Oral drug dosing following bariatric surgery: General concepts and specific dosing advice

Abstract

Bariatric or weight-loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended-release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case-by-case basis is required for each drug.

Keywords: clinical pharmacology; nutrition; obesity; pharmacokinetics; surgery.

FIGURE 1

Midazolam concentration–time profile after bariatric surgeryConcentration–time profile for 7.5 mg oral midazolam in morbidly obese patients before bariatric surgery (black solid line) and after bariatric surgery (black dotted line). Used with permission (http://creativecommons.org/licenses/by/4.0/) from Brill et al. Pharm Res. 2015;32(12):3927–3936

FIGURE 2

Flowchart for oral drug therapy after bariatric surgery