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Posted on: Tuesday, 29 March 2005, 03:00 CST

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What a Pharmacist Needs to Know About Bariatric Surgery: Compounding

Opportunities

According to US government data obtained from the 1999-2000 National

Health and Nutrition Examination Study, approximately two thirds of

adults in the United States are overweight or obese. The most common

method used to measure body-fat percentage is the body mass index

(BMI). The formula to calculate BMI is: weight (in kilograms)/height

(in meters squared). A panel of experts from the National Institutes

of Health (NIH) classifies individuals having a BMI of 25 to 29.9

kg/m^sup 2^ as overweight, while those with a BMI of 30 kg/m^sup 2^

or greater fall into the obese category. However, the BMI

classification system is not perfect and those who are very muscular,

such as weight lifters, may inadvertently be classified as overweight

when, in actuality, they are fit.

Guidelines on the Identification, Evaluation and Treatment of

Overweight and Obesity in Adults published by the XIH and National

Heart, Lung and Blood Institute state that obesity is associated with

higher morbidity and mortality rates, and that losing weight

decreases the risk of diabetes, hyperlipidemia and cardiovascular

disease, as well as other diseases' in this group.

An interesting study conducted by Thorpe et al examined the

relationship between the increasing prevalence of obesity in the

United States and the growth in healthcare spending among four groups

of people categorized by BMI.: The four groups consisted of adults

over 19 years old who were underweight, normal weight, overweight or

obese. This study concluded that the healthcare spending of the obese

group was 37% higher than the spending on the group of normal-weight

individuals. Furthermore, the authors attributed 38% of the increase

in diabetes spending, 41% of the increase in heart disease spending,

and 22% of the hyperlipidemia spending growth from 1987 to 2001 to

obese individuals (see Table 1).

When one puts these results into the perspective of limited

healthcare availability and increased healthcare use due to obesity,

one must wonder why there is not more emphasis on new and innovative

methods to help the overweight and obese patient find successful and

permanent weight loss.

Bariatric (Weight-loss) Surgery

Weight-loss surgery, also known as bariatric surgery, is usually

limited to the morbidly obese patient with a BMI of ¡Ý40, or ¡Ý35 with

some comorbid conditions. Most patients who are surgical weight-loss

candidates have been unsuccessful at losing weight and keeping it off

by other means, and are usually suffering from any number of the

possible complications of obesity. Bariatric surgery alone is not a

cure for obesity. The patient must be motivated to lose weight and be

willing to make lifestyle changes and behavior modifications to

realize long-term weight-loss success.

Table 1. Healthcare Spending Related to Each Group.

Another study conducted by Agren et al' compared the changes in

healthcare costs as well as diabetes and cardiovascular disease

medication use among two groups of extremely obese patients, a

control group treated for obesity using traditional means, and a

group of surgical weight-loss patients. The authors looked at these

two variables at 2 and 6 years and after intervention found that

medication use was approximately 30% less at 2 years for the surgical

patients than for patients treated with more conventional weight-loss

therapy. It is important to note that the difference in medication

use between the two groups at 6 years was not statistically

significant (see Table 2). Further, this study examined the cost of

medication use based on relative weight loss and concluded that

although weight loss of 10% to 15% equated to a decrease in

medication costs at the 2-year point, these savings were reduced at

the 6-year follow-up. The authors also established that the cost

savings for medication were based on weight loss itself and not the

method used to realize the weight loss.

The first human bariatric surgery, jejuno-ileal bypass, was performed

in the 1950s and has progressed and been refined into the bariatric

surgeries most often performed now, LAP-BAND and Roux-en- Y gastric

bypass (RYGBP). The RYGBP is the most commonly performed gastric

bypass procedure and creates a small pouch in part of the stomach.

The LAP-BAND uses an inflatable silicone band that is surgically

placed around the upper portion of the stomach, creating an hourglass

shape. This banding procedure makes a small upper stomach pouch with

a narrow opening to the lower stomach, creating a feeling of early

satiety and decreased food intake. In the biliopancreatic diversion,

another type of bariatric surgery, part of the stomach is actually

removed and the remaining portion of the stomach is attached directly

to the small intestine. There are three main types of bariatric

surgeries:

Restrictive - The digestive system is altered to restrict the intake

of the amount of food.

Malabsorptive -The digestive system is altered to poorly absorb the

food intake resulting in incomplete absorption of calories.

Combination - Combines aspects of restrictive and malabsorptive

surgeries.

Table 2. Characteristics and Medication History of Subjects.

According to the American Society of Bariatric Surgeons,4 morbid

obesity is a disease and not a lack of willpower on the part of the

patient as many might think. Also, surgical treatment of the morbidly

obese is not a cosmetic procedure but the only proven method to

achieve long-term weight control for the severely obese. In bariatric

surgery, the size of the gastric reservoir is decreased to reduce the

amount of calories the patient is able to ingest. The surgery is

supplemented by behavior modification. The patient must practice

eating smaller amounts of food more slowly because the gastric

reservoir volume is significantly reduced to approximately 50 mL or

less. There are a number of ways this is accomplished, including

staple lines, transection of the stomach, superimposed staple lines,

the use of silastic rings and gastric banding.

Bariatric surgery may sound like a panacea for the morbidly obese

patient, but it does present some risks of which the patient and all

Healthcare providers must be aware. These include but are not limited

to:

* Leaking of the stomach contents from a staple line leak, possibly

damaging other organs from exposure to stomach acid in the abdomen

* Nutritional deficiencies, more common with malabsorptive surgeries

* Breakdown of staple lines and/or erosion of bands, reversing the

procedure

* Stretching of the pouch over time, possibly to its normal size

prior to surgery

Pharmacy and Bariatric Surgery

Of primary concern to pharmacists are drugs that may potentially harm

the pouch, nutritional problems and dumping syndrome. Decreased acid

in the stomach pouch affects the ability of the patient to process

drugs and nutrition. One of the most common problems following

bariatric surgery is calcium deficiency. It is extremely important to

address intake of calcium as soon as possible after surgery, as long-

term deficiency of calcium can lead to metabolic bone disease and

result in broken bones and teeth. It can be very difficult to detect

calcium deficiency because laboratory tests report blood levels of

calcium within normal limits. When blood levels of calcium are low,

the body releases calcium from the bone to the blood to make up tor

this deficit. In theory, the bariatric patient with low blood levels

of calcium may constantly release calcium from bone to maintain

normal blood levels, ultimately resulting in metabolic bone disease.

The form of calcium that the bariatric patient must take to prevent

this deficiency is very important. Owing to the lack of acid in the

pouch, calcium carbonate, the most commonly available form of

calcium, is not effective after RYGBP surgery. Calcium carbonate

requires stomach acid to break it down to a form that the body can

use. Because it does not require acid to break it down, calcium

citrate is the only form of calcium that can be absorbed by patients

following bariatric surgery. The recommended daily dose of calcium

for most patients is 1200 to 1500 mg per day.1 Deficiencies in iron,

vitamin B12 and folate arc less common but still a concern for the

bariatric patient. Decreased acid in the pouch, as well as the type

of bariatric surgery, can affect the absorption of these nutrients.

Patients who have undergone restrictive surgeries may require only a

vitamin and mineral supplement, whereas patients who have undergone

malabsorptive surgeries may require more substantial measures to

ensure satisfactory nutritional status.

Prescription and over-the-counter medications are a critical concern

to the bariatric patient. Many seemingly benign medications have the

potential to seriously damage the pouch. Almost all nonsteroidal anti-

inflammatory drugs (NSAIDs) may cause such damage. NSAIDs have two

mechanisms by which they can damage the pouch. An injury to the pouch

can occur owing to the inherent acidic properties of the drugs

themselves on the gastrointestinal mucosa, or owing to the systemic

effects of the NSAIDs. The systemic effects arise from inhibition of

prostaglandin synthesis, which, in turn, causes decreased mucous

production, exposing the stomach to damage to the epithelial layer,

erosions and ulcers.6 Cyclo-oxygenase-2 inhibitors \such as celecoxib

and valdecoxib have less capacity to cause injury to the pouch and

may be prescribed by some physicians in certain patients.

Table 3 lists drugs that should not be taken after bariatric surgery

because they can damage the pouch when taken orally; however,

compounding pharmacists may be able to compound some of these agents

alone or in combination with other agents for use transdermally. When

giving medications transdermally in a topical gel, first-pass hepatic

metabolism through the liver can be avoided, thus allowing for

delivery of the medication directly to the site of the pain. This is

an option when the pain is localized in one or several areas but is

not as advantageous when the pain is throughout the body.

Patient Diet After Bariatric Surgery

The bariatric patient must progress through many phases of dietary

modification following surgery. The patient begins by ingesting only

clear liquids, and gradually progresses to dairy products if

tolerated; pureed foods; and, finally, small amounts and servings of

traditional soft foods. Patients cannot take medications in tablet or

capsule form after surgery, and medications must be taken in liquid

form, presenting compounding and flavoring opportunitites. Behavior

modification and strict adherence to diet must be reinforced at all

points. Patients must learn to drink fluids prior to or after their

meals, avoid certain sauces and seasonings, and follow strict

guidelines about the number of meals they eat. All simple sugars in

concentrated forms must be eliminated from the diet.

Dumping Syndrome and Other Side Effects of Bariatric Surgery

Dumping syndrome is one side effect of bariatric surgery that occurs

when the patient ingests refined sugar following surgery.' This

syndrome can cause rapid heart rate, shakiness, sweating, and

dizziness and sometimes severe diarrhea. Dumping syndrome is a

physiological response to the shift of fluid from the blood to the

intestines. Protein and fluid intake are extremely important in all

postsurgical phases. If patients do not gradually increase their

fluid intake to 32 to 64 oz daily, they may become dehydrated, and a

fluid deficit is very difficult for these patients to overcome. The

proper ratio of proteins, carbohydrates and fats in the diet is also

crucial to maintaining proper nutritional status, as well as safe,

permanent weight control.

Table 3. Drugs That Can Damage the Pouch Following Bariatric Surgery.

Compounding Opportunities

Numerous compounding opportunities are present with these patients

after surgery in the areas of nutrition, pain management, electrolyte

balance, hair loss and dermatology, to name just a few. Liquid and

spray vitamins, topical applications, scar-prevention creams, protein

shampoo and conditioner and appetite-suppressant lollipops are

examples. Pharmacists must reach out to bariatric patients and find

out what their needs are. iMany communities have support groups and

surgeons, which are a good place to start marketing. Online websites

and chat rooms are very popular among these individuals. Compounding

pharmacists can be a tremendous help to this population.

References

1. [No author listed.] National Institutes of Health (NIH)/ National

Heart, Lung, and Blood Institute. Guidelines on the Identification,

Evaluation and Treatment of Overweight and Obesity in Adults:

Executive Summary. Available at: www.nhlbi.nih.gov/

guidelines/obesity/ob_home.htm. Accessed October 18,2004.

2. Thorpe KE, Florence CS, DH et al. Trends: The impact of

obesity on rising medical spending. Health Aff- Web Exclusive 2004

October 20: W4-480-W4-486.

3. gren G, Narbro K, Nslund I et al. Long-term effects of weight loss

on pharmaceutical costs in obese subjects. A report from the SOS

Intervention Study. IntJObes Metab Disord2QQ2; 26(2): 184-192.

4. [No author listed.] American Society for Bariatric Surgery

Website. Available at: www.asbs.org. Accessed October 19, 2004.

5. Elliot K. Nutritional considerations after bariatric surgery. Crit

Care Nurs Q 2003;26(2):133-138.

6. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of

nonsteroidal antiinflamatory drugs. N Engl J Med 1999; 340(24): 1888-

1899.

Kathleen Collier

Dana -Kane, PharmD, FIACP, FACA, FCP, NFPPhC

's Compounding Pharmacy

Tucson, Arizona

Janet Beard, BBA

Harvest Drug & Gift, Inc.

Wichita Falls, Texas

Address correspondence to: Janet Beard, RPh, Harvest Drug & Gift,

Inc., 3409 McNeil, Wichita Falls, TX 76308. E-mail:

jbeard@...

Copyright International Journal of Pharmaceutical Compounding Mar/

Apr 2005

Source: International Journal of Pharmaceutical Compounding

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