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Weight Loss Surgery and Medications

October is ADHD Awareness Month Weight loss surgery and psychiatric medication

It is important to let your doctor know if you are to have any scheduled a Weight Loss Surgery such as gastric bypass, “Roux-en-y,” lap band or sleeve procedure. Bariatric surgery allows for manipulation of the stomach and small intestine; medication absorption may be affected due to the change in the gastrointestinal system. Of note, many medications are absorbed either in the stomach or small intestines and absorption can be a challenge. One factor is that if the size of the stomach is reduced there is not enough potential stomach acid to fully dissolve the medication. Other medications may be absorbed after they pass through the stomach and into the first part of the small intestines called the duodenum. It is the mix of the non-acidic or neutral environment of the small intestines along with specific digestive enzymes and proteins lining the duodenum that allow absorption.   Bariatric surgery techniques, especially the popular Roux-en-y procedure, completely bypass the duodenum, so certain medications may have difficulty being absorbed.

After bariatric surgery, many patients are able to discontinue medications for chronic conditions, such as diabetes and hypertension.  The good news is that most patients after Roux en Y Gastric Bypass surgery require fewer medications, or at least reduced dosages of medications then they needed prior to the surgery.  However, drug therapy is often needed for conditions unrelated to or not improved by weight loss. Chronic psychiatric conditions such as ADHD, depression and anxiety may be among these conditions.  In addition to drug absorption, drug distribution can also be affected following bariatric surgery. Obesity-related factors that can influence drug distribution include increased blood volume, cardiac output, lean body mass, organ size, and adipose mass. After bariatric surgery, these factors are expected to change and, therefore, may necessitate drug dosing adjustments.  To better manage these medications, it is essential to be aware of the changes in the anatomy and physiology of the GI tract following bariatric surgery.

If one is preparing for bariatric surgery it is important to work with your doctor to find alternatives. If there is a version of the drug that is not extended release (referred to as Immediate Release or “IR”), switching to that often drug often works. If there is no IR version of the drug available, then discuss alternatives with your doctor. Very often there is a similar IR drug that may be as clinically effective as  the extended release drug you’re on. Consider crushing all medications and switching all sustained-extended release formulations to immediate-release dosage forms, when appropriate. Alternative dosage formulations such as liquid solutions or suspensions that will circumvent the need for tablet or capsule dissolution should also be considered. Ultimately, frequent and thorough therapeutic monitoring should be implemented in order to ensure correct dosing and to minimize side effects.

The medications that are most at risk of challenges after gastric bypass surgery are those that are extended release, delayed release or enteric coated. These include most branded, non-generic extended release medications that have names that end in “XR”, “XL”, “SR” “ER” or “CR.” Examples include Effexor XR , Wellbutrin SR and  Wellbutrin XL, etc. However, many generic and some branded medications don’t carry that label, so prescribers will need to specify medications that are extended release or enteric coated. Enteric coated tablets are designed to pass through the stomach acid intact and be dissolved in the small intestines. Examples of these psychiatric drugs include:

Extended release ADHD medications such as: Adderall XR, Metadate CD, Vyvanse; antidepressants such as: Cymbalta, Pristiq, Wellbutrin XL, Effexor XR, Paxil CR, Prozac weekly; and other medications including Depakote ER. Lithium levels recently were noted to have high blood levels following bariatric surgery, thus it is important to monitor levels of medications as well.

It is important to know that stopping psychiatric medication suddenly without your prescribing doctor’s consent is dangerous and can lead to relapse in symptoms, withdrawal symptoms and possible lack of effectiveness of the medication in the future.  The most important take away point is to carefully prepare with your bariatric surgeon and medical or psychiatric team for surgery.  Having your depression and mental health issues in good control is critical to a good outcome as keeping your depression in check will allow you to be well motivated and in good form post weight loss surgery.

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