Approximatelytoadult patients undergo bariatric surgery every year, according to the American Society for Metabolic and Bariatric Surgery. The absorption of different pharmacologic agents can be drastically altered in these patients.
There are a number of different bariatric procedures that are performed today to help patients lose weight. These procedures can be categorized as either restrictive or a combination of restrictive and malabsorptive.
Gastric surgeries that are restrictive in nature create a small pouch from the upper portion of the stomach that limits the amount of food that a person can consume but leaves the rest of the GI tract intact.
Procedures that are both restrictive and malabsorptive not only create a smaller pouch from the stomach, but they also bypass a portion of the small intestine generally the duodenum and lung cancer to adrenal glands of the jejunum.
The restrictive and malabsorptive bariatric procedures each have different effects on drug absorption and bioavailability. Reducing the size of the stomach can impede the disintegration and dissolution of certain drugs. Gastric mixing, which promotes drug disintegration, often is compromised to some extent after gastric procedures.
In some cases, this can be overcome by crushing or chewing tablets or capsules, or by simply using a liquid formulation; however, some inflammatory arthritis after gastric bypass cannot be crushed and others do not come in liquid formulations. In addition, many drugs are more soluble in acidic environments and require the low pH of the stomach contents to dissolve.
The dissolution of acidic or enteric-coated drugs is more likely to be impeded by increases in gastric pH, as these drugs are more soluble in a lower pH environment. By removing or bypassing a portion of the small intestine, malabsorptive bariatric surgery can drastically reduce the length and surface area within the GI tract that is available to absorb drugs.
Intestinal transit time is increased in these patients, meaning that any drugs taken orally will spend less time in contact with the intestinal arimidex adrenal glands where they would likely be absorbed. Because of this, drug products formulated in extended-release, delayed-release, sustained- release, inflammatory arthritis after gastric bypass, enteric-coated, and film-coated preparations should be avoided, inflammatory arthritis after gastric bypass, since they have slow dissolution properties and may pass through the GI tract inflammatory arthritis after gastric bypass absorption is complete.
The reduced stomach size with all types of gastric surgery presents a major problem with the use of nonsteroidal anti-inflammatory drugs NSAIDs. Administration of NSAIDs in these patients carries an increased risk for serious damage to the stomach pouch, which may result in gastric ulcers.
NSAIDs can cause this damage through direct irritation of the GI mucosa due to their acidic properties and through their systemic effects, inflammatory arthritis after gastric bypass, which include the inhibition of cyclooxygenase COX -1 leading to reduced prostaglandin synthesis and a decrease in production of gastric mucous that protects the stomach epithelium from damage.
Because of these effects, use of NSAIDs in these patients should be avoided if possible, and alternative oral pain medications, inflammatory arthritis after gastric bypass as acetaminophen, should be substituted.
Addition of a H 2 receptor antagonist, proton pump inhibitor, or misoprostol also should be considered with prolonged use of any NSAIDS in this at risk population. It is important to keep in mind the altered physiology of patients who have undergone bariatric surgery when managing their chronic pain. As obesity rates continue to increase in the United States, inflammatory arthritis after gastric bypass, the number of people who elect to have bariatric procedures also will likely increase.
Avoiding the use of NSAIDs including salicylates in these patients will be a priority when considering the safety of the different agents used for pain management, inflammatory arthritis after gastric bypass.
If unavoidable, then a COX-2 inhibitors are preferred. Crushing or chewing solid formulations or using liquid formulations can aid in absorption when drug disintegration is impaired, and acidic drugs may have decreased dissolution and solubility if gastric pH is increased due to surgery. Immediate-release oral products should be used when possible, despite the inconvenience of more frequent dosing parameters. Use of transdermal pain relievers also should be considered because they may represent a practical way to achieve long-lasting and convenient chronic pain relief in patients with bariatric surgery, given the different factors that can affect oral drug absorption.
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The Conundrum of Epidural Corticosteroid Injections. Letters To the Editor: New evidence prompts update to metabolic and bariatric surgery clinical guidelines; April 5, Accessed June 9, Medication and nutrient administration considerations after bariatric surgery.
Am J Health Syst Pharm. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Sardo P, Walker JH. Marginal ulcer after gastric bypass: Volume 18, Issue 6.
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