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Dvořáčková E, Pilková A, Matoulek M, Slanař O, Hartinger JM. Bioavailability of Orally Administered Drugs After Bariatric Surgery. Curr Obes Rep 2024; 13:141-153. [PMID: 38172482 DOI: 10.1007/s13679-023-00548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery. RECENT FINDINGS The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred. The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.
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Affiliation(s)
- Eliška Dvořáčková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Clinical Pharmacy, Hospital Na Františku, Prague, Czech Republic
| | - Alena Pilková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Matoulek
- Third Internal Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Porat D, Dukhno O, Cvijić S, Dahan A. The Complexity of Bariatric Patient's Pharmacotherapy: Sildenafil Biopharmaceutics and Pharmacokinetics before vs. after Gastric Sleeve/Bypass. Pharmaceutics 2023; 15:2795. [PMID: 38140135 PMCID: PMC10747454 DOI: 10.3390/pharmaceutics15122795] [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: 11/03/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Postbariatric altered gastrointestinal (GI) anatomy/physiology may significantly harm oral drug absorption and overall bioavailability. In this work, sildenafil, the first phosphodiesterase-5 (PDE5) inhibitor, was investigated for impaired postbariatric solubility/dissolution and absorption; this research question is of particular relevance since erectile dysfunction (ED) is associated with higher body mass index (BMI). Sildenafil solubility was determined both in vitro and ex vivo, using pre- vs. postsurgery gastric contents aspirated from patients. Dissolution tests were done in conditions mimicking the stomach before surgery, after sleeve gastrectomy (post-SG, pH 5), and after one anastomosis gastric bypass (post-OAGB, pH 7). Finally, these data were included in physiologically based pharmacokinetic (PBPK) modelling (GastroPlus®) to simulate sildenafil PK before vs. after surgery. pH-dependent solubility was demonstrated with low solubility (0.3 mg/mL) at pH 7 vs. high solubility at pH 1-5, which was also confirmed ex vivo with much lower solubility values in postbariatric gastric samples. Hampered dissolution of all sildenafil doses was obtained under post-OAGB conditions compared with complete (100%) dissolution under both presurgery and post-SG conditions. PBPK simulations revealed delayed sildenafil absorption in postbariatric patients (increased tmax) and reduced Cmax, especially in post-OAGB patients, relative to a presurgery state. Hence, the effect of bariatric surgery on sildenafil PK is unpredictable and may depend on the specific bariatric procedure. This mechanistically based analysis suggests a potentially undesirable delayed onset of action of sildenafil following gastric bypass surgery.
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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, P.O. Box 653, Beer-Sheva 8410501, Israel;
| | - Oleg Dukhno
- Department of Surgery B, Soroka University Medical Center, Beer-Sheva 8410101, Israel;
| | - Sandra Cvijić
- Department of Pharmaceutical Technology and Cosmetology, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221 Belgrade, Serbia;
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel;
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Porat D, Dukhno O, Partook-Maccabi M, Vainer E, Cvijić S, Dahan A. Selective COX-2 inhibitors after bariatric surgery: Celecoxib, etoricoxib and etodolac post-bariatric solubility/dissolution and pharmacokinetics. Int J Pharm 2023; 645:123347. [PMID: 37633536 DOI: 10.1016/j.ijpharm.2023.123347] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
Anatomical/physiological gastrointestinal changes after bariatric surgery may influence the fate of orally administered drugs.Since non-selective NSAIDs are not well-tolerated post-surgery, selective cyclooxygenase-2 (COX-2) inhibitors may be important for these patients. In this work we investigated celecoxib, etoricoxib and etodolac, for impaired post-bariatric solubility/dissolution and absorption. Solubility was studied in-vitro, and ex-vivoin aspirated gastric contents from patients pre- vs. post-surgery. Dissolution was studied in conditions simulating pre- vs. post-surgery stomach. Finally, the experimental solubility data were used in physiologically-based biopharmaceutics model (PBBM) (GastroPlus®) to simulate pre- vs. post-surgery celecoxib/etoricoxib/etodolac pharmacokinetic (PK) profiles.For etoricoxib and etodolac (but not celecoxib), pH-dependent solubility was demonstrated: etoricoxib solubility decreased ∼1000-fold, and etodolac solubility increased 120-fold, as pH increased from 1 to 7, which was also confirmed ex-vivo. Hampered etoricoxib dissolution and improved etodolac dissolution post-surgery was revealed. Tablet crushing, clinically recommended after surgery, failed to improve post-bariatric dissolution. PBBM simulations revealed significantly impaired etoricoxib absorption post-surgery across all conditions; for instance, 79% lower Cmax and 53% decreased AUC was simulated post-gastric bypass procedure, after single 120 mg dose. Celecoxib and etodolac maintained unaffected absorption after bariatric surgery.This mechanistically-based analysis suggests to prefer the acidic drug etodolac or the neutral celecoxib as selective COX-2 inhibitors, over the basic drug etoricoxib, after bariatric surgery.
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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 8410501, Israel
| | - Oleg Dukhno
- Department of Surgery B, Soroka University Medical Center, Beer-Sheva 8410101, Israel
| | - Mazal Partook-Maccabi
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Ella Vainer
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Sandra Cvijić
- Department of Pharmaceutical Technology and Cosmetology, University of Belgrade-Faculty of Pharmacy, Vojvode Stepe 450, 11221 Belgrade, Serbia
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel.
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Carbamazepine Therapy After Bariatric Surgery: Eight Sleeve Gastrectomy Cases and Review of the Literature. Obes Surg 2022; 32:3481-3486. [PMID: 35994180 DOI: 10.1007/s11695-022-06247-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
Abstract
Bariatric surgery modifies the anatomy and physiology of the gastrointestinal tract. Carbamazepine (CBZ) is an anticonvulsant with multiple neuropsychiatric indications. Given CBZ physicochemical properties and narrow therapeutic index, bariatric surgery may potentially introduce clinically significant changes in CBZ oral absorption and bioavailability. In this communication, we describe eight patients undergoing sleeve gastrectomy (SG) and treated with CBZ, including therapeutic drug monitoring (TDM) and dosage adjustments at different timeframes before vs. after the surgery (< 3, 4-6, and 7-12 months post-SG), as well as clinical outcomes. We then provide a review of the available literature on CBZ therapy among bariatric patients, concluding with a mechanistic analysis of the results. Four of the eight patients presented with decreased post-SG CBZ levels, and two of them also experienced significant worsening of their previously well-controlled disease. Overall, altered CBZ levels are likely for at least a year after SG. Clinical recommendations include consultation with a clinical pharmacist, careful clinical monitoring, and periodic TDM after (vs. before) the bariatric surgery.
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Porat D, Dukhno O, Vainer E, Cvijić S, Dahan A. Antiallergic Treatment of Bariatric Patients: Potentially Hampered Solubility/Dissolution and Bioavailability of Loratadine, but Not Desloratadine, Post-Bariatric Surgery. Mol Pharm 2022; 19:2922-2936. [PMID: 35759355 DOI: 10.1021/acs.molpharmaceut.2c00292] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Gastrointestinal anatomical/physiological changes after bariatric surgery influence variables affecting the fate of drugs after ingestion, and medication management of these patients requires a thorough and complex mechanistic analysis. The aim of this research was to study whether loratadine/desloratadine antiallergic treatment of bariatric patients is at risk of being ineffective due to impaired solubility/dissolution. The pH-dependent solubility of loratadine/desloratadine was studied in vitro, as well as ex vivo, in gastric content aspirated from patients before versus after bariatric surgery. Then, a biorelevant dissolution method was developed to simulate the gastric conditions after sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB), accounting for key variables (intragastric volume, pH, and contractility), and the dissolution of loratadine/desloratadine was studied pre- versus post-surgery. Dissolution was also studied after tablet crushing or syrup ingestion, as these actions are recommended after bariatric surgery. Finally, these experimental data were implemented in a newly developed physiologically based pharmacokinetic (PBPK) model to simulate loratadine/desloratadine PK profiles pre- versus post-surgery. For both drugs, pH-dependent solubility was demonstrated, with decreased solubility at higher pH; over the pH range 1-7, loratadine solubility decreased ∼2000-fold, and desloratadine decreased ∼120-fold. Ex vivo solubility in aspirated human gastric fluid pre- versus post-surgery was in good agreement with these in vitro results and revealed that while desloratadine solubility still allows complete dissolution post-surgery, loratadine solubility post-surgery is much lower than the threshold required for the complete dissolution of the drug dose. Indeed, severely hampered loratadine dissolution was revealed, dropping from 100% pre-surgery to only 3 and 1% post-SG and post-OAGB, respectively. Tablet crushing did not increase loratadine dissolution in any post-bariatric condition, nor did loratadine syrup in post-OAGB (pH 7) media, while in post-laparoscopic SG conditions (pH 5), the syrup provided partial improvement of up to 40% dissolution. Desloratadine exhibited quick and complete dissolution across all pre-/post-surgery conditions. PBPK simulations revealed pronounced impaired absorption of loratadine post-surgery, with 84-88% decreased Cmax, 28-36% decreased Fa, and 24-31% decreased overall bioavailability, depending on the type of bariatric procedure. Desloratadine absorption remained unchanged post-surgery. We propose that desloratadine should be preferred over loratadine in bariatric patients, and as loratadine is an over-the-counter medication, antiallergic therapy after bariatric surgery requires special attention by patients and clinicians alike. This mechanistic approach that reveals potential post-surgery complexity, and at the same time provides adequate substitutions, may contribute to better pharmacotherapy and overall patient care after bariatric surgery.
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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 8410501, Israel
| | - Oleg Dukhno
- Department of Surgery B, Soroka University Medical Center, Beer-Sheva 8410101, Israel
| | - Ella Vainer
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Sandra Cvijić
- Department of Pharmaceutical Technology and Cosmetology, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221 Belgrade, Serbia
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
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Dewantoro D, Davenport R, Goh JY, Bakhshi A, Ali A. The Effect of Different Types of Bariatric Surgery on Levothyroxine Requirement in Hypothyroid Bariatric Patients. Cureus 2022; 14:e26165. [PMID: 35891866 PMCID: PMC9306411 DOI: 10.7759/cureus.26165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background Bariatric surgeries are carried out to improve a patient's quality of life, and to reduce respiratory, cardiac, endocrine, and metabolic complications encountered by those with high body mass index (BMI). A complication associated with high hypothyroidism is weight gain, which may lead to obesity. Here, we explore the effect of different bariatric procedures on thyroid function and levothyroxine dosage. Methods This is a retrospective review of 887 patients referred to a tertiary bariatric service between 2008 and 2020 and treated for hypothyroidism at the time of referral. The study identified 57 patients on thyroxine replacement. Of these, 22 underwent restrictive bariatric procedures, 16 underwent restrictive/malabsorptive procedures, and 19 did not undergo operative intervention. Comparisons were made among each group throughout the timeline of interest. Results Out of 57 patients, 50 (87.7%) were female. The average age for patients was 47.26+/- 8.89 years. The average BMI at baseline was 48.72+/- 8.68 kg/m2. The mean dose of levothyroxine in controls was 115.8+/- 53.5 mcg while that of surgical patients was 149.8+/- 68.4 mcg. There were no statistically significant differences in levothyroxine doses between surgical and control at T0 (baseline), T1 (one-year post-op in surgical patient, or two-year post referral in control patient), T2 (two-year post-op in surgical patient, or three-year post referral in control patient), and T3 (most recent result available). The surgical group was then categorized further into restrictive and restrictive/malabsorptive. When they were compared with the control group, there were no statistically significant differences in doses. A generalized linear mixed model was applied to assess differences in levothyroxine dose with time as a random variable. This was adjusted for age, sex, BMI, T4 level, and hypothyroid cause. Through this assessment, there were several statistically significant differences in levothyroxine dosage between the groups. Control group required on average 28.06 mcg less levothyroxine than the restrictive/malabsorptive group (p=0.015). Also, the restrictive group required on average 23.57 mcg less levothyroxine than the restrictive/malabsorptive group (p=0.033). There were no statistically significant differences observed between the control group and the restrictive group (p=0.67) Conclusion Patients who have bariatric surgery have changes to their anatomy and physiology which may affect both their thyroid hormone homeostasis and levothyroxine pharmacokinetics. Thus, hypothyroid bariatric patients requiring levothyroxine must have their thyroid function monitored regularly. In this study, it was found that hypothyroid patients who underwent restrictive surgery had an overall statistically significant lower levothyroxine requirement to remain euthyroid as compared to the restrictive/malabsorptive group (p=0.033). Additionally, the control group required statistically significantly less levothyroxine than the restrictive/malabsorptive group (p=0.015). These factors may determine the type of surgery chosen by hypothyroid bariatric patients. However, further studies that are randomized, controlled, and multi-center with a higher population are required.
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Change in levothyroxine requirements after bariatric surgery in patients with hypothyroidism. Endocr Regul 2022; 56:81-86. [PMID: 35489047 DOI: 10.2478/enr-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives. This study aims to evaluate the need to modify the total and weight-adjusted doses of levothyroxine after bariatric surgery, identify predictors, and assess the influence of the weight loss on the levothyroxine requirements. Methods. A retrospective study in patients with treated hypothyroidism that underwent bariatric surgery. The modification of the levothyroxine dose and its association with the weight loss and other potential predictors were evaluated at 6, 12, and 24 months post-surgery. Results. Among the 63 patients included, 82.54% needed an adjustment of levothyroxine dose during the follow-up. The total weekly dose of levothyroxine (µg) decreased post-surgery at 6 months (β= -49.1; 95%CI-93.7 to -4.5; p=0.031) and 12 months (β=-54.9; 95%CI-102 to -7.8; p=0.022), but did not significantly change at 24 months (p=0.114). The weekly weight-adjusted dose (µg/k) increased at 6 months (β=1.37; 95%CI 0.91 to 1.83; p<0.001), 12 months (β=2.05; 95%CI 1.43 to 2.67; p<0.001), and 24 months (β=2.52; 95%CI 1.74 to 3.30; p<0.001). The weight loss showed association with the weight-adjusted dose (OR=1.07; 95%CI 1.02 to 1.12; p=0.004), but not the total dose (p=0.320). Conclusions. This study shows a significant decrease in the total dose of levothyroxine requirements change after bariatric surgery during the first year of the follow-up and an increase in the weight-adjusted dose over the first two years. No predictors of modification of the total dose of levothyroxine were identified.
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Pereira-Cunill JL, Piñar-Gutiérrez A, Martínez-Ortega AJ, Serrano-Aguayo P, García-Luna PP. Medium-term complications in patients undergoing gastric bypass. ENDOCRINOL DIAB NUTR 2022; 69:240-246. [PMID: 35353678 DOI: 10.1016/j.endien.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/21/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To present our experience in the clinical follow-up of patients undergoing a gastric bypass. METHOD Description of six cases under follow-up by our unit after undergoing a gastric bypass at another private centre. RESULTS The 6 patients presented complications, the most notable being the death of one patient due to severe malnutrition and the need for revision surgery in another for the same reason, destabilisation of type 1 diabetes mellitus in another patient and fat-soluble vitamin deficiency in all of them. CONCLUSIONS There are few publications that support the safety of gastric bypass as a treatment for obesity. In our experience, it is a technique associated with a high rate of serious complications. As it is a technique that is not yet standardised, we consider that these cases should be operated on in centres where there is a multidisciplinary team with expertise in the management of possible complications, with close follow-up by surgeons and endocrinologists.
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Affiliation(s)
- José Luis Pereira-Cunill
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Piñar-Gutiérrez
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Antonio Jesús Martínez-Ortega
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pilar Serrano-Aguayo
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Pedro Pablo García-Luna
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Yska JP, Arfman IJ, van Oijen MA, de Heide LJM, Emous M, Veeger NJGM, van Roon EN. Long-term Effect of Bariatric Surgery on the Use of Levothyroxine and Thyroid Levels. Obes Surg 2021; 32:742-748. [PMID: 34855136 DOI: 10.1007/s11695-021-05810-2] [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: 07/20/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of bariatric surgery on the defined daily dose of levothyroxine (DDD LT4), thyroid-stimulating hormone (TSH), and free thyroxine (fT4) in female patients with hypothyroidism until 48 months after surgery. METHODS A retrospective observational study of hypothyroid patients who underwent bariatric surgery. Changes in DDD LT4, TSH, and fT4 over a 48 month period after surgery were analyzed. RESULTS Thirty-seven patients were included: 27 Roux-en-Y gastric bypass (RYGB), 6 sleeve gastrectomy (SG), 3 adjustable gastric band, and 1 one anastomosis gastric bypass. The median DDD LT4 decreased from 125 µg at baseline to 100 µg 12 months after surgery. From 24 to 48 months after surgery, the median DDD LT4 was stable at 125 µg. Most dose adjustments occurred during the first 24 months after surgery. In the time period of 24-48 months after surgery, the dose remained stable in 73.1% of the RYGB patients and in 60.0% of the SG patients. After 48 months in the RYGB group, no significant change in TSH and fT4 levels was observed. CONCLUSIONS Bariatric surgery led to frequent dose adjustments during the first 2 years after surgery. However, 24-48 months after surgery in the majority of patients, the dosage remained stable. No significant change in TSH and fT4 was observed 48 months after RYGB. In the first 2 years after surgery, clinicians should frequently monitor TSH and fT4 for individual dose adjustment of levothyroxine. Thereafter, the frequency of monitoring may be decreased.
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Affiliation(s)
- Jan Peter Yska
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Center Leeuwarden, PO Box 888, 8901 BR, Leeuwarden, the Netherlands.
| | - Inge J Arfman
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Center Leeuwarden, PO Box 888, 8901 BR, Leeuwarden, the Netherlands
| | - Maarten A van Oijen
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Center Leeuwarden, PO Box 888, 8901 BR, Leeuwarden, the Netherlands
| | - Loek J M de Heide
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Marloes Emous
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, Medical Center Leeuwarden, MCL Academy, Leeuwarden, the Netherlands
| | - Eric N van Roon
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Center Leeuwarden, PO Box 888, 8901 BR, Leeuwarden, the Netherlands.,Groningen Research Institute of Pharmacy, PharmacoTherapy, -Epidemiology & -Economics, University of Groningen, Groningen, the Netherlands
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Or Koca A, Öztürk D, Koca HS, Dağdeviren M, Keskin M, Buluş H. The Effect of Sleeve Gastrectomy on the Function and Volume of the Thyroid Gland. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2019.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arzu Or Koca
- Department of Endocrinology and Metabolism, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Doğan Öztürk
- Department of General Surgery, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Hüseyin Samet Koca
- Department of Otorhinolaryngology, Yüksek İhtisas University, Ankara, Turkey
| | - Murat Dağdeviren
- Department of Endocrinology and Metabolism, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Müge Keskin
- Department of Endocrinology and Metabolism, Ankara City Hospital, Ankara, Turkey
| | - Hakan Buluş
- Department of General Surgery, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Porat D, Azran C, Kais H, Dahan A. Managing the Unpredictable: Mechanistic Analysis and Clinical Recommendations for Lamotrigine Treatment after Bariatric Surgery. J Clin Med 2021; 10:jcm10235627. [PMID: 34884328 PMCID: PMC8658697 DOI: 10.3390/jcm10235627] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/24/2021] [Indexed: 01/05/2023] Open
Abstract
Bariatric surgery may alter the absorption and overall bioavailability of oral drugs. Lamotrigine is a major antiepileptic and mood stabilizer, that its use after bariatric surgery has not yet been studied. In this article, we provide a thorough mechanistic analysis of the effects of bariatric surgery on multiple mechanisms important for the absorption, bioavailability and overall pharmacokinetics of lamotrigine. Attributable to its pharmacokinetic properties and drug characteristics, the use of lamotrigine after bariatric surgery may be challenging. The complex situation in which some mechanisms may lead to increased drug exposure (e.g., decreased metabolism, weight loss) while others to its decrease (e.g., hampered dissolution/solubility, decreased gastric volume), may result in lowered, unchanged, or enhanced lamotrigine plasma levels after the surgery. We conclude with a set of clinical recommendations for lamotrigine treatment after bariatric surgery, aiming to allow better patient care, and emphasizing the extra caution that needs to be taken with these patients.
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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, P.O. Box 653, Beer-Sheva 8410501, Israel
| | - Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya 4685107, Israel
| | - Hasan Kais
- Division of Surgery, Shamir (Assaf Harofeh) Medical Center, Zerifin, Beer-Yaakov 7033001, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel
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Porat D, Azran C, Mualem Y, Vainer E, Gibori R, Vaynshtein J, Dukhno O, Dahan A. Lamotrigine therapy in patients after bariatric surgery: Potentially hampered solubility and dissolution. Int J Pharm 2021; 612:121298. [PMID: 34793937 DOI: 10.1016/j.ijpharm.2021.121298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022]
Abstract
Bariatric surgery is an effective treatment of obesity and related comorbidities. With surgery, the stomach undergoes major anatomical/physiological changes that may affect the oral exposure of drugs, especially marginally soluble weak bases, such as lamotrigine. The aim of this work was to study the solubility/dissolution of lamotrigine in conditions simulating the stomach before vs. after bariatric surgery. Lamotrigine solubility was studied in-vitro, as well as ex-vivo in gastric content aspirated from patients before vs. after bariatric surgery. We then compared the dissolution kinetics of various marketed lamotrigine products in pre- vs. post-operative stomach conditions, different in volume, pH, agitation strength and speed. Decreased lamotrigine solubility with increasing pH (from 1.37 ± 0.09 (pH = 1) to 0.22 ± 0.03 mg/mL (pH = 7)) was obtained. Twelve-fold higher lamotrigine solubility was revealed in gastric content aspirated before vs. after surgery (8.5 ± 0.7 and 0.7 ± 0.01 mg/mL, respectively). Dissolution studies showed that only the lowest dose (25 mg) fully dissolved in the post-surgery stomach conditions, while at higher doses, lamotrigine tablet dissolution was impaired. Neither fast-dissolving tablet, nor tablet crushing, helped resolving this problem. Based on these results, and given that dissolution of the drug dose governs the subsequent absorption, close monitoring of this essential drug is advised after bariatric surgery.
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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 8410501, Israel
| | - Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya 46140, Israel
| | - Yoni Mualem
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Ella Vainer
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Roni Gibori
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Julie Vaynshtein
- Department of Surgery B, Soroka University Medical Center, Beer-Sheva 8410101, Israel
| | - Oleg Dukhno
- Department of Surgery B, Soroka University Medical Center, Beer-Sheva 8410101, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel.
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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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14
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Pereira-Cunill JL, Piñar-Gutiérrez A, Martínez-Ortega AJ, Serrano-Aguayo P, García-Luna PP. Medium-term complications in patients undergoing gastric bypass. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00189-0. [PMID: 34456162 DOI: 10.1016/j.endinu.2021.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To present our experience in the clinical follow-up of patients undergoing a gastric bypass. METHOD Description of six cases under follow-up by our unit after undergoing a gastric bypass at another private centre. RESULTS The 6 patients presented complications, the most notable being the death of one patient due to severe malnutrition and the need for revision surgery in another for the same reason, destabilisation of type 1 diabetes mellitus in another patient and fat-soluble vitamin deficiency in all of them. CONCLUSIONS There are few publications that support the safety of gastric bypass as a treatment for obesity. In our experience, it is a technique associated with a high rate of serious complications. As it is a technique that is not yet standardised, we consider that these cases should be operated on in centres where there is a multidisciplinary team with expertise in the management of possible complications, with close follow-up by surgeons and endocrinologists.
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Affiliation(s)
- José Luis Pereira-Cunill
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Ana Piñar-Gutiérrez
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - Antonio Jesús Martínez-Ortega
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Pilar Serrano-Aguayo
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Pedro Pablo García-Luna
- Unidad de Nutrición, Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, España
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15
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Kaur N, Suryanarayanan R. Levothyroxine sodium pentahydrate tablets - formulation considerations. J Pharm Sci 2021; 110:3743-3756. [PMID: 34384799 DOI: 10.1016/j.xphs.2021.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 12/16/2022]
Abstract
Even though levothyroxine sodium pentahydrate tablets have been in the market since 1955, there continue to be recalls due to sub potency. We have comprehensively reviewed the factors affecting its stability in solid oral dosage forms. A compilation of marketed formulation compositions enabled the identification of the potential 'problem excipients'. Two excipient properties, hygroscopicity and microenvironmental acidity, appeared to be responsible for inducing drug instability. In drug products, depending on the formulation composition and storage conditions, the pentahydrate can dehydrate to highly reactive levothyroxine sodium monohydrate, or undergo salt disproportionation to the free acid form of the drug. The USP assay method (HPLC based) is insensitive to these different physical forms of the drug. The influence of physical form of levothyroxine on its chemical stability is incompletely understood. The USP has five product-specific dissolution tests reflecting the complexity in its evaluation.
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Affiliation(s)
- Navpreet Kaur
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, 9-177 WDH, 308 Harvard Street Southeast, Minneapolis, Minnesota 55455, United States
| | - Raj Suryanarayanan
- Department of Pharmaceutics, College of Pharmacy, University of Minnesota-Twin Cities, 9-177 WDH, 308 Harvard Street Southeast, Minneapolis, Minnesota 55455, United States.
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16
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Azran C, Hanhan-Shamshoum N, Irshied T, Ben-Shushan T, Dicker D, Dahan A, Matok I. Hypothyroidism and levothyroxine therapy following bariatric surgery: a systematic review, meta-analysis, network meta-analysis, and meta-regression. Surg Obes Relat Dis 2021; 17:1206-1217. [PMID: 33839048 DOI: 10.1016/j.soard.2021.02.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/01/2021] [Accepted: 02/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many health benefits of bariatric surgery are known and well-studied, but there is scarce data on the benefits of bariatric surgery on the thyroid function. OBJECTIVE We aimed to make a meta-analysis regarding the impact of bariatric surgery on thyroid-stimulating hormone (TSH) levels, levothyroxine dose, and the status of subclinical hypothyroidism. SETTING Systematic review and meta-analysis. METHODS PubMed, EMBASE, and Cochrane Library were searched up to December 2020 for relevant clinical studies. Random-effects model was used to pool results. Network meta-analysis was performed, incorporating direct and indirect comparisons among different types of bariatric surgery. Meta-regression analysis was performed to evaluate the impact of moderator variables on TSH levels and required levothyroxine dose after surgery. We followed the PRISMA guidelines for data selection and extraction. PROSPERO registry number: CRD42018105739. RESULTS A total of 28 studies involving 1284 patients were included. There was a statistically significant decrease in TSH levels after bariatric surgery (mean difference = -1.66 mU/L, 95%CI [-2.29, -1.03], P < .0001). In meta-regression analysis, we found that the following moderator variables: length of follow-up, mean age, baseline TSH, and preoperative thyroid function, could explain 1%, 43%, 68%, and 88% of the between-study variance, respectively. Furthermore, subclinical hypothyroidism was completely resolved in 87% of patients following bariatric surgery. In addition, there was a statistically significant decrease of levothyroxine dose in frank hypothyroid patients following bariatric surgery (mean difference = -13.20 mcg/d, 95%CI [-19.69, -6.71]). In network meta-analysis, we found that discontinuing or decreasing levothyroxine dose was significant following Roux-en-Y gastric bypass, 1 anastomosis gastric bypass, and sleeve gastrectomy, (OR = 31.02, 95%CI [10.34, 93.08]), (OR = 41.73, 95%CI [2.04, 854.69]), (OR = 104.03, 95%CI [35.79, 302.38]), respectively. CONCLUSIONS Based on our meta-analysis, bariatric surgery is associated with the resolution of subclinical hypothyroidism, a decrease in TSH levels, and a decrease in levothyroxine dose.
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Affiliation(s)
| | - Nirvana Hanhan-Shamshoum
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tujan Irshied
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ben-Shushan
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dror Dicker
- Rabin Medical Center, Hasharon Hospital, Petah Tikva, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
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17
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Porat D, Vaynshtein J, Gibori R, Avramoff O, Shaked G, Dukhno O, Czeiger D, Sebbag G, Dahan A. Stomach pH before vs. after different bariatric surgery procedures: Clinical implications for drug delivery. Eur J Pharm Biopharm 2021; 160:152-157. [DOI: 10.1016/j.ejpb.2021.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 01/19/2023]
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18
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Treatment of COVID-19 Patients Post-Bariatric Surgery: Issues for Consideration. J Clin Med 2020; 9:jcm9092827. [PMID: 32878333 PMCID: PMC7565829 DOI: 10.3390/jcm9092827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 12/21/2022] Open
Abstract
As COVID-19 has been expanding rapidly around the world, the types of patients and their backgrounds vary. The substantially altered GI anatomy/physiology after bariatric surgery presents new challenges to the field of oral drug therapy. In this report we highlight issues for consideration when treating COVID-19 patients who previously underwent bariatric surgery and provide practical tools to allow optimal care of these patients. Post-bariatric absorption/pharmacokinetic changes may warrant dose adjustment, as well as the use of liquid oral dosage forms or parenteral routes of administration, if available. 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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19
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Rossato M. Comment on: Outcome of bariatric surgery on hypothyroidism: experience from a tertiary care center in India. Surg Obes Relat Dis 2020; 16:1302-1303. [PMID: 32611493 DOI: 10.1016/j.soard.2020.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Marco Rossato
- Clinica Medica 3, Department of Medicine - DIMED, University-Hospital of Padova, Padova, Italy
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20
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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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21
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Virili C, Brusca N, Capriello S, Centanni M. Levothyroxine Therapy in Gastric Malabsorptive Disorders. Front Endocrinol (Lausanne) 2020; 11:621616. [PMID: 33584549 PMCID: PMC7876372 DOI: 10.3389/fendo.2020.621616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
Oral levothyroxine sodium is absorbed in the small intestine, mainly in the jejunum and the ileum being lower the absorption rate at duodenal level. The time interval between the ingestion of oral thyroxine and its appearance in the plasma renders unlike a gastric absorption of the hormone. However, several evidence confirm the key role of the stomach as a prerequisite for an efficient absorption of oral levothyroxine. In the stomach, in fact, occur key steps leading to the dissolution of thyroxine from the solid form, the process bringing the active ingredient from the pharmaceutical preparation to the aqueous solution. In particular, gastric juice pH, volume, viscosity, as well as gastric emptying time seem to be the most important limiting factors. These hypotheses are confirmed by the detection of an increased need for levothyroxine in patients with Helicobacter pylori infection, chronic atrophic gastritis, gastroparesis, or in simultaneous treatment with drugs interfering with gastric acidic output. The aim of the present article is to focus on the knowledge of pathophysiologic events that determine the absorptive fate of traditional (tablet) and alternative thyroxine preparations (softgel capsule and liquid solution) in patients bearing gastric disorders.
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Affiliation(s)
- Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Nunzia Brusca
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Capriello
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Endocrinology Unit, Santa Maria Goretti Hospital, AUSL Latina, Latina, Italy
- *Correspondence: Marco Centanni,
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22
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Garayalde Gamboa MDLÁ, Saban M, Curriá MI. Treatment with Intramuscular Levothyroxine in Refractory Hypothyroidism. Eur Thyroid J 2019; 8:319-323. [PMID: 31934558 PMCID: PMC6944946 DOI: 10.1159/000503324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/11/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Orally and daily levothyroxine (LT4) is the treatment of choice for hypothyroidism. In the majority of cases, the lack of effectiveness by this way may be due to poor adherence; however, gastrointestinal malabsorption may explain more cases of thyroxine refractoriness than previously reputed, due to the number of occult forms of these disorders. CASE PRESENTATION A 55-year-old white man with a diagnosis of low risk of recurrence of follicular variant of papillary thyroid carcinoma was treated with total thyroidectomy, 30 mCi iodine 131, and oral LT4. A year before he presented a gastric adenocarcinoma that required a partial gastrectomy. He evolved with multiple episodes of intestinal subocclusion that had to be treated with enterectomy in the first instance, then digestive rest and total parenteral nutrition. In spite of having made increases in oral LT4 dose (3 µg/kg), the patient persisted with a thyroid-stimulating hormone level >100 mIU/L. For this reason, we decided to administer intramuscular LT4. CONCLUSION Since there are no guidelines or consensus of intramuscular LT4 use, our experience and how we decided the dose and way of administration are presented in this article to contribute to future cases.
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Affiliation(s)
| | - Melina Saban
- Service of Endocrinology, Metabolism, Nutrition, and Diabetes, Buenos Aires British Hospital, Buenos Aires, Argentina
| | - Marina Ines Curriá
- Service of Endocrinology, Metabolism, Nutrition, and Diabetes, Buenos Aires British Hospital, Buenos Aires, Argentina
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23
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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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24
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Review of Advances in Anti-obesity Pharmacotherapy: Implications for a Multimodal Treatment Approach with Metabolic Surgery. Obes Surg 2019; 29:4095-4104. [DOI: 10.1007/s11695-019-04206-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Fain K, Rojas AP, Peiris AN. Hypothyroidism following gastric sleeve surgery resolved by ingesting crushed thyroxine tablets. Proc AMIA Symp 2019; 33:38-39. [PMID: 32063762 DOI: 10.1080/08998280.2019.1669412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022] Open
Abstract
Bariatric procedures for weight loss have increased in the past few decades. Levothyroxine malabsorption has been reported following gastric bypass; however, few studies have addressed this issue after gastric sleeve procedures. Levothyroxine dosing is usually weight based and administered at approximately 1.6 μg/kg body weight. Absorption occurs mainly in the jejunum and upper ileum, which can be altered by gastric pH, other drugs, food, and other factors. We present a 35-year-old woman with longstanding iatrogenic hypothyroidism treated with thyroxine, whose thyroid-stimulating hormone level rose following a gastric sleeve procedure despite taking levothyroxine daily.
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Affiliation(s)
- Kristen Fain
- School of Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Alexsandra P Rojas
- School of Medicine, Texas Tech University Health Sciences CenterLubbockTexas
| | - Alan N Peiris
- Clinical Research Institute and Department of Internal Medicine, Texas Tech University Health Sciences CenterLubbockTexas
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26
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Brutus L, Poupard A, Le Glatin C. Major imbalance of thyroid function after laparoscopic sleeve gastrectomy. BMJ Case Rep 2019; 12:12/8/e230515. [PMID: 31401581 DOI: 10.1136/bcr-2019-230515] [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: 01/19/2023] Open
Abstract
In patients with substituted hypothyroidism, laparoscopic sleeve gastrectomy may interfere with thyroid balance by varying body weight or by altering the absorption of hormone therapy. A 58-year-old female patient presented with a major thyroid imbalance after sleeve gastrectomy, manifesting itself in large-scale changes in thyroid stimulating hormone (TSH) levels. The transition from a tablet treatment to a liquid form alleviated burden of treatment, unfortunately without normalising TSH. Our case emphasises the importance of the understanding of hypothalamic-pituitary-thyroid feedback control mechanisms together with good galenic choice, management of associated conditions and the elimination of other causes of variations of TSH levels during the management of hypothyroid patients after sleeve gastrectomy.
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Affiliation(s)
- Laurent Brutus
- Pôle de Santé du Marais, Sallertaine, France.,Département de médecine générale, Université de Nantes, Nantes, Pays de la Loire, France
| | - Armelle Poupard
- Pôle de Santé du Marais, Sallertaine, France.,Département de médecine générale, Université de Nantes, Nantes, Pays de la Loire, France
| | - Clément Le Glatin
- Pôle de Santé du Marais, Sallertaine, France.,Département de médecine générale, Université de Nantes, Nantes, Pays de la Loire, France
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