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Medications after Bariatric Surgery

Medications after Bariatric Surgery: Do’s and Don’ts

Atlanta Bariatric Support Group

JK Champion MD

Medications after Bariatric SurgeryWe are frequently asked questions about medication use after weight loss surgery. Patients want to know:

1)      Why they shouldn’t take aspirin or anti-inflammatory medications

2)      Are there other medications Bariatric Patients should avoid?

3)      Whether medications they are routinely on will be absorbed normally or will the dose need to be changed.

Aspirin and Anti-Inflammatory Medications (NSAIDS and steroids):

This class of medications includes aspirin products, non-steroidal anti-inflammatory meds (NSAIDS), COX-2 inhibitors, and steroids. All these medications can irritate the stomach or impair healing and lead to an ulcer in the stomach, which is quite serious after any weight loss operation.

They should only be taken if there is a good medical indication and the patient also takes a proton pump inhibitor medication at the same time. In no circumstance should they be taken for at least 6 weeks after surgery!!!!!!

After gastric bypass patients can develop a “marginal ulcer” which occurs where the stomach is re-attached to the small intestine. This can lead to pain, bleeding, excessive scar tissue build-up and the inability to eat solids, or eat a hole all the way through the bowel wall and perforate, causing peritonitis. Marginal ulcers occur in around 1% of gastric bypass patients, and half of these are due to anti-inflammatory drug use or smoking. Half the patients with ulcers will need an operation to manage a complication of the ulcer, so it’s quite serious and the risk needs to be minimized with your cooperation.

After Lap-band or VBG these medications can cause an ulcer in the pouch or distal stomach, or can cause the band to erode into the stomach wall. Again this may result in hemorrhage, pain, scarring, or a perforation with the need for subsequent surgery.

Aspirin, even baby aspirin, should be avoided unless the patient has documented coronary artery disease which requires an angioplasty, stent, or surgery. Prophylactic use after a gastric bypass, in an attempt to reduce risk in patient with know risk factors or a strong family history of heart disease, causes more problems then it helps, and is unproven to benefit women under age 60.

NSAIDS include a wide range of name brand products and generics, so if in doubt ask.

Examples include Advil, Motrin, ibuprofen, Aleve, naprosyn, daypro, anaprox, voltaren, dolobid, feldene, mobic, Relafen, toradol, Indocin, and clinoril. This list is not all inclusive, so ask questions of the pharmacist or our office if in doubt. Most family physicians, orthopedists and internists don’t understand the need to avoid these meds after bariatric surgery and may mistakenly assure you it’s OK.

COX-2 inhibitors are also frequently prescribed for pain and have included celebrex, vioxx, and bextra. Some of these have been removed from the market due to increasing the risk of heart disease, but they may be re-introduced in the future. It was mistakenly believed these meds caused less stomach irritation and had less risk of bleeding from the stomach, but this has not been found to be the case, and is just as likely as aspirin or NSAIDS to cause stomach irritation.

Steroids delay healing in the stomach and impair the lining of the stomachs’ ability to repair itself and form a protective layer between the muscle wall and acid. This can again lead to an ulcer, bleeding or perforation. Examples of steroids are prednisone, medrol dose pack, decadron, depo-medrol, and solu-cortef.

Steroids should be avoided the first 6 weeks after surgery, and then if required must be accompanied by a proton pump inhibitor (PPI) for at least 30 days after the medication is stopped. Steroid injections into a joint or the back don’t affect the stomach so don’t require PPI’s.

Examples of PPI’s are:

Prilosec, Prevacid, Nexium, Protonix and Aciphex.

Medications which are classified as antacids but are NOT PPI’s and are not acceptable protection are: Pepcid, Zantac, and Tagamet

Other Medications to Avoid:

A commonly prescribed medication for women today is for the treatment of osteoporosis and it can result in ulceration of the esophagus or stomach if it doesn’t empty out of the pouch quickly, so I have advised my patients not to use them unless all other methods of treatment have failed. Examples are Fosamax and Actonel, but new meds are being introduced now. The safety of these meds after gastric bypass and other bariatric surgery is unknown. If needed, discuss with your physician using the once weekly dose schedule, and make sure you remain upright for an hour after the medication and report any heartburn, indigestion or abdominal pain promptly and stop the medication. These medications should not be prescribed for osteopenia, or to prevent osteoporosis due to a strong family history.

I recommend eliminating herbal supplements after bariatric surgery. These are not regulated by any agency and are of unknown strength and purity. Many have effects which are poorly understood and can cause un-wanted side effects.

Concentrate on a good brand name multi-vitamin and eat fruit and vegetables and you’ll be fine.

Patients should exhibit caution when on immune suppressant drugs, such as chemotherapy, or the newer immune suppressant drugs for arthritis and psoriasis. If in doubt stay on a PPI to reduce your risk.

Nicotine in the common form of smoking is one of the worst things patients can do after weight loss surgery, due to the high risk of ulceration of the stomach.

Illicit drug use in the form of cocaine also is known to result in ulceration and perforation of even normal stomachs.

Medication Dosage after Weight Loss Surgery:

Lap-band and VBG don’t alter the intestinal tract and don’t require any consideration except to not take 2 pills at once or they may get caught in the outlet.

The universal rule is: don’t take 2 pills at the same time. Take a medication, then drink some fluids and wait 5-10 minutes to take the next medication unless they are chewable.

Medications after gastric bypass are absorbed normally unless you have frequent diarrhea. No medication is absorbed in the stomach, so bypassing the stomach doesn’t affect it. Vitamin B, iron and calcium are not absorbed as well because we bypass the first foot of the small bowel called the duodenum. We supplement those nutrients and monitor them with lab tests on a routine basis. Other medications don’t require an adjustment due to poor absorption.

Medications may need to be reduced after surgery as medical conditions improve. Many diabetics leave the hospital off medication. Hypertension meds usually require 3-4 months to see a reduction as you lose weight, but only half the patients will come off the meds as not all hypertension is due to weight. High cholesterol meds are stopped post-op as 80% will not need them, but again we monitor them for the first year and if cholesterol or triglycerides remain elevated we may need to re-start the medication. Thyroid hormone requirements usually remain the same after surgery.

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