Diabetes |
Frequent follow-up and monitoring by a health care provider is required in the postoperative period to ensure ongoing effectiveness and timely modifications of antihyperglycemic medications7 While the medication burden might decrease initially after surgery, long-term monitoring is recommended given that diabetes is a progressive disease and can worsen with time in some patients7 Drug-specific recommendations for type 2 diabetes Insulin*
Insulin requirements might be volatile and are expected to decrease for at least 12 months after surgery or until weight loss stabilizes, with the most substantial reductions occurring during the first months7,8 If the basal insulin dose is < 30 units/day before surgery, then discontinue after surgery7–9 If the basal insulin dose is ≥ 30 units/day before surgery, then decrease by 50% to 80% after surgery7–10 Short-acting insulin might be used to manage elevated glucose levels7–9
Noninsulin options
In patients taking 1 oral antidiabetic agent before surgery, the agent can be discontinued after surgery8,9 If the patient is taking > 1 oral medication and ...
-HbA1c is < 9%, metformin is the preferred single-agent therapy7,10 -HbA1c is ≥ 9%, a second agent can be coupled with metformin, preferably an agent that facilitates CV risk reduction7,11†
Avoid oral medications that increase the risk of hypoglycemia7,8,11‡
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Anticoagulation |
Drug-specific recommendations Warfarin
Warfarin doses should typically decrease in the immediate postoperative period (about 3–4 wk) and then increase further out from surgery12–14 To reduce bleeding risk, decrease the warfarin dose after surgery and adjust it based on the INR results, similar to a new warfarin start
Apixaban, rivaroxaban
Limited evidence suggests that rivaroxaban and apixaban do not require dose adjustment after bariatric surgery15,16 Drug-specific laboratory monitoring is recommended to ensure levels are within the expected therapeutic range12
Dabigatran, edoxaban
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Antiplatelet therapy |
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Dyslipidemia |
Lipid levels might decrease with weight loss; consider monitoring every 3 mo until weight loss stabilizes and discontinue therapy if appropriate17–19 In patients who are taking dyslipidemia therapy for secondary prevention of CV events, the dose might be determined by the previous event rather than postoperative laboratory values
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Hypertension |
The need to use antihypertensive medications typically decreases after surgery. This decrease might begin immediately after surgery and continue for up to 2 y20–22
Consider discontinuing or changing diuretic therapy if patients develop dehydration8 In patients with diabetes it might be preferable to continue an ACEI or ARB owing to their renoprotective effects8
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Depression and anxiety |
Close monitoring for psychiatric symptom relapse after surgery is recommended23
If relapse occurs, adjust psychiatric medications as quickly as possible owing to the anticipated lengthy response time associated with changing regimens The literature suggests that the concentration of SSRIs might drop initially and then rebound within a few months; dose adjustments occurring in the immediate postoperative period might be temporary23,24 Switching to a formulation that is absorbed more readily (eg, liquids, crushed pills, immediate-release preparations, tablets that dissolve orally) might be necessary
Drug-specific recommendations for medications that do not have an immediate-release version available in Canada Venlafaxine
Duloxetine
Desvenlafaxine
Bupropion
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Migraine |
Migraine or headache frequency might decrease after surgery28,29 Average time to medication reduction was about 5.6 mo after surgery (range 1 to 36 mo)28 If initial migraines began after obesity onset, there is a greater probability that migraines will resolve postoperatively28
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Epilepsy or seizures |
Seizures should be well controlled with medications before surgery Consider empirically switching to a liquid formulation, crushable tablets, or capsules that can be opened before malabsorptive procedures Where indicated, drug monitoring during the early postoperative period is recommended to ensure therapeutic drug levels
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Asthma |
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Psoriasis |
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Pain |
Avoid NSAIDs after bariatric surgery owing to increased risk of gastric injury (eg, marginal ulcers)4,6 For patients undergoing malabsorptive surgery and who are taking extended-release medications or high-dose opioid therapy, consider changing to immediate-release formulations or alternate routes of administration before surgery Liquid acetaminophen contains sorbitol, which increases the risk of dumping syndrome6
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Transplant |
If the patient is receiving transplant medications, consider stabilizing medication levels using a liquid formulation before surgery Increased levels of tacrolimus and mycophenolate have been observed after sleeve gastrectomy34 Where indicated, monitor drug levels postoperatively and adjust the dose as appropriate
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Ulcer prevention and GERD |
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HIV |
Sleeve gastrectomy does not appear to negatively affect CD4 counts and viral load, and appears to be safe in individuals living with HIV36,37 Substantially decreased absorption has been observed with raltegravir and atazanavir after sleeve gastrectomy36–38
-Suggest replacing raltegravir and atazanavir with alternative HIV therapy before bariatric surgery36 -If replacing raltegravir and atazanavir is not possible, then ensure postoperative pharmacokinetic monitoring is performed and adjust medication doses accordingly36
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Contraception |
Rocha et al39 and Curtis et al40 indicate that for women who have undergone a ...
-malabsorptive procedure, oral contraceptives are not recommended owing to a theoretical risk of decreased drug absorption resulting in reduced contraceptive efficacy39 -restrictive procedure, all contraceptive methods are acceptable39,40
Caution is recommended in all cases. Ensure the patient understands the potential risks of using oral contraception and that secondary methods (eg, male or female condoms, diaphragms) should be employed
Drug-specific considerations Effective after restrictive procedures only
Effective after both procedures, but might be less effective in women weighing ≥ 90 kg (≥ 198 lb)41
Effective after both procedures, but effectiveness in women who are obese is not well studied42
Effective after both malabsorptive and restrictive procedures
Subcutaneous or intramuscular injection of medroxyprogesterone Levonorgestrel intrauterine device Copper intrauterine device
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