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Lajeunesse-Trempe F, Okroj D, Ostarijas E, Ramalho A, Tremblay EJ, Llewellyn D, Harlow C, Chandhyoke N, Chew NWS, Vincent RP, Tchernof A, Piché ME, Poirier P, Biertho L, Morin MP, Copeland CS, Dimitriadis GK. Medication and supplement pharmacokinetic changes following bariatric surgery: A systematic review and meta-analysis. Obes Rev 2024; 25:e13759. [PMID: 38710656 DOI: 10.1111/obr.13759] [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: 08/07/2023] [Revised: 02/26/2024] [Accepted: 03/19/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVES To evaluate the impact of bariatric surgery on the pharmacokinetic (PK) parameters of orally administered medications and supplements. METHODS Systematic searches of bibliographic databases were conducted to identify studies. Pooled effect estimates from different surgical procedures were calculated using a random-effects model. RESULTS Quantitative data were synthesized from 58 studies including a total of 1985 participants. Whilst 40 medications and 6 supplements were evaluated across these studies, heterogeneity and missing information reduced the scope of the meta-analysis to the following medications and supplements: atorvastatin, paracetamol, omeprazole, midazolam, vitamin D, calcium, zinc, and iron supplements. There were no significant differences in PK parameters post-surgery for the drugs atorvastatin and omeprazole, and supplements calcium, ferritin, and zinc supplements. Paracetamol showed reduced clearance (mean difference [MD] = -15.56 L/hr, p = 0.0002, I2 = 67%), increased maximal concentration (MD = 6.90 μg/ml, p = 0.006, I2 = 92%) and increased terminal elimination half-life (MD = 0.49 hr, p < 0.0001, I2 = 3%) post-surgery. The remaining 36 medications and 2 supplements were included in a systematic review. Overall, 18 of the 53 drugs and supplements showed post-operative changes in PK parameters. CONCLUSION This study demonstrates heterogeneity in practice and could not reach conclusive findings for most PK parameters. Prospective studies are needed to inform best practice and enhance patient healthcare and safety following bariatric surgery.
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Affiliation(s)
- Fannie Lajeunesse-Trempe
- Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
- Quebec Heart and Lung Institute, Laval University, Canada
| | - Dominika Okroj
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Eduard Ostarijas
- Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Alan Ramalho
- Quebec Heart and Lung Institute, Laval University, Canada
| | | | - David Llewellyn
- Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Chris Harlow
- Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Nikhil Chandhyoke
- Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
| | - Royce P Vincent
- Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Andre Tchernof
- Quebec Heart and Lung Institute, Laval University, Canada
| | | | - Paul Poirier
- Quebec Heart and Lung Institute, Laval University, Canada
| | | | | | - Caroline S Copeland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Georgios K Dimitriadis
- Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
- Obesity, Type 2 Diabetes and Immunometabolism Research Group, Faculty of Cardiovascular and Metabolic Medicine & Sciences, School of Life Course Sciences, King's College London, London, UK
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2
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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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3
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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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4
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Avvari SK, Cusumano JA, Jogiraju VK, Manchandani P, Taft DR. PBPK Modeling of Azithromycin Systemic Exposure in a Roux-en-Y Gastric Bypass Surgery Patient Population. Pharmaceutics 2023; 15:2520. [PMID: 38004500 PMCID: PMC10674169 DOI: 10.3390/pharmaceutics15112520] [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: 09/26/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
In this investigation, PBPK modeling using the Simcyp® Simulator was performed to evaluate whether Roux-en-Y gastric bypass (RYGB) surgery impacts the oral absorption and bioavailability of azithromycin. An RYGB surgery patient population was adapted from the published literature and verified using the same probe medications, atorvastatin and midazolam. Next, a PBPK model of azithromycin was constructed to simulate changes in systemic drug exposure after the administration of different oral formulations (tablet, suspension) to patients pre- and post-RYGB surgery using the developed and verified population model. Clinically observed changes in azithromycin systemic exposure post-surgery following oral administration (single-dose tablet formulation) were captured using PBPK modeling based on the comparison of model-predicted exposure metrics (Cmax, AUC) to published clinical data. Model simulations predicted a 30% reduction in steady-state AUC after surgery for three- and five-day multiple dose regimens of an azithromycin tablet formulation. The relative bioavailability of a suspension formulation was 1.5-fold higher than the tablet formulation after multiple dosing. The changes in systemic exposure observed after surgery were used to evaluate the clinical efficacy of azithromycin against two of the most common pathogens causing community acquired pneumonia based on the corresponding AUC24/MIC pharmacodynamic endpoint. The results suggest lower bioavailability of the tablet formulation post-surgery may impact clinical efficacy. Overall, the research demonstrates the potential of a PBPK modeling approach as a framework to optimize oral drug therapy in patients post-RYGB surgery.
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Affiliation(s)
- Suvarchala Kiranmai Avvari
- Samuel J. and Joan B. Williamson Institute for Pharmacometrics, Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
| | - Jaclyn A. Cusumano
- Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
| | | | | | - David R. Taft
- Samuel J. and Joan B. Williamson Institute for Pharmacometrics, Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
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5
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Andrade NL, Shenouda R, Sockalingam S, Fipps DC. Consultation-Liaison Case Conference: Psychiatric Care of Patients Who Undergo Bariatric Surgery. J Acad Consult Liaison Psychiatry 2023; 64:267-276. [PMID: 36764484 DOI: 10.1016/j.jaclp.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
We present the case of a 42-year-old female with major depressive disorder who received a Roux-en-Y gastric bypass and subsequently decompensated in her depression symptoms and began newly engaging in problematic alcohol use. Top experts in the consultation-liaison field, specifically bariatric surgery psychiatry, provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching points include the presurgical psychosocial assessment, pertinent perioperative psychopharmacology, and problematic alcohol use after bariatric surgery.
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Affiliation(s)
| | - Raymone Shenouda
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
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6
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Outcomes with direct acting oral anticoagulants in patients with a history of bariatric surgery: a retrospective cohort study. Surg Obes Relat Dis 2022. [DOI: 10.1016/j.soard.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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7
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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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8
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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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9
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Alalwan AA, Friedman J, Alfayez O, Hartzema A. Drug absorption in bariatric surgery patients: A narrative review. Health Sci Rep 2022; 5:e605. [PMID: 35509385 PMCID: PMC9059175 DOI: 10.1002/hsr2.605] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/14/2022] [Accepted: 03/19/2022] [Indexed: 12/17/2022] Open
Abstract
Background Despite the increase in the number of bariatric surgeries performed, little is known about the impact of the surgery on drug absorption. Unpredictability is assumed with drugs, given the anatomical changes after surgery. Objective To evaluate the impact of bariatric surgery on drug absorption based on the type of procedure performed. Methods We conducted a comprehensive literature review searching PubMed/Medline for published studies (from inception to December 2017) that evaluate the use of drugs and the assessment of drug absorption after bariatric surgery. Pharmacokinetic/pharmacodynamic studies, case reports, and observational studies were included in our review. Results We found 60 studies addressing drug use after bariatric surgery. Twenty‐eight studies reported a decrease in drug absorption after bariatric surgery while only four studies showed an increase in drug absorption. Unchanged absorption of drugs was seen in 23 studies after the surgery. Conclusion The available information shows variations in drug absorption after bariatric surgery. The unpredictability may result from factors related to the patient, drug, and/or type of surgery. Therefore, pharmacists' involvement and close monitoring of patients after bariatric surgery could be effective to avoid sub‐/supratherapeutic responses.
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Affiliation(s)
- Abdullah Abdulaziz Alalwan
- Department of Pharmacy Practice, College of Pharmacy Qassim University Qassim Saudi Arabia
- Pharmaceutical Outcomes and Policy, College of Pharmacy University of Florida Gainesville Florida USA
| | - Jeffrey Friedman
- Department of Surgery, UF Health Bariatric Surgery Center University of Florida Gainesville Florida USA
| | - Osamah Alfayez
- Department of Pharmacy Practice, College of Pharmacy Qassim University Qassim Saudi Arabia
| | - Abraham Hartzema
- Pharmaceutical Outcomes and Policy, College of Pharmacy University of Florida Gainesville Florida USA
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10
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Coughlin JW, Steffen KJ, Sockalingam S, Mitchell JE. Psychotropic Medications in Metabolic and Bariatric Surgery: Research Updates and Clinical Considerations. Curr Psychiatry Rep 2022; 24:89-98. [PMID: 35076886 DOI: 10.1007/s11920-022-01317-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW We review evidence for assessing and monitoring psychotropic medications in metabolic and bariatric surgery (MBS) patients. We describe weight gain side effects, potential perioperative risks, pharmacokinetic changes that occur after MBS, and conclude with clinical recommendations. RECENT FINDINGS Research on psychiatric medication use and post-MBS weight outcomes is lacking and inconsistent; however, there is consistent evidence that, though variable, psychiatric medication use is associated with weight gain. Several meta-analyses and reviews provide guidance on lowering risk when appropriate. Perioperative lithium toxicity and SSRI discontinuation syndrome also warrant consideration, as do potential post-operative pharmacokinetic changes. In the absence of data for each psychiatric drug classification, close symptom monitoring and, where appropriate, serum concentration monitoring are recommended. MBS patients are a psychiatrically vulnerable population, and many are on psychiatric medications. Given potential weight/metabolic side effects, perioperative complications, and post-operative pharmacokinetic changes that occur with psychotropic medication use, providers should stay well informed on psychiatric medication management considerations.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, MD, 21224, Baltimore, USA.
| | - Kristine J Steffen
- North Dakota State University, College of Health Professions, ND, 58103, Fargo, USA.,Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA
| | - Sanjeev Sockalingam
- University Health Network Bariatric Surgery Program Centre for Addiction and Mental Health University of Toronto, ON, M6J 1H4, Toronto, Canada
| | - James E Mitchell
- Sanford Center for Biobehavioral Research, ND, 58103, Fargo, USA.,University of North Dakota School of Medicine and Health Sciences, ND, 58103, Fargo, USA
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11
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Kvitne KE, Robertsen I, Skovlund E, Christensen H, Krogstad V, Wegler C, Angeles PC, Wollmann BM, Hole K, Johnson LK, Sandbu R, Artursson P, Karlsson C, Andersson S, Andersson TB, Hjelmesaeth J, Jansson-Löfmark R, Åsberg A. Short- and long-term effects of body weight loss following calorie restriction and gastric bypass on CYP3A-activity - a non-randomized three-armed controlled trial. Clin Transl Sci 2021; 15:221-233. [PMID: 34435745 PMCID: PMC8742654 DOI: 10.1111/cts.13142] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 11/29/2022] Open
Abstract
It remains uncertain whether pharmacokinetic changes following Roux-en-Y gastric bypass (RYGB) can be attributed to surgery-induced gastrointestinal alterations per se and/or the subsequent weight loss. The aim was to compare short- and long-term effects of RYGB and calorie restriction on CYP3A-activity, and cross-sectionally compare CYP3A-activity with normal weight to overweight controls using midazolam as probe drug. This three-armed controlled trial included patients with severe obesity preparing for RYGB (n = 41) or diet-induced (n = 41) weight-loss, and controls (n = 18). Both weight-loss groups underwent a 3-week low-energy-diet (<1200 kcal/day) followed by a 6-week very-low-energy-diet or RYGB (both <800 kcal/day). Patients were followed for 2 years, with four pharmacokinetic investigations using semisimultaneous oral and intravenous dosing to determine changes in midazolam absolute bioavailability and clearance, within and between groups. The RYGB and diet groups showed similar weight-loss at week 9 (13 ± 2.4% vs. 11 ± 3.6%), but differed substantially after 2 years (-30 ± 7.0% vs. -3.1 ± 6.3%). At baseline, mean absolute bioavailability and clearance of midazolam were similar in the RYGB and diet groups, but higher compared with controls. On average, absolute bioavailability was unaltered at week 9, but decreased by 40 ± 7.5% in the RYGB group and 32 ± 6.1% in the diet group at year 2 compared with baseline, with no between-group difference. No difference in clearance was observed over time, nor between groups. In conclusion, neither RYGB per se nor weight loss impacted absolute bioavailability or clearance of midazolam short term. Long term, absolute bioavailability was similarly decreased in both groups despite different weight loss, suggesting that the recovered CYP3A-activity is not only dependent on weight-loss through RYGB.
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Affiliation(s)
- Kine Eide Kvitne
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Ida Robertsen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Hege Christensen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Veronica Krogstad
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Christine Wegler
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.,DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Philip Carlo Angeles
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | | | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Rune Sandbu
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Per Artursson
- Department of Pharmacy and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Cecilia Karlsson
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Shalini Andersson
- Research and Early Development, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Tommy B Andersson
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Jøran Hjelmesaeth
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rasmus Jansson-Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Anders Åsberg
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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12
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Steenackers N, Vanuytsel T, Augustijns P, Tack J, Mertens A, Lannoo M, Van der Schueren B, Matthys C. Adaptations in gastrointestinal physiology after sleeve gastrectomy and Roux-en-Y gastric bypass. Lancet Gastroenterol Hepatol 2021; 6:225-237. [PMID: 33581761 DOI: 10.1016/s2468-1253(20)30302-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023]
Abstract
Linked to the growing obesity epidemic, demand for bariatric and metabolic surgery has increased, the most common procedures being sleeve gastrectomy and Roux-en-Y gastric bypass. Originally, bariatric procedures were described as purely restrictive, malabsorptive, or combined restrictive-malabsorptive procedures limiting food intake, nutrient absorption, or both. Nowadays, anatomical alterations are known to affect gastrointestinal physiology, which in turn affects the digestion and absorption of nutrients and drugs. Therefore, understanding gastrointestinal physiology is crucial to prevent postoperative nutritional deficiencies and to optimise postoperative drug therapy. Preclinical and clinical research indicates that sleeve gastrectomy accelerates liquid and solid gastric emptying and small intestinal transit, and increases bile acid serum levels, whereas its effects on gastrointestinal acidity, gastric and pancreatic secretions, surface area, and colonic transit remain largely unknown. Roux-en-Y gastric bypass diminishes gastric acid secretion, accelerates liquid gastric emptying, and increases bile acid serum levels, but its effects on intestinal pH, solid gastric emptying, intestinal transit time, gastric enzyme secretions, and surface area remain largely unknown. In this Review, we summarise current knowledge of the effects of these two procedures on gastrointestinal physiology and assess the knowledge gaps.
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Affiliation(s)
- Nele Steenackers
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Chronic Diseases and Metabolism, and Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Ann Mertens
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Matthias Lannoo
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
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13
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Almeanazel O, Alanazi F, Alsarra I, Alshora D, Shakeel F, Almnaizel A, Alahmed M, Fouad E. Nanotechnology as a tool to overcome the bariatric surgery malabsorption. Saudi Pharm J 2020; 28:565-573. [PMID: 32435137 PMCID: PMC7229319 DOI: 10.1016/j.jsps.2020.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/12/2020] [Indexed: 12/22/2022] Open
Abstract
Obesity is a metabolic disease that affects all ages; it is considered life-threatening condition as it leads to fatal complications such as; cardiovascular diseases and diabetes. The therapeutic options include; life-style modifications, pharmacotherapy intervention, and surgical intervention. Bariatric surgery (BS) is considered as the most effective option among the others for its rapid weight loss, maintaining the lost mass, and improving the quality of life of the patients. Nevertheless, BS leads to severe changes in the bioavailability of medications, especially for chronic diseases, which may reach to limit where the patient's life endangers. Recently, pharmaceutical formulations had developed several methods to improve the drug bioavailability of drugs though the implying of nanotechnology. Nonotechnology is responsible for reducing the size of the drugs to the nano range (<1000 nm), which increase the drug surface area, dissolution, absorption, and, most importantly, the bioavailability of these drugs. It is believed that BS malabsorption and drugs bioavailability problems can be solved using nanotechnology for its advantages in overcoming BS complications.
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Key Words
- AGB, Adjustable Gastric band
- ASMBS, American Society for Metabolic and Bariatric Surgery
- Absorption
- BS, Bariatric Surgery
- Bariatric surgery
- Bioavailability
- CFR, Code of Federal Regulations
- DDS, Drug Delivery System
- FDA, Food and Drug Administration
- GIT, Gastrointestinal Tract
- GRS, Generally Recognized as Safe
- ISCRPE, improved supercritical reverse phase evaporation
- JIB, Jejunoileal bypass
- LAG, Laparoscopic Sleeve Gastrectomy
- MBI, Body Mass Index
- MIC, Minimum Inhibitory Concentration
- Nanotechnology
- RYGB, Roux-en-Y gastric bypass
- SCF, supercritical fluid
- SNEDDS, selfnanoemulsifying drug delivery system
- T2DM, Type 2 Diabetes Mellitus
- VA, veteran affairs
- WHO, World health organization
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Affiliation(s)
- Osaid Almeanazel
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
| | - Fars Alanazi
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alsarra
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
| | - Doaa Alshora
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
| | - Faiyaz Shakeel
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Almnaizel
- Prince Naif for Health Research Center, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Alahmed
- Prince Naif for Health Research Center, King Saud University, Riyadh, Saudi Arabia
| | - Ehab Fouad
- Kayyali Chair for Pharmaceutical Industries, Department of Pharmaceutics, King Saud University, Riyadh, Saudi Arabia
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14
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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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15
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McLachlan LA, Chaar BB, Um IS. Pharmacokinetic changes post-bariatric surgery: A scoping review. Obes Rev 2020; 21:e12988. [PMID: 32100411 DOI: 10.1111/obr.12988] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 01/11/2023]
Abstract
Bariatric surgeries induce structural changes that can alter the absorption of drugs in patients already at risk of polypharmacy. This scoping review aimed to explore pharmacokinetic changes of orally administered drugs in patients post-bariatric surgery, and assess the quality and level of bias. Electronic databases were searched for articles relating to bariatric surgery and pharmacokinetics published between 1998 and 2019. Pre-post studies reporting on pharmacokinetic parameters were included, and the Newcastle-Ottawa Scale was used to assess risk-of-bias. A total of 21 studies were included in this review, and changes in absorption were reported in all included studies across 29 drugs. In 11 studies, this change was reported as statistically significant (p<.05), while six reported a nonsignificant change. More drugs exhibited a shorter Tmax and higher Cmax after surgery than otherwise, however changes in AUC were variable. Four studies were assessed as having fair quality while the remainder of the included studies were of good quality and low risk-of-bias. Bariatric surgery alters the absorption of drugs and several mechanisms are implicated to be responsible. Short and long-term monitoring is recommended in patients post-surgery for clinical changes in response to medications. Future research with a higher number of participants and greater control of variables, such as concurrent medications, malabsorptive disorders, and body composition should be considered.
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Affiliation(s)
- Liam A McLachlan
- The University of Sydney School of Pharmacy Faculty of Medicine and Health, Australia
| | - Betty B Chaar
- The University of Sydney School of Pharmacy Faculty of Medicine and Health, Australia
| | - Irene S Um
- The University of Sydney School of Pharmacy Faculty of Medicine and Health, Australia
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16
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Chen KF, Chan LN, Senn TD, Oelschlager BK, Flum DR, Shen DD, Horn JR, Lin YS. The Impact of Proximal Roux-en-Y Gastric Bypass Surgery on Acetaminophen Absorption and Metabolism. Pharmacotherapy 2020; 40:191-203. [PMID: 31960977 DOI: 10.1002/phar.2368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGBS), a surgery that creates a smaller stomach pouch and reduces the length of small intestine, is one of the most common medical interventions for the treatment of obesity. AIM The aim of this study was to determine how RYGBS affects the absorption and metabolism of acetaminophen. MATERIALS AND METHODS Ten morbidly obese patients received 1.5 g of liquid acetaminophen (APAP) orally on three separate pharmacokinetic study days (i.e., pre-RYGBS baseline and 3 and 12 months post-RYGBS). Plasma was collected at pre-specified timepoints over 24 hours, and the samples were analyzed using liquid chromatography-mass spectrometry for APAP, APAPglucuronide (APAP-gluc), APAP-sulfate (APAP-sulf), APAP-cysteine (APAP-cys), and APAP-Nacetylcysteine (APAP-nac). RESULT Following RYGBS, peak APAP concentrations at the 3-month and 12-month visits increased by 2.0-fold compared to baseline (p=0.0039 and p=0.0078, respectively) and the median time to peak concentration decreased from 35 to 10 minutes. In contrast, peak concentrations of APAP-gluc, APAP-sulf, APAP-cys, and APAP-nac were unchanged following RYGBS. The apparent oral clearance of APAP and the ratios of metabolite area under the curve (AUC)-to-APAP AUC for all four metabolites decreased at 3 and 12 months post-RYGBS compared to the presurgical baseline. In a simulation of expected steady-state plasma concentrations following multiple dosing of 650 mg APAP every 4 hours, post-RYGBS patients had higher steady-state peak APAP concentrations compared to healthy individuals and obese pre-RYGBS patients, though APAP exposure was unchanged compared to healthy individuals. CONCLUSION Following RYGBS, the rate and extent of APAP absorption increased and decreased formation of APAP metabolites was observed, possibly due to downregulation of Phase II and cytochrome P450 2E1 enzymes.
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Affiliation(s)
- Kuan-Fu Chen
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | | | - Taurence D Senn
- Department of Medicinal Chemistry, University of Washington, Seattle, Washington
| | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Danny D Shen
- Department of Pharmaceutics, University of Washington, Seattle, Washington
| | - John R Horn
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Yvonne S Lin
- Department of Pharmaceutics, University of Washington, Seattle, Washington
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17
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Kannan R, Przekwas A. A multiscale absorption and transit model for oral drug delivery: Formulation and applications during fasting conditions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3317. [PMID: 32011090 DOI: 10.1002/cnm.3317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 06/10/2023]
Abstract
Most Food and Drug Administration (FDA)-approved drugs are administered orally, despite the complex process of oral drug absorption that is difficult to analyze experimentally. Oral bioavailability is dependent on the drug compound as well as the physiological and anatomical states of the user. Thus, computational models have emerged to mechanistically capture and predict the oral absorption process. The current models are generally 0D compartmental models and are limited by (a) simplified physiological characteristics of the gastrointestinal tract (GIT), (b) semiempirical/analytical dissolution profiles of the tested drugs, (c) incorrect absorption for some drug BCS classes (class IIa, for example), (d) GITs size variability among population, (e) incorrectly predicting the absorption of drugs that are GIT target specific, and (f) erroneous mixing in the domain. In this study, we have developed a multiscale absorption and transit (MAT) toolkit to simulate the dissolution, transport, absorption, distribution, metabolism, and elimination of orally administered drugs in the human GIT at multiple levels. MAT was constructed by integrating the spatially accurate first-principles driven high-fidelity drug transport, dissolution, and absorption model in the human stomach and GIT using our recently published quasi-3D (Q3D) framework. The process integrated the multilayer intestine physiologically based pharmacokinetics models with the whole-body compartmental models to predict the systemic pharmacokinetics of oral drugs. The computational results showed that this multiscale tool was able to match the experimental concentration results (individual and population) better than the traditional compartmental models. Ultimately, MAT will be developed into a commercial product to meet urgent demands from pharmaceutical and biomedical industries.
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Affiliation(s)
| | - Andrzej Przekwas
- Research Department, CFD Research Corporation, Huntsville, Alabama
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18
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Angeles PC, Robertsen I, Seeberg LT, Krogstad V, Skattebu J, Sandbu R, Åsberg A, Hjelmesæth J. The influence of bariatric surgery on oral drug bioavailability in patients with obesity: A systematic review. Obes Rev 2019; 20:1299-1311. [PMID: 31232513 PMCID: PMC6852510 DOI: 10.1111/obr.12869] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/30/2019] [Accepted: 03/31/2019] [Indexed: 12/16/2022]
Abstract
Anatomical changes in the gastrointestinal tract and subsequent weight loss may influence drug disposition and thus drug dosing following bariatric surgery. This review systematically examines the effects of bariatric surgery on drug pharmacokinetics, focusing especially on the mechanisms involved in restricting oral bioavailability. Studies with a longitudinal before-after design investigating the pharmacokinetics of at least one drug were reviewed. The need for dose adjustment following bariatric surgery was examined, as well as the potential for extrapolation to other drugs subjected to coinciding pharmacokinetic mechanisms. A total of 22 original articles and 32 different drugs were assessed. The majority of available data is based on Roux-en-Y gastric bypass (RYGBP) (18 of 22 studies), and hence, the overall interpretation is more or less limited to RYGBP. In the case of the majority of studied drugs, an increased absorption rate was observed early after RYGBP. The effect on systemic exposure allows for a low degree of extrapolation, including between drugs subjected to the same major metabolic and transporter pathways. On the basis of current understanding, predicting the pharmacokinetic change for a specific drug following RYGBP is challenging. Close monitoring of each individual drug is therefore recommended in the early postsurgical phase. Future studies should focus on the long-term effects of bariatric surgery on drug disposition, and they should also aim to disentangle the effects of the surgery itself and the subsequent weight loss.
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Affiliation(s)
- Philip Carlo Angeles
- Morbid Obesity Centre, Department of MedicineVestfold Hospital TrustTønsbergNorway
- Department of SurgeryVestfold Hospital TrustTønsbergNorway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Ida Robertsen
- Section of Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
| | | | - Veronica Krogstad
- Section of Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
| | - Julie Skattebu
- Library of Health SciencesVestfold Hospital TrustTønsbergNorway
| | - Rune Sandbu
- Morbid Obesity Centre, Department of MedicineVestfold Hospital TrustTønsbergNorway
- Department of SurgeryVestfold Hospital TrustTønsbergNorway
| | - Anders Åsberg
- Section of Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
- Department of Transplantation MedicineOslo University Hospital‐RikshospitaletOsloNorway
| | - Jøran Hjelmesæth
- Morbid Obesity Centre, Department of MedicineVestfold Hospital TrustTønsbergNorway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical MedicineUniversity of OsloOsloNorway
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19
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Longitudinal Impacts of Gastric Bypass Surgery on Pharmacodynamics and Pharmacokinetics of Statins. Obes Surg 2019; 29:2571-2583. [PMID: 31004269 DOI: 10.1007/s11695-019-03885-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Undergoing Roux-en-Y gastric bypass (RYGB) is expected to affect orally administered drug absorption. Statins are commonly prescribed to patients with obesity for the prevention of atherosclerotic cardiovascular diseases by lowering cholesterol. This is the first longitudinal prospective study on impacts of RYGB on weight loss, pharmacodynamics, and pharmacokinetics of atorvastatin, rosuvastatin, and simvastatin, and their active metabolites, up to 1-year post-surgery. METHODS Forty-six patients were recruited, five patients on atorvastatin, twelve on rosuvastatin, nine on simvastatin, and twenty on no statin. The concentrations of atorvastatin, rosuvastatin, and simvastatin with their active metabolites were monitored. RESULTS Mean plasma concentrations of atorvastatin and metabolites and rosuvastatin normalized by the unit dose [(nM)/(mg/kg)] decreased by 3- to 6-month post-surgery. Conversely, simvastatin and its metabolite concentrations increased up to 6-month post-surgery, then declined to preoperative levels by 1-year post-surgery. The metabolisms of atorvastatin to hydroxyl-metabolites and simvastatin to simvastatin acid were decreased after RYGB. The weight loss and PD outcomes were comparable between statin and non-statin groups suggesting the key impacts were from RYGB. The discontinuation or reduction of dose of atorvastatin or rosuvastatin post-RYGB exhibited rebounds of LDL levels in some subjects, but the rebound was not apparent with patients on simvastatin pre-surgery. CONCLUSION Discontinuations of statin dosing post-RYGB require LDL monitoring and reducing the dose to half seems to have better results. Patients on statin treatment post-RYGB should be followed-up closely based on our pharmacokinetic findings, to ensure therapeutic effects of the treatment with minimal adverse effects.
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20
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Azran C, Porat D, Fine-Shamir N, Hanhan N, Dahan A. Oral levothyroxine therapy postbariatric surgery: Biopharmaceutical aspects and clinical effects. Surg Obes Relat Dis 2019; 15:333-341. [PMID: 30704913 DOI: 10.1016/j.soard.2019.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/13/2018] [Accepted: 01/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bariatric surgery can lead to changes in the oral absorption of many drugs. Levothyroxine is a narrow therapeutic drug for hypothyroidism, a common condition among patients with obesity. OBJECTIVE The purpose of this work was to provide a mechanistic overview of levothyroxine absorption, and to thoroughly analyze the expected effects of bariatric surgery on oral levothyroxine therapy. METHODS We performed a systematic review of the relevant literature reporting the effects of bariatric surgery on oral levothyroxine absorption and postoperative thyroid function. A PubMed search for relevant keywords resulted in a total of 14 articles reporting levothyroxine status before versus after bariatric surgery. RESULTS Different mechanisms may support opposing trends as to levothyroxine dose adjustment postsurgery. On the one hand, based on impaired drug solubility/dissolution attributable to higher gastric pH as well as reduced gastric volume, compromised levothyroxine absorption is expected. On the other hand, the great weight loss, and altered set-point of thyroid hormone homeostasis with decreased thyroid-stimulating hormone after the surgery, may result in a decreased dose requirement. CONCLUSIONS For patients after bariatric surgery, close monitoring of both the clinical presentation and plasma thyroid-stimulating hormone and T4 levels is strongly advised. Better understanding and awareness of the science presented in this article may help to avoid preventable complications and provide optimal patient care.
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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, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nirvana Hanhan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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21
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22
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Santamaría MM, Villafranca JJA, Abilés J, López AF, Rodas LV, Goitia BT, Navarro PU. Systematic review of drug bioavailability following gastrointestinal surgery. Eur J Clin Pharmacol 2018; 74:1531-1545. [PMID: 30136101 DOI: 10.1007/s00228-018-2539-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 08/07/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE Inter- and intraindividual pharmacokinetics variability in humans affects the way in which drugs act on the body. Gastrointestinal surgery has an impact on this variability and significantly alters the kinetics of drugs in post-surgical patients. The way in which pharmacokinetic profiles are modified depends on the type of operative procedure performed. The extent to which the absorption of different groups of drugs is affected varies according to the site and length of intestinal resections. METHODS A literature search was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Three databases were searched: MEDLINE, Embase, and the Cochrane Library. For each drug, potential changes in absorption were described, including recommendations extracted from the results of the studies and collected according to authors' criteria as practical conclusions, and grades of recommendation were determined by levels of evidence using the Oxford Centre for Evidence-Based Medicine scale. RESULTS Sixty-eight articles were collected during the selection process after the bibliographic search. The main outcomes for 60 drugs from the various studies were classified according to each type of surgery. CONCLUSIONS Modifications in the digestive tract secondary to gastrointestinal surgery may compromise the bioavailability of drugs. Decreased absorption surface, gastric emptying speed, and gastric pH alteration are factors to be taken into account in the management of pharmacological treatment after surgery. Evidence supported by data in clinical practice is scarce, but after studying the pharmacokinetic profile of some molecules, it is possible to offer recommendations for its adaptation to the patient's clinical situation.
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Affiliation(s)
- Manuela Moreno Santamaría
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain.
| | | | - Jimena Abilés
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
| | - Alberto Fernández López
- Surgery Department, Quirónsalud Hospital, Edificio Arttysur, Avda. de los Empresarios, s/n, 11379, Palmones, Cádiz, Spain
| | - Lucia Visiedo Rodas
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
| | - Begoña Tortajada Goitia
- Pharmacy and Nutrition Department, Costa del Sol Hospital, A-7, Km 187, 29603, Marbella, Málaga, Spain
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23
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Hatton GB, Madla CM, Rabbie SC, Basit AW. All disease begins in the gut: Influence of gastrointestinal disorders and surgery on oral drug performance. Int J Pharm 2018; 548:408-422. [PMID: 29969711 DOI: 10.1016/j.ijpharm.2018.06.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
The term "disease" conjures a plethora of graphic imagery for many, and the use of drugs to combat symptoms and treat underlying pathology is at the core of modern medicine. However, the effects of the various gastrointestinal diseases, infections, co-morbidities and the impact of gastrointestinal surgery on the pharmacokinetic and pharmacodynamic behaviour of drugs have been largely overlooked. The better elucidation of disease pathology and the role of underlying cellular and molecular mechanisms have increased our knowledge as far as diagnoses and prognoses are concerned. In addition, the recent advances in our understanding of the intestinal microbiome have linked the composition and function of gut microbiota to disease predisposition and development. This knowledge, however, applies less so in the context of drug absorption and distribution for orally administered dosage forms. Here, we revisit and re-evaluate the influence of a portfolio of gastrointestinal diseases and surgical effects on the functionality of the gastrointestinal tract, their implications for drug delivery and attempt to uncover significant links for clinical practice.
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Affiliation(s)
- Grace B Hatton
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Christine M Madla
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Sarit C Rabbie
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom
| | - Abdul W Basit
- UCL School of Pharmacy, University College London, 29 - 39 Brunswick Square, London, WC1N 1AX, United Kingdom.
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24
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Hjelmesæth J, Åsberg A, Andersson S, Sandbu R, Robertsen I, Johnson LK, Angeles PC, Hertel JK, Skovlund E, Heijer M, Ek AL, Krogstad V, Karlsen TI, Christensen H, Andersson TB, Karlsson C. Impact of body weight, low energy diet and gastric bypass on drug bioavailability, cardiovascular risk factors and metabolic biomarkers: protocol for an open, non-randomised, three-armed single centre study (COCKTAIL). BMJ Open 2018; 8:e021878. [PMID: 29844102 PMCID: PMC5988193 DOI: 10.1136/bmjopen-2018-021878] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Roux-en-Y gastric bypass (GBP) is associated with changes in cardiometabolic risk factors and bioavailability of drugs, but whether these changes are induced by calorie restriction, the weight loss or surgery per se, remains uncertain. The COCKTAIL study was designed to disentangle the short-term (6 weeks) metabolic and pharmacokinetic effects of GBP and a very low energy diet (VLED) by inducing a similar weight loss in the two groups. METHODS AND ANALYSIS This open, non-randomised, three-armed, single-centre study is performed at a tertiary care centre in Norway. It aims to compare the short-term (6 weeks) and long-term (2 years) effects of GBP and VLED on, first, bioavailability and pharmacokinetics (24 hours) of probe drugs and biomarkers and, second, their effects on metabolism, cardiometabolic risk factors and biomarkers. The primary outcomes will be measured as changes in: (1) all six probe drugs by absolute bioavailability area under the curve (AUCoral/AUCiv) of midazolam (CYP3A4 probe), systemic exposure (AUCoral) of digoxin and rosuvastatin and drug:metabolite ratios for omeprazole, losartan and caffeine, levels of endogenous CYP3A biomarkers and genotypic variation, changes in the expression and activity data of the drug-metabolising, drug transport and drug regulatory proteins in biopsies from various organs and (2) body composition, cardiometabolic risk factors and metabolic biomarkers. ETHICS AND DISSEMINATION The COCKTAIL protocol was reviewed and approved by the Regional Committee for Medical and Health Research Ethics (Ref: 2013/2379/REK sørøst A). The results will be disseminated to academic and health professional audiences and the public via presentations at conferences, publications in peer-reviewed journals and press releases and provided to all participants. TRIAL REGISTRATION NUMBER NCT02386917.
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Affiliation(s)
- Jøran Hjelmesæth
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anders Åsberg
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Shalini Andersson
- Drug Metabolism and Pharmacokinetics, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
| | - Rune Sandbu
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ida Robertsen
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | | | | | | | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Maria Heijer
- Study Operations, Early Clinical Development, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
| | - Anna-Lena Ek
- Study Operations, Early Clinical Development, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
| | - Veronica Krogstad
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Tor-Ivar Karlsen
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway
- Faculty of Health and Sports Science, University of Agder, Kristiansand, Norway
| | - Hege Christensen
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Tommy B Andersson
- Drug Metabolism and Pharmacokinetics, Cardiovascular, Renal and Metabolism, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Karlsson
- Cardiovascular, Renal and Metabolism Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca Gothenburg, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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25
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Strong AT, Sharma G, Nor Hanipah Z, Tu C, Brethauer SA, Schauer PR, Cetin D, Aminian A. Adjustments to warfarin dosing after gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis 2018; 14:700-706. [DOI: 10.1016/j.soard.2017.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022]
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26
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The effect of bariatric surgery on direct-acting oral anticoagulant drug levels. Thromb Res 2018; 163:190-195. [DOI: 10.1016/j.thromres.2017.11.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 12/13/2022]
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The Effect of Roux-en-Y Gastric Bypass Surgery in Morbidly Obese Patients on Pharmacokinetics of (Acetyl)Salicylic Acid and Omeprazole: the ERY-PAO Study. Obes Surg 2018; 26:2051-2058. [PMID: 26797705 DOI: 10.1007/s11695-016-2065-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Data on the absorption of orally administered drugs following Roux-en-Y gastric bypass (RYGB) surgery in obese patients are limited and inconclusive. As it is difficult to predict changes in absorption, studies on frequently used drugs in this population are necessary. Acetylsalicylic acid (ASA) and omeprazole are two commonly prescribed drugs in obese patients. METHODS In this repeated measures study, omeprazole and salicylic acid (SA) serum concentrations were measured before and after RYGB in 34 morbidly obese subjects. Time to maximum concentration (Tmax), lag time (Tlag), maximum concentration (Cmax), and area under the serum concentration versus time curve (AUC) were calculated for both drugs to determine possible differences in drug absorption after the procedure. RESULTS For SA, Tmax significantly decreased after RYGB, while both Cmax and AUC0-24 significantly increased. For omeprazole, both Tmax and Tlag significantly decreased after RYGB, while Cmax significantly increased. Mean AUC0-12 significantly decreased post-surgery. The difference in AUC0-12 before and after surgery varied between subjects. CONCLUSIONS Our study shows a faster absorption of both ASA and omeprazole after RYGB. The exposure to ASA is higher post-surgery, but the standard dose of 80 mg does not need to be modified, considering its range in effective dose. The exposure to omeprazole is, on average, decreased after surgery. Clinicians should be aware to increase the dose of omeprazole if symptoms suggest inadequate response.
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Hachon L, Declèves X, Faucher P, Carette C, Lloret-Linares C. RYGB and Drug Disposition: How to Do Better? Analysis of Pharmacokinetic Studies and Recommendations for Clinical Practice. Obes Surg 2017; 27:1076-1090. [PMID: 28124236 DOI: 10.1007/s11695-016-2535-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An important issue in the follow-up of patients with bariatric surgery remains to determine whether their therapeutic management should be different after surgery. In this article, we first reviewed all pharmacokinetic studies involving at least four subjects who underwent the Roux-en-Y gastric bypass (RYGB) bariatric surgery. Twenty-five publications were selected and, overall, 25 drugs were studied. Drug solubility and permeability parameters for each drug were defined using different parameters or classifications. Increased rates of oral drug absorption were predominantly observed. Conversely, drug exposure differed from one drug to another. Considering the galenic formulation and the Biopharmaceutics Classification System (BCS) class may help the prediction of oral drug exposure outcome after RYGB. We propose a strategy aiming to guide prescription and drug monitoring in patients with RYGB. But further research is clearly needed due to the unique characteristics of the bariatric population. Priority should be given to drugs that do not have clinical or biological surrogates for dose adaptation.
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Affiliation(s)
- Lorry Hachon
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France.,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France
| | - Xavier Declèves
- Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Pharmacokinetics and Pharmacochemistry Unit, Paris, F-75014, France
| | - Pauline Faucher
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital La Pitié Salpêtrière, Paris, France
| | - Claire Carette
- Nutrition Department, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Célia Lloret-Linares
- Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, Therapeutic Research Unit, Department of Internal Medicine, Paris, F-75010, France. .,Inserm, UMR-S 1144 Université Paris Descartes-Paris Diderot, Variabilité de réponse aux psychotropes, Paris, France.
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29
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Van Den Abeele J, Rubbens J, Brouwers J, Augustijns P. The dynamic gastric environment and its impact on drug and formulation behaviour. Eur J Pharm Sci 2017; 96:207-231. [DOI: 10.1016/j.ejps.2016.08.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/08/2023]
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Carswell KA, Belgaumkar AP, Amiel SA, Patel AG. A Systematic Review and Meta-analysis of the Effect of Gastric Bypass Surgery on Plasma Lipid Levels. Obes Surg 2016. [PMID: 26210195 DOI: 10.1007/s11695-015-1829-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Obesity-related dyslipidaemia comprises hypercholesterolaemia, hypertriglyceridaemia, low HDL-cholesterol and normal to raised LDL-cholesterol levels. 40% of morbidly obese surgical patients have dyslipidaemia. Roux-en-Y gastric bypass (RYGB) surgery has many beneficial metabolic effects, but the full impact on plasma lipids has not been clearly defined. METHODS A systematic review of electronic databases (Ovid; Medline; PubMed; Embase) between 1960 and March 2012 was performed using search terms including the following: obesity surgery, bariatric surgery, gastric bypass, cholesterol, lipids, triglycerides and non-esterified fatty acids. A total of 2442 manuscripts were screened. Papers with paired plasma lipid levels around RYGB surgery were included. Exclusions included the following: editorials, dual publications, n < 10, resulting in 75 papers of relevance. A meta-analysis was performed of the effect of RYGB surgery upon plasma lipids at different time points up to 4 years following surgery, using a random effects model. RESULTS Paired data were available for 7815 subjects around RYGB surgery for morbid obesity with a baseline BMI 48 kg/m(2) (n = 2331). There was a reduction in plasma total cholesterol and LDL-C from 1 month up to 4 years post-RYGB (p < 0.00001, p < 0.00001). Following RYGB, HDL-C increased from 1 year onwards (p < 0.00001), and triglyceride levels were reduced postoperatively from 3 months up to 4 years (p < 0.00001). NEFA levels were increased at 1 month postoperatively (p = 0.003), but from 3 months onwards did not differ from preoperative levels (p = 0.07). CONCLUSIONS RYGB surgery reverses the dyslipidaemia of obesity. These findings support the use of RYGB in the management of high cardiovascular risk lipid profiles in morbid obesity.
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Affiliation(s)
- Kirstin A Carswell
- Department of General Surgery, King's College Hospital, Denmark Hill, London, UK, SE5 9RS. .,Division of Diabetes and Nutritional Sciences, King's College London, London, UK.
| | - Ajay P Belgaumkar
- Department of General Surgery, King's College Hospital, Denmark Hill, London, UK, SE5 9RS
| | - Stephanie A Amiel
- Division of Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Ameet G Patel
- Department of General Surgery, King's College Hospital, Denmark Hill, London, UK, SE5 9RS
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31
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Srinivas NR. Impact of Roux-en-Y Gastric Bypass Surgery on Pharmacokinetics of Administered Drugs: Implications and Perspectives. Am J Ther 2016; 23:e1826-e1838. [DOI: 10.1097/mjt.0000000000000317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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32
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Azran C, Wolk O, Zur M, Fine-Shamir N, Shaked G, Czeiger D, Sebbag G, Kister O, Langguth P, Dahan A. Oral drug therapy following bariatric surgery: an overview of fundamentals, literature and clinical recommendations. Obes Rev 2016; 17:1050-1066. [PMID: 27335140 DOI: 10.1111/obr.12434] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
Bariatric surgery is the most effective solution for severe obesity and obesity with comorbidities, and the number of patients going through bariatric surgery is rapidly and constantly growing. The modified gastrointestinal anatomy of the patient may lead to significant pharmacokinetic alterations in the oral absorption of drugs after the surgery; however, because of insufficient available literature and inadequate awareness of the medical team, bariatric surgery patients may be discharged from the hospital with insufficient instructions regarding their medication therapy. In this article, we aim to present the various mechanisms by which bariatric surgery may influence oral drug absorption, to provide an overview of the currently available literature on the subject, and to draw guidelines for the recommendations bariatric surgery patients should be instructed before leaving the hospital. To date, and until more robust data are published, it is essential to follow and monitor patients closely for safety and efficacy of their medication therapies, both in the immediate and distant time post-surgery.
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Affiliation(s)
- Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya, Israel
| | - Omri Wolk
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Moran Zur
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Noa Fine-Shamir
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gad Shaked
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - David Czeiger
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - Gilbert Sebbag
- Department of Surgery B, Soroka University Medical Center, Beer Sheva, Israel
| | - Olga Kister
- Institute of Pharmacy, Biopharmaceutics and Pharmaceutical Technology, Johannes Gutenberg-University, Mainz, Germany
| | - Peter Langguth
- Institute of Pharmacy, Biopharmaceutics and Pharmaceutical Technology, Johannes Gutenberg-University, Mainz, Germany
| | - Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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33
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Steffen KJ, Wonderlich JA, Erickson AL, Strawsell H, Mitchell JE, Crosby RD. Comparison of Warfarin Dosages and International Normalized Ratios Before and After Roux-en-Y Gastric Bypass Surgery. Pharmacotherapy 2016; 35:876-80. [PMID: 26406775 DOI: 10.1002/phar.1632] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE As data are limited for dosing warfarin in patients who have undergone bariatric surgery, our objective was to gather data on warfarin pharmacotherapy to aid in the prescribing practices and dosage adjustment of warfarin after Roux-en-Y gastric bypass (RYGB) surgery. DESIGN Retrospective medical record review. SETTING Anticoagulation clinic. PATIENTS Twelve patients who underwent RYGB surgery between 2009 and 2011. MEASUREMENTS AND MAIN RESULTS Data were collected on patient demographics, therapeutic indications for warfarin, weekly warfarin doses, and international normalized ratio (INR) values before and after RYGB surgery. To examine whether the relationship between the warfarin dose and therapeutic effect (i.e., INR) of warfarin changed from before to after surgery, we generated a ratio between each INR measurement and the weekly warfarin dose that immediately preceded it (warfarin dose/INR ratio). Mean weekly warfarin dose after RYGB surgery decreased significantly relative to presurgery dose (estimated marginal mean ± SE presurgery dose 37.08 ± 3.31 mg vs postsurgery dose 28.08 ± 3.27 mg; [F(205.63) = 13.23, p<0.001]), whereas INRs increased significantly after surgery from presurgery levels (estimated marginal mean ± SE presurgery INR 2.36 ± 0.15 vs postsurgery INR 2.94 ± 0.14; [F(213.76) = 6.55, p<0.05]). The ratio of warfarin dose/INR from presurgery (estimated marginal mean ± SE 17.64 ± 1.67) to postsurgery (estimated marginal mean ± SE 10.94 ± 1.64) was also significantly reduced [F(206.47) = 20.61, p<0.001], suggesting that a lower warfarin dose was required to produce the desired INR after surgery compared with before surgery. CONCLUSION Warfarin dosages tended to decrease after RYGB surgery, in agreement with previously published literature. These findings suggest the need for increased INR monitoring and patient education for patients taking warfarin after RYGB surgery.
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Affiliation(s)
- Kristine J Steffen
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, North Dakota.,Neuropsychiatric Research Institute, Fargo, North Dakota
| | | | - Ann L Erickson
- Neuropsychiatric Research Institute, Fargo, North Dakota
| | | | - James E Mitchell
- Neuropsychiatric Research Institute, Fargo, North Dakota.,Department of Neuroscience, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota
| | - Ross D Crosby
- Neuropsychiatric Research Institute, Fargo, North Dakota.,Department of Neuroscience, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota
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34
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Musfeldt D, Levinson A, Nykiel J, Carino G. Lithium toxicity after Roux-en-Y bariatric surgery. BMJ Case Rep 2016; 2016:bcr2015214056. [PMID: 26994048 PMCID: PMC4800199 DOI: 10.1136/bcr-2015-214056] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 01/06/2023] Open
Abstract
A 61-year-old woman with medical history significant for morbid obesity, type II diabetes mellitus, nephrogenic diabetes insipidus and bipolar disorder, had been stable on lithium carbonate therapy for several years. She had undergone a Roux-en-Y bypass surgery and, at the time of her surgery, her lithium level was found to be 0.61 mEq/L on a maintenance dose of 600 mg orally twice per day. She was discharged 8 days postoperatively on the same lithium dose, but presented to the emergency department 12 days postoperatively with signs of lithium toxicity. Her lithium level was elevated to 1.51 mEq/L and she was treated for lithium toxicity with supportive care and, ultimately, reduction of her lithium dose. Clinicians should be aware that dramatic and poorly understood changes in drug absorption may occur after bariatric surgery.
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Affiliation(s)
- Deanna Musfeldt
- Department of Critical Care Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Andrew Levinson
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jennifer Nykiel
- Department of Emergency Medicine, University of Chicago, Chicago, Illinois, USA
| | - Gerardo Carino
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
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35
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Roerig JL, Steffen K. Psychopharmacology and Bariatric Surgery. EUROPEAN EATING DISORDERS REVIEW 2015; 23:463-9. [PMID: 26338011 DOI: 10.1002/erv.2396] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/30/2015] [Indexed: 12/20/2022]
Abstract
Currently, it has been demonstrated that psychotropic drugs, particularly antidepressants, are frequently prescribed for patients who seek bariatric surgery. Many bariatric surgery patients have a history of a mood disorder. Unlike medications for diabetes, hypertension or hyperlipidemia, which are generally reduced and at times discontinued, postsurgery antidepressants use is only slightly reduced. The Roux-en-Y procedure is most frequently associated with alteration in drug exposure. Medication disintegration, dissolution, absorption, metabolism and excretion have been found to be altered in postbariatric patients, although data are sparse at this time. This paper will review the current evidence regarding the effect of bariatric surgery on drug treatment including mechanism of interference as well as the extent of changes identified to date. Data will be presented as controlled trials followed by case series and reports.
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Affiliation(s)
- James L Roerig
- Department of Psychiatry and Behavioral Science, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA.,Neuropsychiatric Research Institute, Fargo, ND, USA
| | - Kristine Steffen
- Neuropsychiatric Research Institute, Fargo, ND, USA.,Department of Pharmaceutical Sciences, College of Pharmacy, North Dakota State University, Grand Forks, ND, USA
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36
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Koutsavlis I, Lasebai M. Dose-Dependent Carbamazepine-Induced Agranulocytosis Following Bariatric Surgery (Sleeve Gastrectomy): A Possible Mechanism. Bariatr Surg Pract Patient Care 2015. [DOI: 10.1089/bari.2015.0020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - Muayed Lasebai
- Department of Haematology, NHS Lothian, Edinburgh, United Kingdom
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37
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Gesquiere I, Darwich AS, Van der Schueren B, de Hoon J, Lannoo M, Matthys C, Rostami A, Foulon V, Augustijns P. Drug disposition and modelling before and after gastric bypass: immediate and controlled-release metoprolol formulations. Br J Clin Pharmacol 2015; 80:1021-30. [PMID: 25917170 DOI: 10.1111/bcp.12666] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/17/2015] [Accepted: 04/23/2015] [Indexed: 12/15/2022] Open
Abstract
AIMS The aim of the present study was to evaluate the disposition of metoprolol after oral administration of an immediate and controlled-release formulation before and after Roux-en-Y gastric bypass (RYGB) surgery in the same individuals and to validate a physiologically based pharmacokinetic (PBPK) model for predicting oral bioavailability following RYGB. METHODS A single-dose pharmacokinetic study of metoprolol tartrate 200 mg immediate release and controlled release was performed in 14 volunteers before and 6-8 months after RYGB. The observed data were compared with predicted results from the PBPK modelling and simulation of metoprolol tartrate immediate and controlled-release formulation before and after RYGB. RESULTS After administration of metoprolol immediate and controlled release, no statistically significant difference in the observed area under the curve (AUC(0-24 h)) was shown, although a tendency towards an increased oral exposure could be observed as the AUC(0-24 h) was 32.4% [95% confidence interval (CI) 1.36, 63.5] and 55.9% (95% CI 5.73, 106) higher following RYGB for the immediate and controlled-release formulation, respectively. This could be explained by surgery-related weight loss and a reduced presystemic biotransformation in the proximal gastrointestinal tract. The PBPK values predicted by modelling and simulation were similar to the observed data, confirming its validity. CONCLUSIONS The disposition of metoprolol from an immediate-release and a controlled-release formulation was not significantly altered after RYGB; there was a tendency to an increase, which was also predicted by PBPK modelling and simulation.
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Affiliation(s)
- Ina Gesquiere
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Adam S Darwich
- Centre for Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Jan de Hoon
- Center for Clinical Pharmacology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Matthias Lannoo
- Department of Abdominal Surgery, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Christophe Matthys
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Amin Rostami
- Centre for Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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38
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Chan LN, Lin YS, Tay-Sontheimer JC, Trawick D, Oelschlager BK, Flum DR, Patton KK, Shen DD, Horn JR. Proximal Roux-en-Y gastric bypass alters drug absorption pattern but not systemic exposure of CYP3A4 and P-glycoprotein substrates. Pharmacotherapy 2015; 35:361-9. [PMID: 25757445 DOI: 10.1002/phar.1560] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVES To evaluate the effect of Roux-en-Y gastric bypass surgery (RYGB) on the pharmacokinetics of midazolam (a CYP3A4 substrate) and digoxin (a P-glycoprotein substrate). DESIGN Prospective, nonblinded, longitudinal, single-dose pharmacokinetic study in three phases: presurgery baseline and postoperative assessments at 3 and 12 months. PATIENTS Twelve obese patients meeting current standards for bariatric surgery. MEASUREMENTS AND MAIN RESULTS At each study visit, patients received a single dose of oral digoxin and midazolam at 8 a.m. Blood samples were collected at regular intervals for 24 hours after dosing. Continuous 12-lead electrocardiogram (EKG), heart rate, blood pressure, and respiratory rate were monitored, and pharmacokinetic parameters from the three visits were compared. The peak plasma concentration (Cmax ) of midazolam increased by 66% and 71% at 3- and 12-month post-RYGB (p=0.017 and p=0.001, respectively), whereas the median time to peak concentration (Tmax ) was reduced by 50%. The mean Cmax for 1'-hydroxymidazolam increased by 87% and 80% at 3 and 12 months (p=0.001 and p<0.001, respectively). However, neither the area under the concentration-time curve (AUC) for midazolam nor the metabolite-to-parent AUC ratio changed significantly over time. For digoxin, the median Tmax decreased from 40 minutes at baseline to 30 and 20 minutes at 3 and 12 months, respectively. The mean AUC for digoxin, heart rate, and EKG patterns were similar across the three study phases. CONCLUSION Contemporary proximal RYGB increases the rate of drug absorption without significantly changing the overall exposure to midazolam and digoxin. The Cmax of a CYP3A4 substrate with a high extraction ratio was substantially increased after RYGB.
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Affiliation(s)
- Lingtak-Neander Chan
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
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39
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Guedes BLDS, Montanha MC, Teixeira JJV, Diniz A, Silva SRB, Previdelli I, Nasser D, Yamada SS, Kimura E. Clinicians' prescribing practices for bariatric surgery patients: is there an issue? J Clin Pharm Ther 2014; 40:104-9. [PMID: 25302403 DOI: 10.1111/jcpt.12217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/10/2014] [Indexed: 12/18/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Patients undergoing Roux-en-Y gastric bariatric (RYGB) surgery present a reduced absorption site, and special attention should therefore be taken when prescribing oral-dosage forms. This study was carried out to investigate the extent to which non-bariatric clinicians are aware of this issue when prescribing medicines for this population, and what type of information is available to aid them in their decision-making. METHODS Two questionnaires were created, one for non-bariatric clinicians and another for their patients who had undergone RYGB surgery, to gather information about the prescription practices for this population. Additionally, a literature search of pharmacokinetic studies on bariatric patients and recommended prescription practices was carried out. RESULTS AND DISCUSSION Of the 62 non-bariatric clinicians surveyed, 50% believed RYGB surgery interferes with drug absorption; however, 68% still prescribed tablets as the first choice form of dosage. Young clinicians (35%) were less likely to believe that RYGB surgery could affect drug absorption than experienced clinicians (43%). The main reasons for changing dosage forms were patient complaints about efficacy or difficulty in swallowing tablets. Of the 73 patients, 43 were taking drugs in tablet form after the surgery, 24 of whom had health issues unrelated to the surgery. None of the journals read by the clinicians contained pharmacokinetics (PK) studies involving bariatric surgery patients or presented recommendations for the prescription of oral-dosage forms for this population. The literature search revealed a total of 22 drugs that had undergone PK studies in RYGB patients. Fifteen of them were reported to have decreased effects, 12 of which were administered as tablets. WHAT IS NEW AND CONCLUSION There is still a relative lack of clinical evidence to guide clinicians when prescribing medicines for bariatric patients. It is therefore recommended that pharmacists should have greater participation in the prescription process to advise non-bariatric clinicians and educate RYGB surgery patients to help avoid therapeutic failure.
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Affiliation(s)
- B L da S Guedes
- Post-Graduate Program in Bioscience and Physiopathology, State University of Maringa, Paraná, Brazil
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40
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Stein J, Stier C, Raab H, Weiner R. Review article: The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther 2014; 40:582-609. [PMID: 25078533 DOI: 10.1111/apt.12872] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/22/2013] [Accepted: 06/21/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obesity surgery is acknowledged as a highly effective therapy for morbidly obese patients. Beneficial short-term effects on common comorbidities are practically undisputed, but a growing data pool from long-term follow-up reveals increasing evidence of potentially severe nutritional and pharmacological consequences. AIMS To assess the prevalence, causes and symptoms of complications after obesity surgery, to elucidate and compare therapy recommendations for macro- and micronutrient deficiencies, and to explore surgically-induced effects on drug absorption and bioavailability, discussing ramifications for long-term therapy and prophylaxis. METHODS PubMed, Embase and MEDLINE were searched using terms including, but not limited to, bariatric surgery, gastric bypass, obesity surgery and Roux-en-Y, coupled with secondary search terms, e.g. anaemia, micronutrients, vitamin deficiency, bacterial overgrowth, drug absorption, pharmacokinetics, undernutrition. All studies in English, French or German published January 1980 through March 2014 were included. RESULTS Macro- and micronutrient deficiencies are common after obesity surgery. The most critical, depending on surgical technique, are hypoalbuminemia (3-18%) and deficiencies of vitamins B1 (≤49%), B12 (19-35%) and D (25-73%), iron (17-45%) and zinc (12-91%). Many drugs commonly administered to obese patients (e.g. anti-depressants, anti-microbials, metformin) are subject to post-operative and/or PPI-associated changes affecting bioavailability and absorption. CONCLUSIONS Complications are associated with pre-operative and/or post-operative malnutrition or procedure-related changes in intake, absorption and drug bioavailability. The high prevalence of nutrient deficiencies after obesity surgery makes life-long nutritional monitoring and supplementation essential. Post-operative changes to drug absorption and bioavailability in bariatric patients cast doubt on the validity of standard drug dosage and administration recommendations.
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Affiliation(s)
- J Stein
- Department of Gastroenterology and Clinical Nutrition, Sachsenhausen Hospital, Frankfurt/Main, Germany; German Obesity Center (GOC), Frankfurt-Sachsenhausen, Frankfurt/Main, Germany
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Lloret-Linares C, Hirt D, Bardin C, Bouillot JL, Oppert JM, Poitou C, Chast F, Mouly S, Scherrmann JM, Bergmann JF, Declèves X. Effect of a Roux-en-Y Gastric Bypass on the Pharmacokinetics of Oral Morphine Using a Population Approach. Clin Pharmacokinet 2014; 53:919-30. [DOI: 10.1007/s40262-014-0163-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Faye E, Corcos O, Bergmann JF, Simoneau G, Joly F, Lloret-Linares C. Utilisation des médicaments par voie orale et syndrome de grêle court : analyse des pratiques. Therapie 2014; 69:207-12. [DOI: 10.2515/therapie/2014024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/23/2013] [Indexed: 11/20/2022]
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Pharmacokinetic and Pharmacodynamic Alterations in the Roux-en-Y Gastric Bypass Recipients. Ann Surg 2013; 258:262-9. [DOI: 10.1097/sla.0b013e31827a0e82] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Roerig JL, Steffen KJ, Zimmerman C, Mitchell JE, Crosby RD, Cao L. A comparison of duloxetine plasma levels in postbariatric surgery patients versus matched nonsurgical control subjects. J Clin Psychopharmacol 2013; 33:479-84. [PMID: 23771193 DOI: 10.1097/jcp.0b013e3182905ffb] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Bariatric surgery such as the Roux-en-Y gastric bypass (RYGB) is currently used as a treatment for severe obesity. Alteration of the gastrointestinal tract by this procedure suggests a potential for clinically significant alterations in the bioavailability of ingested medications including antidepressants. OBJECTIVES The purpose of this trial was to determine to what extent the RYGB procedure alters the area under the plasma concentration/time curve (AUC(0-infinity)) of the antidepressant, duloxetine. METHODS Ten subjects who were 1 year post-RYGB where compared with healthy control subjects matched for body mass index, age, and sex. Ultrarapid or poor metabolizers for cytochrome P450 2D6 were excluded from the study. Subjects received a single dose of 60 mg of duloxetine. Nineteen plasma samples were obtained during 72 hours to characterize the plasma level profile. RESULTS The mean AUC(0-infinity) was significantly smaller for the postbariatric surgery (PBS) group (646.74 ng × h/mL [SD, 79.70; range, 539.57-791.62], P = 0.017) compared to the nonsurgical control group (1119.91 ng × h/mL [SD, 593.40; range, 415.5-2426.56]). The Tmax was also significantly shorter for the PBS group (2.2 hours) compared to the nonsurgical control group (6 hours; P = 0.005). No significant difference in Cmax or half-life was identified. CONCLUSIONS To our knowledge, this is the first reported study exploring duloxetine pharmacokinetics PBS. This trial found that the bariatric surgery group was exposed to only 57.7% of duloxetine as compared to the nonsurgery group. This finding suggests that clinicians need to monitor patients closely after bariatric surgery and that further exploration of the effects of bariatric surgery on antidepressant pharmacokinetic parameters is warranted.
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Affiliation(s)
- James L Roerig
- Department of Clinical Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, ND 58107-1415, USA.
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Darwich AS, Pade D, Rowland-Yeo K, Jamei M, Asberg A, Christensen H, Ashcroft DM, Rostami-Hodjegan A. Evaluation of an In Silico PBPK Post-Bariatric Surgery Model through Simulating Oral Drug Bioavailability of Atorvastatin and Cyclosporine. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2013; 2:e47. [PMID: 23903405 PMCID: PMC3697036 DOI: 10.1038/psp.2013.23] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/13/2013] [Indexed: 01/12/2023]
Abstract
An increasing prevalence of morbid obesity has led to dramatic increases in the number of bariatric surgeries performed. Altered gastrointestinal physiology following surgery can be associated with modified oral drug bioavailability (Foral). In the absence of clinical data, an indication of changes to Foral via systems pharmacology models would be of value in adjusting dose levels after surgery. A previously developed virtual "post-bariatric surgery" population was evaluated through mimicking clinical investigations on cyclosporine and atorvastatin after bariatric surgery. Cyclosporine simulations displayed a reduced fraction absorbed through gut wall (fa) and Foral after surgery, consistent with reported observations. Simulated atorvastatin Foral postsurgery was broadly reflective of observed data with indications of counteracting interplay between reduced fa and an increased fraction escaping gut wall metabolism (FG). Inability to fully recover observed atorvastatin exposure after biliopancreatic diversion with duodenal switch highlights the current gap regarding the knowledge of associated biological changes.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e47; doi:10.1038/psp.2013.23; advance online publication 12 June 2013.
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Affiliation(s)
- A S Darwich
- Centre for Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
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Sawaya RA, Jaffe J, Friedenberg L, Friedenberg FK. Vitamin, mineral, and drug absorption following bariatric surgery. Curr Drug Metab 2013; 13:1345-55. [PMID: 22746302 DOI: 10.2174/138920012803341339] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/28/2012] [Accepted: 05/02/2012] [Indexed: 02/07/2023]
Abstract
UNLABELLED The prevalence of obesity continues to rise throughout the world. Increasingly, bariatric surgery is used for those with morbid obesity as a pivotal approach to achieve weight loss. Along with substantial weight loss, malabsorption of essential vitamins, minerals, and drugs also occurs. Therefore, more than ever, a better understanding of the physiology and mechanisms by which these deficiencies occur is essential. We review the normal physiology of vitamin, mineral, and drug absorption. This is followed by a description of currently performed bariatric surgeries in the United States. A detailed review of specific nutrient and mineral deficiency states is presented, based on the most significant studies published in the last two decades. Of note, screening and supplementation recommendations have been included. Drug absorption data after these procedures is presented and discussed. Studies were identified by searching the Cochrane Registry and MEDLINE using relevant search terms, as well as through review of the reference section of included manuscripts. CONCLUSIONS Bariatric surgery can be effectively used to achieve sustainable weight-loss in morbidly obese patients. It simultaneously brings forth important functional consequences on nutrient deficiencies and drug absorption that clinician's must be aware of. Further prospective, randomized research on specific procedures and deficiencies is required.
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Aron-Wisnewsky J, Lemaitre F, Clément K, Bouillot JL, Fernandez C, Basdevant A, Oppert JM, Buyse M. Pharmacokinetics of Immunomodulator Treatments After Roux-En-Y Bypass in Obese Patient. J Clin Pharmacol 2013; 53:779-84. [DOI: 10.1002/jcph.99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/15/2013] [Indexed: 01/08/2023]
Affiliation(s)
| | - Florian Lemaitre
- Clinical Pharmacy Laboratory; Faculty of Pharmacy, University Paris XI; 5, rue Jean Baptiste Clément; 92296; Chatenay-Malabry; France
| | | | - Jean-Luc Bouillot
- Surgery Department; Ambroise Paré Hospital Assistance Publique-Hôpitaux de Paris; 9, avenue Charles de Gaulle; 92104; Boulogne-Billancourt cedex; France
| | | | | | - Jean-Michel Oppert
- Nutrition Department, Part of the Institute of Cardio-metabolism and Nutrition (ICAN); Pitié-Salpétrière Hospital (AP-HP) and Center for Human Nutrition Research-Ile-de-France (CRNH-IdF), University Pierre et Marie Curie-Paris 6; 83 boulevard de l'Hôpital; 75013; Paris; France
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Mitchell JE, Crosby R, de Zwaan M, Engel S, Roerig J, Steffen K, Gordon KH, Karr T, Lavender J, Wonderlich S. Possible risk factors for increased suicide following bariatric surgery. Obesity (Silver Spring) 2013; 21:665-72. [PMID: 23404774 PMCID: PMC4372842 DOI: 10.1002/oby.20066] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 08/02/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE There is a growing research literature suggesting that there may be elevated risk of suicide following bariatric surgery. Most of the data reported thus far has been cross-sectional and observational, and very little is known about the possible specific causal variables involved. DESIGN AND METHODS The purpose of this report is to review this literature and to review possible risk factors for increased suicidal risk following bariatric surgery, to delineate future research directions. RESULTS First a variety of medical, biological, and genetic factors, including the persistence or recurrence of medical comorbidities after bariatric surgery, the disinhibition and impulsivity secondary to changes in the absorption of alcohol, hypoglycemia, as well as pharmacokinetic changes that may affect the absorption of various medications including antidepressant medications are reviewed. Also reviewed are possible mediating factors involving changes in various peptidergic systems such as GLP-1 and Ghrelin. A number of psychosocial issues that might be involved are discussed, including lack of improvement in quality of life after surgery, continued or recurrent physical mobility restrictions, persistence or recurrence of sexual dysfunction and relationship problems, low self-esteem, and a history of child maltreatment. Inadequate weight loss or weight regain are also discussed. CONCLUSIONS A number of possible contributing factors have been identified. Possible theoretical models involved and directions for research are suggested.
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Darwich AS, Henderson K, Burgin A, Ward N, Whittam J, Ammori BJ, Ashcroft DM, Rostami-Hodjegan A. Trends in oral drug bioavailability following bariatric surgery: examining the variable extent of impact on exposure of different drug classes. Br J Clin Pharmacol 2013; 74:774-87. [PMID: 22463107 DOI: 10.1111/j.1365-2125.2012.04284.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Changes to oral drug bioavailability have been observed post bariatric surgery. However, the magnitude and the direction of changes have not been assessed systematically to provide insights into the parameters governing the observed trends. Understanding these can help with dose adjustments. WHAT THIS STUDY ADDS Analysis of drug characteristics based on a biopharmaceutical classification system is not adequate to explain observed trends in altered oral drug bioavailability following bariatric surgery, although the findings suggest solubility to play an important role. AIMS To identify the most commonly prescribed drugs in a bariatric surgery population and to assess existing evidence regarding trends in oral drug bioavailability post bariatric surgery. METHODS A retrospective audit was undertaken to document commonly prescribed drugs amongst patients undergoing bariatric surgery in an NHS hospital in the UK and to assess practice for drug administration following bariatric surgery. The available literature was examined for trends relating to drug permeability and solubility with regards to the Biopharmaceutics Classification System (BCS) and main route of elimination. RESULTS No significant difference in the 'post/pre surgery oral drug exposure ratio' (ppR) was apparent between BCS class I to IV drugs, with regards to dose number (Do) or main route of elimination. Drugs classified as 'solubility limited' displayed an overall reduction as compared with 'freely soluble' compounds, as well as an unaltered and increased ppR. CONCLUSION Clinical studies establishing guidelines for commonly prescribed drugs, and the monitoring of drugs exhibiting a narrow therapeutic window or without a readily assessed clinical endpoint, are warranted. Using mechanistically based pharmacokinetic modelling for simulating the multivariate nature of changes in drug exposure may serve as a useful tool in the further understanding of postoperative trends in oral drug exposure and in developing practical clinical guidance.
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Affiliation(s)
- Adam S Darwich
- Centre of Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
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50
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Influence of Bariatric Surgery on the Use and Pharmacokinetics of Some Major Drug Classes. Obes Surg 2013; 23:819-25. [DOI: 10.1007/s11695-013-0882-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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