Magazine article Drug Topics

Will Bypass Alter Drug Choice?

Magazine article Drug Topics

Will Bypass Alter Drug Choice?

Article excerpt

A 52-year-old morbidly obese woman, M.A., will soon undergo a Roux-en-Y gastric bypass at your hospital. Her current daily medications include rosiglitazone 8 mg (Avandia, GlaxoSntithKline), ezetimibe 10 mg (Zetia, Schering/Merck), simvastatin 80 mg, ramipril 20 mg, hydrochlorothiazide 25 mg, sertraline 150 mg, aspirin 325 mg, huice-daily nicardipine sustained-release 60 mg (Cardene SR, PDL BioPhartna), metformin extended-release (ER) 1,000 mg, and esomeprazolc 40 mg (Nexititn, AstraZeneca) before breakfast daily. Her medical team anticipatesat least initially-no change in her medication postsurgery but wonders hoiv drug therapy will be affected by the procedure. Wliat changes do you anticipate?

Bariatric surgery procedures are associated with unpredictable reductions in medication and nutrient absorption postoperatively due to reduced functional intestinal length. Substitution of immediate-release (IR) products for ER or enteric-coated medications is necessary; these formulations have long absorptive phases requiring a significant portion of small intestine; postoperatively they will exhibit decreased bioavailability. Change metformin ER to IR. Because IR nifedipine products are associated with a potential for profound hypotension and ischemia, nifedipine should be changed to another IR calcium-channel blocker, e.g., amlodipine. Esomeprazole and other proton pump inhibitors are ER products; however, lack of exact therapeutic equivalents justifies continued use postoperatively.

If M.A. has symptoms of GERD, a change to an H^sub 2^-receptor antagonist is recommended. M. A.'s use of aspirin and other NSAIDs carries an increased risk of gastrointestinal events; however, her comorbidities place her at high risk for cardiovascular events. An 81-mg dose aspirin daily with food is recommended. Beginning at discharge, supplementation with a daily multivitamin is recommended, along with calcium for osteoporosis prevention.

Close monitoring is needed after discharge and as M.A. begins to experience weight loss. Metformin, ramipril, and simvastatin all have potential for decreased bioavailability based on the site of absorption, but immediate changes are not necessary. Instead, M.A.'s home blood glucose, hemoglobin AIc, blood pressure, and cholesterol should be followed. If medication efficacy decreases, changing to liquid formulations or other agents in the class would be recommended. As M.A. loses weight, improved blood glucose, blood pressure, and cholesterol are likely to be observed; downward titration of medications will be necessary. …

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