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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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daSilva-deAbreu A, Rodgers JE, Seltz J, Mandras SA, Lavie CJ, Loro-Ferrer JF, Ventura HO, Schauer PR, Vest AR. Obesity, Challenges, and Weight-Loss Strategies for Patients With Ventricular Assist Devices. JACC. HEART FAILURE 2024:S2213-1779(24)00324-X. [PMID: 38904644 DOI: 10.1016/j.jchf.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 03/26/2024] [Accepted: 04/02/2024] [Indexed: 06/22/2024]
Abstract
For adults with advanced heart failure, class II/III obesity (body mass index ≥35 kg/m2) represents major challenges, and it is even considered a contraindication for heart transplantation (HT) at many centers. This has led to growing interest in preventing and treating obesity to help patients with advanced heart failure become HT candidates. Among all weight-loss strategies, bariatric surgery (BSx) has the greatest weight loss efficacy and has shown value in enabling select patients with left ventricular assist devices (LVADs) and obesity to lose sufficient weight to access HT. Nevertheless, both BSx and antiobesity medications warrant caution in the LVAD population. In this review, the authors describe and interpret the available published reports on the impact of obesity and weight-loss strategies for patients with LVADs from general and HT candidacy standpoints. The authors also provide an overview of the journey of LVAD recipients who undergo BSx and review major aspects of perioperative protocols.
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Affiliation(s)
- Adrian daSilva-deAbreu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Doctoral School, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jessica Seltz
- Frances Stern Nutrition Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Stacy A Mandras
- Transplant Institute, AdventHealth Orlando, Orlando, Florida, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the University of Queensland School of Medicine New Orleans, Louisiana, USA
| | | | - Hector O Ventura
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the University of Queensland School of Medicine New Orleans, Louisiana, USA
| | - Philip R Schauer
- Metamor Metabolic Institute, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Amanda R Vest
- Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
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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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Patel PH, Ho T, Upadhyay SM. A Systematic Review of Warfarin Use in Post-Bariatric Surgery Patients: Cases Compiled From a Literature Review. Ann Pharmacother 2023; 57:193-197. [PMID: 35699512 DOI: 10.1177/10600280221105312] [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: 01/05/2023] Open
Abstract
OBJECTIVE The objective of this review was to provide dosing recommendations for percentage change in weekly warfarin dose and rates of thrombotic and bleeding events in patients requiring long-term warfarin therapy after bariatric surgery. DATA SOURCES A comprehensive literature search of PubMed (through April 5, 2021), Cochrane Library, and Google Scholar (through April 5, 2021) databases was completed using the keywords warfarin OR vitamin k antagonist AND bariatric surgery. STUDY SELECTION AND DATA EXTRACTION Retrospective studies and matched-cohort studies evaluating preoperative and postoperative use of warfarin after bariatric surgery for obesity were considered. Weekly dose defined as sum of daily doses of warfarin for 7 consecutive days was a required outcome to be considered in this review. Patients were excluded from review if post-operative dosage change was not reported. DATA SYNTHESIS Six studies were included with a total of 160 patients who met the criteria. A decrease in average warfarin dose was seen in all studies, with the largest decrease occurring at 1 month postsurgery followed by an upward trend toward baseline about 90 days postsurgery. While thrombotic events were observed in none of the patients, there was an increased risk of bleeding in patients, particularly in those who underwent roux-en-y gastric bypass (RYGB) surgery. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The study provides a specific warfarin dosing titration regimen, as well as embolic and bleed risk in post-bariatric surgery population. CONCLUSIONS Clinicians may consider lowering warfarin weekly dose by about 25% immediately postsurgery, with doses approaching closer to baseline about 90 days postsurgery.
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Affiliation(s)
- Pooja H Patel
- Department of Pharmacy Practice, Texas A&M University, Houston, TX, USA
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Direct oral Xa inhibitors for the treatment of venous thromboembolism after bariatric surgery. Blood Adv 2022; 7:224-226. [PMID: 35640233 PMCID: PMC9841032 DOI: 10.1182/bloodadvances.2021006696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 01/21/2023] Open
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Lupoli R, Lembo E, Giosuè A, Schiavo L, Capaldo B. Clinical insights into management options for recurrent type 2 diabetes and cardiovascular risk after metabolic-bariatric surgery. Nutr Metab Cardiovasc Dis 2022; 32:1335-1342. [PMID: 35365370 DOI: 10.1016/j.numecd.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
AIMS Long-term clinical trials evaluating the effects of metabolic-bariatric surgery (MBS) on type 2 diabetes (T2D) demonstrate that a significant proportion of patients either fail to achieve remission or experience T2D recurrence over time. Furthermore, patients with recurrent T2D might require reinstitution of pharmacotherapy to control comorbidities (hypertension, dyslipidemia). This paper reviews therapeutic options in patients with T2D relapse. DATA SYNTHESIS Although presently there is no recommended pharmacological strategy, the available data support GLP-1 analogues (GLP-1a) as the most suitable option to control hyperglycemia post-MBS. Beside their efficacy in lowering glycemia and body weight while preserving lean mass, GLP-1a exert cardiovascular/renal-protection and are also safe and well tolerated in surgical patients. In addition, the s.c. route of administration of these medications circumvents the problem of changes in oral drugs bioavailability following MBS. Of note, the available data refers to liraglutide and needs to be confirmed with weekly GLP-1a agents. Information regarding the impact of MBS on the pharmacokinetics of lipid lowering and anti-hypertensive drugs is scarce and inconclusive. The findings indicate that timing from intervention is particularly important because of adaptive intestinal mechanisms. CONCLUSIONS The recurrence of T2D following MBS is a clinically relevant issue. GLP-1a therapy represents the best option to improve glycemic and weight control with good tolerability. Long-term clinical trials will clarify the impact of these drugs on cardiovascular outcomes. A close monitoring of MBS patients is advised to guide drug dosage adjustments and ensure the control of cardiovascular risk factors.
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Affiliation(s)
- Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Erminia Lembo
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy
| | - Annalisa Giosuè
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy.
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Impact of Laparoscopic Sleeve Gastrectomy on Cardiovascular Pharmacotherapy in Left Ventricular Assist Device Patients. J Cardiovasc Pharmacol 2022; 79:646-649. [DOI: 10.1097/fjc.0000000000001223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/24/2021] [Indexed: 11/26/2022]
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Nasser MF, Jabri A, Gandhi S, Rader F. Oral Anticoagulant Use in Morbid Obesity and Post Bariatric Surgery: A Review. Am J Med 2021; 134:1465-1475. [PMID: 34403701 DOI: 10.1016/j.amjmed.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
Bariatric surgery has emerged as a therapy for obesity and the associated comorbidities. Obesity has been shown to be a risk factor for atrial fibrillation as well as venous thromboembolism, both of which are conditions that warrant anticoagulation. There is significant underrepresentation of the morbidly obese population in prospective trials that evaluated direct oral anticoagulants and vitamin K antagonists in atrial fibrillation and venous thromboembolism. We aim to review all the available data that assessed these oral anticoagulants in the morbidly obese population (body mass index >40 kg/m2 and weight >120 kg) and in the post-bariatric surgery population. Our findings suggest that direct oral anticoagulants may be safe and effective for anticoagulation in morbidly obese patients for both atrial fibrillation and venous thromboembolism. However, warfarin is the preferred agent in the post-bariatric surgery population, given the limited number of studies on direct oral anticoagulants in this population. Further adequately powered randomized control trials are needed to confirm the safety and efficacy of these oral anticoagulants in the morbidly obese and post-bariatric surgery population.
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Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sanjay Gandhi
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
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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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10
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Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
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11
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Briggler R, Matherne E, Johnson C, Boehmer K. Recurrent Thrombi in an Obese Patient With History of Bariatric Surgery Despite Anti-Xa Therapy. J Pharm Pract 2021; 35:811-816. [PMID: 33827312 DOI: 10.1177/08971900211004837] [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: 11/16/2022]
Abstract
Obesity and gastric bypass surgery can complicate anticoagulation therapy. In general, patients post-bariatric surgery are considered to be at a moderate risk for deep venous thromboembolism or pulmonary embolism. American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists guidelines recommend chemical prophylaxis with unfractionated heparin or low molecular weight heparin after surgery until the patient is fully mobile, and for those who require chronic anticoagulation, the International Society of Thrombosis and Haemostasis recommend warfarin if body mass index (BMI) is above 40 kg/m2 or weight is more than 120 kg. Clinical decision making regarding anticoagulation in the following patient case is complicated by multiple factors, most notably the combination of obesity and history of gastric bypass surgery. This patient failed multiple anticoagulation regimens, with apixaban and rivaroxaban therapies each ending in venous thromboemboli and warfarin leading to subtherapeutic International Normalized Ratio (INR)s despite dose adjustment. However, she is currently therapeutic on the combination of enoxaparin and warfarin as shown by INR and anti-Xa level monitoring. In this case and similar instances, there could be a need for anticoagulant dose adjustments, different INR goals, or a combination of different anticoagulants. Providers should take an individualized approach to patients who have had bariatric surgery with elevated BMI as a key factor in anticoagulant selection.
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Affiliation(s)
- Rachel Briggler
- 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Emma Matherne
- 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Chris Johnson
- Pharmacy Practice, 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Kaci Boehmer
- Pharmacy Practice, 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
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12
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Wadsworth D, Sullivan E, Jacky T, Sprague T, Feinman H, Kim J. A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant. J Clin Pharm Ther 2021; 46:560-570. [PMID: 33393699 DOI: 10.1111/jcpt.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
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Affiliation(s)
- Daniel Wadsworth
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Emma Sullivan
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas Jacky
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Taylor Sprague
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Hannah Feinman
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer Kim
- Cone Health Department of Internal Medicine, Greensboro, NC, USA
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13
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, Sharma K, Watthanasuntorn K, Lertjitbanjong P, Pachariyanon P, Prechawat S, Mao MA, Torres‐Ortiz A, Cheungpasitporn W. Incident atrial fibrillation in patients undergoing bariatric surgery: a systematic review and meta‐analysis. Intern Med J 2020; 50:810-817. [DOI: 10.1111/imj.14436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of MedicineFaculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok Thailand
| | | | - Tarun Bathini
- Department of Internal MedicineUniversity of Arizona Tucson Arizona USA
| | - Konika Sharma
- Department of Internal MedicineBassett Medical Center Cooperstown New York USA
| | | | | | - Pavida Pachariyanon
- Department of Internal MedicineTexas Tech University Health Sciences Center Lubbock Texas USA
| | - Somchai Prechawat
- Division of Cardiology, Department of MedicineFaculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok Thailand
| | - Michael A. Mao
- Department of Internal MedicineMayo Clinic Jacksonville Florida USA
| | - Aldo Torres‐Ortiz
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi USA
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14
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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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15
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Porat D, Markovic M, Zur M, Fine-Shamir N, Azran C, Shaked G, Czeiger D, Vaynshtein J, Replyanski I, Sebbag G, Dahan A. Increased Paracetamol Bioavailability after Sleeve Gastrectomy: A Crossover Pre- vs. Post-Operative Clinical Trial. J Clin Med 2019; 8:jcm8111949. [PMID: 31726725 PMCID: PMC6912358 DOI: 10.3390/jcm8111949] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/03/2019] [Accepted: 11/08/2019] [Indexed: 12/22/2022] Open
Abstract
Oral drug bioavailability may be significantly altered after laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure worldwide. Paracetamol (acetaminophen) is the post-bariatric analgesic/antipyretic drug of choice. In this work we studied and analyzed the LSG effects on systemic bioavailability and pharmacokinetics of paracetamol after oral administration of solid vs. liquid dosage form. A 4-armed, pharmacokinetic, crossover trial was performed in patients enrolled for LSG. Single paracetamol dose (500 mg), as caplet (n = 7) or syrup (n = 5), was administered before vs. 4–6 months post-LSG. Bioavailability was enhanced after LSG; in the caplet groups, average AUC0–t increased from 9.1 to 18.6 µg·h/mL with AUC0–t difference of 9.5 µg·h/mL (95% CI 4.6–14.5, p = 0.003). Cmax increased from 1.8 (95% CI 1.2–2.5) to 4.2 µg/mL (3.6–4.8) after LSG (p = 0.032). In the syrup groups, AUC0–t increased from 13.4 to 25.6 µg·h/mL, with AUC0–t difference of 12.2 µg·h/mL (95% CI 0.9–23.5, p = 0.049). Cmax changed from 5.4 (95% CI 2.5–8.4) to 7.8 µg/mL (6.1–9.6), and systemic bioavailability was complete (102%) after the surgery. Overall, decreased paracetamol exposure in obesity, with recovery to normal drug levels (caplet) or even higher (syrup) post-LSG, was revealed. In conclusion, attention to paracetamol effectiveness/safety in obesity, and after bariatric surgery, is prudent.
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Affiliation(s)
- Daniel Porat
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Milica Markovic
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Moran Zur
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya 46140, Israel
| | - Gad Shaked
- Department of Surgery B, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - David Czeiger
- Department of Surgery B, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Julie Vaynshtein
- Department of Surgery B, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Ilya Replyanski
- Department of Surgery B, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Gilbert Sebbag
- Department of Surgery B, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
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16
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Huang R, Ding X, Fu H, Cai Q. Potential mechanisms of sleeve gastrectomy for reducing weight and improving metabolism in patients with obesity. Surg Obes Relat Dis 2019; 15:1861-1871. [DOI: 10.1016/j.soard.2019.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 02/07/2023]
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17
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Quintal S, Culley CL, Hayashi A. Warfarin Absorption in Short Bowel Syndrome. J Pharm Technol 2019; 35:43-44. [PMID: 34861017 PMCID: PMC6313266 DOI: 10.1177/8755122518808291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Affiliation(s)
- Sadie Quintal
- Victoria General Hospital, Island Health,
Victoria, British Columbia, Canada
| | - Celia L. Culley
- Royal Jubilee Hospital, Island Health,
Victoria, British Columbia, Canada
- The University of British Columbia, Vancouver,
British Columbia, Canada
| | - Allen Hayashi
- The University of British Columbia, Vancouver,
British Columbia, Canada
- Island Health, Victoria, British Columbia,
Canada
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