092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/17/2019] [Indexed: 12/13/2022]
Abstract
Abstract
Background and aims
Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery.
Methods
PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening.
Results
Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3–61% of subjects with health care contacts or readmissions 1–5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4–14% initiated a persistent opioid use 1–7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects.
Conclusions
Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.
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Affiliation(s)
- Amalie H. Simoni
- Danish Center for Clinical Health Service Research (DACS), Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Louise Ladebo
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - Lona L. Christrup
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - Asbjørn M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Service Research (DACS), Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Anne E. Olesen
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Department of Clinical Pharmacology , Aalborg University Hospital , Gartnerboligen, Ground Floor, Mølleparkvej 8a , 9000 Aalborg , Denmark , Phone: +45 97664376
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23
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Bishop-Freeman SC, Skirnick O, Noble CN, Eagerton DH, Winecker RE. Effects of Bariatric Surgery Observed in Postmortem Toxicology Casework. J Anal Toxicol 2019; 43:651-659. [PMID: 31424074 DOI: 10.1093/jat/bkz062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 12/28/2022] Open
Abstract
Bariatric surgery has been on the rise and patients often have multiple indications for pre- and post-operative pharmacotherapy. Procedures target the stomach and/or small intestine and affect weight loss through restriction, malabsorption, or a combination of the two. The absorption and/or metabolism of drugs via the gastrointestinal tract could be altered by different mechanisms. Several cases at the North Carolina Office of the Chief Medical Examiner's Toxicology Laboratory (NCOCME) have raised questions about the potential impact of these procedures on the disposition of drugs in the body and how that altered disposition may affect cause and manner of death. Overmedication and postmortem redistribution are not enough to explain the phenomena seen in some NCOCME bariatric surgery-related casework. Case examples include a 46-year-old female with a history of Roux-en-Y gastric bypass (RYGB) who suffered a witnessed collapse. Toxicological findings included elevated concentrations of oxymorphone at 0.49 mg/L in vena cava blood. A 67-year-old female, who died from vomiting and bacterial gastritis one day after placement of two intragastric weight-loss balloons, had elevated concentrations of duloxetine at 1.4 mg/L in the iliac vein blood and 9.3 mg/kg in the liver. Her medication was strictly controlled by her sister and gastric contents were without intact tablets or residue at autopsy.
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Affiliation(s)
| | - Olivia Skirnick
- North Carolina Office of the Chief Medical Examiner, Raleigh, NC, USA
| | | | - David H Eagerton
- Campbell University, College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - Ruth E Winecker
- Center for Forensic Sciences, RTI International, Research Triangle Park, NC, USA
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Angeles PC, Robertsen I, Seeberg LT, Krogstad V, Skattebu J, Sandbu R, Åsberg A, Hjelmesaeth J. The influence of bariatric surgery on oral drug bioavailability in patients with obesity: A systematic review. Obes Rev 2019; 20:1299-1311. [PMID: 31232513 PMCID: PMC6852510 DOI: 10.1111/obr.12869] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/30/2019] [Accepted: 03/31/2019] [Indexed: 12/16/2022]
Abstract
Anatomical changes in the gastrointestinal tract and subsequent weight loss may influence drug disposition and thus drug dosing following bariatric surgery. This review systematically examines the effects of bariatric surgery on drug pharmacokinetics, focusing especially on the mechanisms involved in restricting oral bioavailability. Studies with a longitudinal before-after design investigating the pharmacokinetics of at least one drug were reviewed. The need for dose adjustment following bariatric surgery was examined, as well as the potential for extrapolation to other drugs subjected to coinciding pharmacokinetic mechanisms. A total of 22 original articles and 32 different drugs were assessed. The majority of available data is based on Roux-en-Y gastric bypass (RYGBP) (18 of 22 studies), and hence, the overall interpretation is more or less limited to RYGBP. In the case of the majority of studied drugs, an increased absorption rate was observed early after RYGBP. The effect on systemic exposure allows for a low degree of extrapolation, including between drugs subjected to the same major metabolic and transporter pathways. On the basis of current understanding, predicting the pharmacokinetic change for a specific drug following RYGBP is challenging. Close monitoring of each individual drug is therefore recommended in the early postsurgical phase. Future studies should focus on the long-term effects of bariatric surgery on drug disposition, and they should also aim to disentangle the effects of the surgery itself and the subsequent weight loss.
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Affiliation(s)
- Philip Carlo Angeles
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida Robertsen
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | | | - Veronica Krogstad
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Julie Skattebu
- Library of Health Sciences, Vestfold Hospital Trust, Tønsberg, Norway
| | - Rune Sandbu
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Anders Åsberg
- Section of Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Jøran Hjelmesaeth
- Morbid Obesity Centre, Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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25
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Lubberman FJE, van der Graaf WTA, Xu L, Cleton A, Demetri GD, Gelderblom H, van Erp NP. The effect of gastrectomy on regorafenib exposure and progression-free survival in patients with advanced gastrointestinal stromal tumours. Br J Clin Pharmacol 2019; 85:2399-2404. [PMID: 31290566 PMCID: PMC6783594 DOI: 10.1111/bcp.14061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/22/2019] [Accepted: 07/04/2019] [Indexed: 12/29/2022] Open
Abstract
Aims We investigated whether major gastrectomy influences the plasma exposure of regorafenib and treatment outcome. Methods Efficacy and pharmacokinetic data from 133 gastrointestinal stromal tumour patients included in a phase III trial were analysed. Patients were subdivided into 2 groups according to the extent of the gastrectomy (no/nonsignificant gastrectomy and major gastrectomy). Progression‐free survival (PFS) on regorafenib was measured and regorafenib and its pharmacological active metabolites plasma exposure were measured. Results A total of 133 patient were included, of whom 27 underwent major gastrectomy. In patients with no/nonsignificant gastrectomy the median PFS was 145 (interquartile range 43–281) days. The PFS in patients with a major gastrectomy was 172 (interquartile range 57–280) days. Regorafenib pharmacokinetic samples were collected in 80 patients of which 19 patients with a major gastrectomy and 61 patients with no/nonsignificant gastric surgery. The average ± standard deviation total concentration of regorafenib including the metabolites M‐2 and M‐5 was 6.9 ± 1.53 μmol/L and 6.7 ± 1.56 μmol/L in patient with major gastrectomy and no/nonsignificant gastrectomy respectively. Conclusion Our study shows that major gastrectomy did not influence plasma exposure of regorafenib and metabolites. In addition, no difference in PFS between the subgroups was seen.
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Affiliation(s)
- Floor J E Lubberman
- Department of pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Lei Xu
- Bayer HealthCare Pharmaceuticals, Whippany, NJ, USA
| | | | - George D Demetri
- Dana-Farber Cancer Institute, Harvard Medical School, Department of Oncology, Boston, MA, USA
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nielka P van Erp
- Department of pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
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26
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Hatton GB, Madla CM, Rabbie SC, Basit AW. All disease begins in the gut: Influence of gastrointestinal disorders and surgery on oral drug performance. Int J Pharm 2018; 548:408-422. [PMID: 29969711 DOI: 10.1016/j.ijpharm.2018.06.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
The term "disease" conjures a plethora of graphic imagery for many, and the use of drugs to combat symptoms and treat underlying pathology is at the core of modern medicine. However, the effects of the various gastrointestinal diseases, infections, co-morbidities and the impact of gastrointestinal surgery on the pharmacokinetic and pharmacodynamic behaviour of drugs have been largely overlooked. The better elucidation of disease pathology and the role of underlying cellular and molecular mechanisms have increased our knowledge as far as diagnoses and prognoses are concerned. In addition, the recent advances in our understanding of the intestinal microbiome have linked the composition and function of gut microbiota to disease predisposition and development. This knowledge, however, applies less so in the context of drug absorption and distribution for orally administered dosage forms. Here, we revisit and re-evaluate the influence of a portfolio of gastrointestinal diseases and surgical effects on the functionality of the gastrointestinal tract, their implications for drug delivery and attempt to uncover significant links for clinical practice.
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Affiliation(s)
- Grace B Hatton
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Christine M Madla
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Sarit C Rabbie
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Abdul W Basit
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom.
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27
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Pharmacokinetics in Morbid Obesity: Influence of Two Bariatric Surgery Techniques on Paracetamol and Caffeine Metabolism. Obes Surg 2018; 27:3194-3201. [PMID: 28560524 DOI: 10.1007/s11695-017-2745-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of the study was to study the impact of the two most common bariatric surgery techniques on paracetamol pharmacokinetics (a marker of gastric emptying) and caffeine metabolism (a marker of liver function). MATERIALS AND METHODS In the present prospective study, we studied 24 morbid obese patients before, at 4 weeks, and 6 months after having undergone sleeve gastrectomy (n = 10) or Roux-en-Y gastric bypass (n = 14). For comparative purposes, 28 healthy controls (14 normal weights and 14 overweights) were also included in the study. RESULTS Paracetamol pharmacokinetics was altered in the obese participants leading to lower bioavailability. Bariatric surgery resulted in faster absorption and normalized pharmacokinetic parameters, prompting an increase in paracetamol bioavailability. No differences were found between surgical procedures. In the case of caffeine, the ratio paraxanthine/caffeine did not differ between morbid obese and healthy individuals. This ratio remained unmodified after surgery, indicating that the liver function (assessed by cytochrome P450 1A2 activity) was unaffected by obesity or bariatric surgery. CONCLUSIONS Paracetamol pharmacokinetics and caffeine plasma levels are altered in severely obese patients. The two studied bariatric surgical techniques normalize paracetamol oral bioavailability without impairing the liver function (measured by cytochrome P450 1A2 activity).
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29
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Hachon L, Declèves X, Faucher P, Carette C, Lloret-Linares C. RYGB and Drug Disposition: How to Do Better? Analysis of Pharmacokinetic Studies and Recommendations for Clinical Practice. Obes Surg 2017; 27:1076-1090. [PMID: 28124236 DOI: 10.1007/s11695-016-2535-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An important issue in the follow-up of patients with bariatric surgery remains to determine whether their therapeutic management should be different after surgery. In this article, we first reviewed all pharmacokinetic studies involving at least four subjects who underwent the Roux-en-Y gastric bypass (RYGB) bariatric surgery. Twenty-five publications were selected and, overall, 25 drugs were studied. Drug solubility and permeability parameters for each drug were defined using different parameters or classifications. Increased rates of oral drug absorption were predominantly observed. Conversely, drug exposure differed from one drug to another. Considering the galenic formulation and the Biopharmaceutics Classification System (BCS) class may help the prediction of oral drug exposure outcome after RYGB. We propose a strategy aiming to guide prescription and drug monitoring in patients with RYGB. But further research is clearly needed due to the unique characteristics of the bariatric population. Priority should be given to drugs that do not have clinical or biological surrogates for dose adaptation.
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Affiliation(s)
- Lorry Hachon
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France.,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France
| | - Xavier Declèves
- Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Pharmacokinetics and Pharmacochemistry Unit, Paris, F-75014, France
| | - Pauline Faucher
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital La Pitié Salpêtrière, Paris, France
| | - Claire Carette
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Célia Lloret-Linares
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France. .,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.
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30
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Lee DH, Kim MJ, Song EJ, Kim JH, Ahn J, Nam YD, Jang YJ, Ha TY, Jung CH. Nutrikinetic study of genistein metabolites in ovariectomized mice. PLoS One 2017; 12:e0186320. [PMID: 29059247 PMCID: PMC5653299 DOI: 10.1371/journal.pone.0186320] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/28/2017] [Indexed: 11/18/2022] Open
Abstract
This study was designed to evaluate the effect of ovariectomy on nutrikinetics of genistein metabolites. To characterize the time-dependent changes in genistein metabolite concentrations, we identified 13 genistein metabolites using ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry. The nutrikinetics of the individual metabolites at different time points were analyzed. Nutrikinetic analysis showed that genistein, genistein 4'-glucuronide, genistein 7-glucuronide, 3-hydroxygenistein, and hippuric acid showed relatively high bioavailability in the sham group compared to that in the ovariectomy group, suggesting that ovariectomy likely results in lower genistein bioavailability. These results may be related to alteration of gut microbiota by ovariectomy. The relative abundance of species of the Parabacteroides, Dorea, and Butyricimonas genera, and Desulfovibrionaceae_unclassified, Lachnospiraceae_unclassified, and Rikenellaceae_unclassified families increased in the ovariectomy group while the relative abundance of 523_7_unclassified and Y52_unclassified_unclassified increased in the sham group. These results suggest that gut microbiota alteration by ovariectomy may affect genistein bioavailability.
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Affiliation(s)
- Da-Hye Lee
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
| | - Min Jung Kim
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
| | - Eun-Ji Song
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
- Research Group of Gut Microbiome, Korea Food Research Institute, Seongnam, Republic of Korea
| | - Jin Hee Kim
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
| | - Jiyun Ahn
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
| | - Young-Do Nam
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
- Research Group of Gut Microbiome, Korea Food Research Institute, Seongnam, Republic of Korea
| | - Young-Jin Jang
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
| | - Tae-Youl Ha
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
| | - Chang Hwa Jung
- Research Group of Metabolic Mechanism, Korea Food Research Institute, Seongnam, Republic of Korea
- Department of Food Biotechnology, Korea University of Science and Technology, Seongnam, Republic of Korea
- * E-mail:
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31
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Hachon L, Reis R, Labat L, Poitou C, Jacob A, Declèves X, Lloret-Linares C. Morphine and metabolites plasma levels after administration of sustained release morphine in Roux-en-Y gastric bypass subjects versus matched control subjects. Surg Obes Relat Dis 2017; 13:1869-1874. [PMID: 28864105 DOI: 10.1016/j.soard.2017.07.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/18/2017] [Accepted: 07/25/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Better knowledge of opioid pharmacology after Roux-en-Y gastric bypass (RYGB) is required for optimizing their use in this growing population. OBJECTIVE The aim of this case-controlled pharmacokinetic (PK) study was to compare morphine and its glucuronidated metabolites (morphine-3-glucuronide and morphine-6-glucuronide) plasma PKs between patients with RYGB and their controls. SETTINGS University hospital, Lariboisière Hospital, Paris. METHODS Thirty milligrams of morphine as a sustained-release formulation was orally administered in 12 women who had undergone RYGB for at least 2 years (RYGB group) and in their nonsurgical controls matched for sex, body mass index (±2 points), and age (±5 yr). Morphine, morphine-3-glucuronide, and morphine-6-glucuronide plasma concentrations over a 12-hour period were determined by a validated method using liquid chromatography mass spectrometry in tandem. Drowsiness, respiratory rate, and oxygen saturation were monitored during the PK visit. RESULTS Morphine oral area under the curve (for time 0-12 hr; 115.8 ± 108.0 nmol.hr/L and 86.9 ± 38.8 nmol.hr/L for RYGB group and control group, respectively, P = .71), morphine at maximal concentration, metabolites oral area under the curve (for time 0-12 hr), and other PK parameters were similar between groups. After drug administration, mean drowsiness was superior in RYGB group. Mean respiratory rate and oxygen saturation were similar in both groups. CONCLUSION No dose adjustment seems to be needed for sustained release morphine when prescribed to RYGB patients.
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Affiliation(s)
- Lorry Hachon
- Inserm U1144, Paris, France; Therapeutic Research Unit, Department of Internal Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - Rafael Reis
- Inserm U1144, Paris, France; Biologie du médicament et Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Laurence Labat
- Inserm U1144, Paris, France; Biologie du médicament et Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France; Université Paris Descartes, UMR-S 1144, Paris, France
| | - Christine Poitou
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Service de Nutrition, Université Pierre et Marie Curie, Institut cardiométabolisme et nutrition (ICAN), Paris, France
| | - Aude Jacob
- Inserm U1144, Paris, France; Université Paris Descartes, UMR-S 1144, Paris, France
| | - Xavier Declèves
- Inserm U1144, Paris, France; Biologie du médicament et Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France; Université Paris Descartes, UMR-S 1144, Paris, France
| | - Celia Lloret-Linares
- Inserm U1144, Paris, France; Therapeutic Research Unit, Department of Internal Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Paris, France; Université Paris Diderot, UMR-S 1144, Paris, France.
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32
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Martin KA, Lee CR, Farrell TM, Moll S. Oral Anticoagulant Use After Bariatric Surgery: A Literature Review and Clinical Guidance. Am J Med 2017; 130:517-524. [PMID: 28159600 PMCID: PMC5401640 DOI: 10.1016/j.amjmed.2016.12.033] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 12/13/2022]
Abstract
Bariatric surgery may alter the absorption, distribution, metabolism, or elimination (disposition) of orally administered drugs via changes to the gastrointestinal tract anatomy, body weight, and adipose tissue composition. As some patients who have undergone bariatric surgery will need therapeutic anticoagulation for various indications, appropriate knowledge is needed regarding anticoagulant drug disposition and resulting efficacy and safety in this population. We review general considerations about oral drug disposition in patients after bariatric surgery, as well as existing literature on oral anticoagulation after bariatric surgery. Overall, available evidence on therapeutic anticoagulation is very limited, and individual drug studies are necessary to learn how to safely and effectively use the direct oral anticoagulants. Given the sparsity of currently available data, it appears most prudent to use warfarin with international normalized ratio monitoring, and not direct oral anticoagulants, when full-dose anticoagulation is needed after bariatric surgery.
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Affiliation(s)
- Karlyn A Martin
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill.
| | - Craig R Lee
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Timothy M Farrell
- Division of Gastrointestinal Surgery, University of North Carolina at Chapel Hill
| | - Stephan Moll
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill
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33
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Van Den Abeele J, Rubbens J, Brouwers J, Augustijns P. The dynamic gastric environment and its impact on drug and formulation behaviour. Eur J Pharm Sci 2017; 96:207-231. [DOI: 10.1016/j.ejps.2016.08.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/08/2023]
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34
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Gesquiere I, Hens B, Van der Schueren B, Mols R, de Hoon J, Lannoo M, Matthys C, Foulon V, Augustijns P. Drug disposition before and after gastric bypass: fenofibrate and posaconazole. Br J Clin Pharmacol 2016; 82:1325-1332. [PMID: 27367040 DOI: 10.1111/bcp.13054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/24/2016] [Accepted: 06/22/2016] [Indexed: 01/11/2023] Open
Abstract
AIMS Roux-en-Y gastric bypass (RYGB) alters the anatomical structure of the gastrointestinal tract, which can result in alterations in drug disposition. The aim of the present study was to evaluate the oral disposition of two compounds belonging to the Biopharmaceutical Classification System Class II - fenofibrate (bile salt-dependent solubility) and posaconazole (gastric pH-dependent dissolution) - before and after RYGB in the same individuals. METHODS A single-dose pharmacokinetic study with two model compounds - namely, 67 mg fenofibrate (Lipanthyl®) and 400 mg posaconazole (Noxafil®) - was performed in 12 volunteers pre- and post-RYGB. After oral administration, blood samples were collected at different time points up to 48 h after administration. Plasma concentrations were determined by high-performance liquid chromatography in order to calculate the area under the concentration-time curve up to 48 h (AUC0-48 h ), the peak plasma concentration (Cmax) and the time to reach peak concentration (Tmax ). RESULTS After administration of fenofibrate, no relevant differences in AUC0-48 h , Cmax and Tmax between the pre- and postoperative setting were observed. The geometric mean of the ratio of AUC0-48 h post/pre-RYGB for fenofibrate was 1.10 [95% confidence interval (CI) 0.87, 1.40; P = 0.40]. For posaconazole, an important decrease in AUC0-48 h and Cmax following RYGB was shown; the geometric mean of the AUC0-48 h post/pre-RYGB ratio was 0.68 (95% CI 0.48, 0.96; P = 0.03) and the geometric mean of the Cmax pre/post-RYGB ratio was 0.60 (95% CI 0.39, 0.94; P = 0.03). The decreased exposure of posaconazole could be explained by the increased gastric pH and accelerated gastric emptying of fluids post-RYGB. No difference for Tmax was observed. CONCLUSIONS The disposition of fenofibrate was not altered after RYGB, whereas the oral disposition of posaconazole was significantly decreased following RYGB.
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Affiliation(s)
- Ina Gesquiere
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Bart Hens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Raf Mols
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jan de Hoon
- Center for Clinical Pharmacology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Matthias Lannoo
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium.,Department of Abdominal Surgery, KU Leuven/University Hospitals Leuven, Leuven, Belgium
| | - Christophe Matthys
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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35
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Elliott KR, Harmatz JS, Zhao Y, Greenblatt DJ. Body Size Changes Among National Collegiate Athletic Association New England Division III Football Players, 1956-2014: Comparison With Age-Matched Population Controls. J Athl Train 2016; 51:373-81. [PMID: 27159189 DOI: 10.4085/1062-6050-51.5.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CONTEXT Collegiate football programs encourage athletes to pursue high body weights. OBJECTIVE To examine position-dependent trends over time in body size characteristics among football players in the National Collegiate Athletic Association Division III New England Small College Athletic Conference (NESCAC) from 1956 to 2014 and to compare the observed absolute and relative changes with those in age-matched male population controls. DESIGN Descriptive laboratory study. SETTING Medical school affiliated with a NESCAC institution. PATIENTS OR OTHER PARTICIPANTS Football team rosters from the 10-member NESCAC schools, available as public documents, were analyzed along with body size data from general population males aged 20 to 29 years from the National Health and Nutrition Examination Survey (NHANES). MAIN OUTCOME MEASURE(S) Body weight, height, and calculated body mass index were evaluated using analysis of variance, linear regression, and nonlinear regression to determine the distribution features of size variables and changes associated with time (year), school, and position. RESULTS Among NESCAC linemen, absolute and relative changes over time in body weight and body mass index exceeded corresponding changes in the NHANES population controls. New England Small College Athletic Conference offensive linemen body weights increased by 37.5% from 1956 to 2014 (192 to 264 lb [86.4 to 118.8 kg]), compared with a 12% increase (164 to 184 lb [73.8 to 82.8 kg]) since 1961 in the NHANES population controls. Body mass index changed in parallel with body weight and exceeded 35 kg/m(2) in more than 30% of contemporary NESCAC offensive linemen. Among skill players in the NESCAC group, time-related changes in body size characteristics generally paralleled those in the NHANES controls. CONCLUSIONS High body weight and body mass indices were evident in offensive linemen, even among those in Division III football programs with no athletic scholarships. These characteristics may be associated with adverse cardiovascular and metabolic outcomes. We need approaches to encourage risk modification in the postfootball lifestyles of these individuals.
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Affiliation(s)
- Kayla R Elliott
- Master of Science in Biomedical Science Program, Tufts University School of Medicine, Boston, MA
| | - Jerold S Harmatz
- Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine, Boston, MA
| | - Yanli Zhao
- Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine, Boston, MA
| | - David J Greenblatt
- Master of Science in Biomedical Science Program, Tufts University School of Medicine, Boston, MA.,Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine, Boston, MA
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