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How bariatric surgery affects psychotropic drug absorption
Ms. B, age 60, presents to the clinic with high blood pressure, hyperlipidemia, type 2 diabetes mellitus, depression, and anxiety. Her blood pressure is 138/82 mm Hg and pulse is 70 beats per minute. Her body mass index (BMI) is 41, which indicates she is obese. She has always struggled with her weight and has tried diet and lifestyle modifications, as well as medications, for the past 5 years with no success. Her current medication regimen includes lisinopril 40 mg daily, amlodipine 5 mg daily, atorvastatin 40 mg daily, metformin 500 mg twice daily, dulaglutide 0.75 mg weekly, lithium 600 mg daily, venlafaxine extended-release (XR) 150 mg daily, and alprazolam 0.5 mg as needed up to twice daily. Due to Ms. B’s BMI and because she has ≥1 comorbid health condition, her primary care physician refers her to a gastroenterologist to discuss gastric bypass surgery options.
Ms. B is scheduled for Roux-en-Y gastric bypass surgery. You need to determine if any changes should be made to her psychotropic medications after she undergoes this surgery.
There are multiple types of bariatric surgeries, including Roux-en-Y gastric bypass, sleeve gastrectomy, laparoscopic adjustable gastric band, and biliopancreatic diversion with duodenal switch (BPD/DS) (Figure1-4). These procedures all restrict the stomach’s capacity to hold food. In most cases, they also bypass areas of absorption in the intestine and cause increased secretion of hormones in the gut, including (but not limited to) peptide-YY (PYY) and glucagon-like peptide 1 (GLP-1). These hormonal changes impact several factors, including satiety, hunger, and blood sugar levels.5
Roux-en-Y is commonly referred to as the gold standard of weight loss surgery. It divides the top of the stomach into a smaller stomach pouch that connects directly to the small intestine to facilitate smaller meals and alters the release of gut hormones. Additionally, a segment of the small intestine that normally absorbs nutrients and medications is completely bypassed. In contrast, the sleeve gastrectomy removes approximately 80% of the stomach, consequently reducing the amount of food that can be consumed. The greatest impact of the sleeve gastrectomy procedure appears to result from changes in gut hormones. The adjustable gastric band procedure works by placing a band around the upper portion of the stomach to create a small pouch above the band to satisfy hunger with a smaller amount of food. Lastly, BPD/DS is a procedure that creates a tubular stomach pouch and bypasses a large portion of the small intestine. Like the gastric bypass and sleeve gastrectomy, BPD/DS affects gut hormones impacting hunger, satiety, and blood sugar control.
How bariatric surgery can affect drug absorption
As illustrated in the Table,6-19 each type of bariatric surgery may impact drug absorption differently depending on the mechanism by which the stomach is restricted.
Drug malabsorption is a concern for clinicians with patients who have undergone bariatric surgery. There is limited research measuring changes in psychotropic exposure and outcomes following bariatric surgery. A 2009 literature review by Padwal et al7 found that one-third of the 26 studies evaluated provided evidence of decreased absorption following bariatric surgery in patients taking medications that had intrinsic poor absorption, high lipophilicity, and/or undergo enterohepatic recirculation. In a review that included a small study of patients taking selective serotonin reuptake inhibitors or venlafaxine, Godini et al8 demonstrated that although there was a notable decrease in drug absorption closely following the surgery, drug absorption recovered for some patients 1 month after Roux-en-Y surgery. These reviews suggest patients who have undergone any form of bariatric surgery must be observed closely because drug absorption may vary based on the individual, the medication administered, and the amount of time postprocedure.
Until more research becomes available, current evidence supports recommendations to assist patients who have a decreased ability to absorb medications after gastric bypass surgery by switching from an extended-release formulation to an immediate-release or solution formulation. This allows patients to rely less on gastric mixing and unpredictable changes in drug release from extended- or controlled-release formulations.
Continue to: Aside from altered...
Aside from altered pharmacokinetics after bariatric surgery, many patients experience an increased risk of self-harm and suicide.20 Therefore, a continued emphasis on and reinforcement of proper antidepressant use and adjustment in these patients is important. This can be facilitated through frequent follow-up visits, either in-person or via telehealth.
Understanding the effect of bariatric surgery on drug absorption is critical to identifying a potential need to adjust a medication dose or formulation after the surgery. Available evidence and data suggest it is reasonable to switch from an extended- or sustained-release formulation to an immediate-release formulation, and to monitor patients more frequently immediately following the surgery.
CASE CONTINUED
Related Resources
- Colvin C, Tsia W, Silverman AL, et al. Nothing up his sleeve: decompensation after bariatric surgery. Current Psychiatry. 2021;20(4):15-19. doi:10.12788/cp.010
Drug Brand Names
Alprazolam • Xanax
Amlodipine • Norvasc
Atorvastatin • Lipitor
Dulaglutide • Trulicity
Lisinopril • Zestril, Prinivil
Lithium • Eskalith, Lithobid
Metformin • Glucophage
Olanzapine • Zyprexa
Venlafaxine • Effexor
1. Obesity Treatments: Gastric Bypass Surgery. UCLA Health. Accessed April 4, 2021. http://surgery.ucla.edu/bariatrics-gastric-bypass
2. Thomas L. Gastric bypass more likely to require further treatment than gastric sleeve. News Medical. January 15, 2020. Accessed April 4, 2021. https://www.news-medical.net/news/20200115/Gastric-bypass-more-likely-to-require-further-treatment-than-gastric-sleeve.aspx
3. Lap Adjustable Gastric Banding. Laser Stone Surgery & Endoscopy Centre. September 5, 2016. Accessed April 4, 2021. http://www.laserstonesurgery.org/project/lap-adjustable-gastric-banding/
4. BPD/DS Weight-Loss Surgery. Johns Hopkins Medicine. Accessed April 4, 2021. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/bpdds-weightloss-surgery
5. Holst JJ, Madsbad S, Bojsen-Møller KN, et al. Mechanisms in bariatric surgery: gut hormones, diabetes resolution, and weight loss. Surg Obes Relat Dis. 2018;14(5):708-714. doi:10.1016/j.soard.2018.03.003
6. Public Education Committee. Bariatric Surgery Procedures. American Society for Metabolic and Bariatric Surgery. Updated May 2021. Accessed September 4, 2021. https://asmbs.org/patients/bariatric-surgery-procedures
7. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41-50. doi:10.1111/j.1467-789x.2009.00614.x
8. Godini L, Castellini G, Facchiano E, et al. Mood disorders and bariatric surgery patients: pre- and post- surgery clinical course- an overview. J Obes Weight Loss Medicat. 2016;2(1). doi:10.23937/2572-4010.1510012
9. Smith A, Henriksen B, Cohen A. Pharmacokinetic considerations in Roux-en-Y gastric bypass patients. Am J Health Syst Pharm. 2011;68(23):2241-2247. doi:10.2146/ajhp100630
10. Brocks DR, Ben-Eltriki M, Gabr RQ, et al. The effects of gastric bypass surgery on drug absorption and pharmacokinetics. Expert Opin Drug Metab Toxicol. 2012;8(12):1505-1519. doi:10.1517/17425255.2012.722757
11. Hamad GG, Helsel JC, Perel JM, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry. 2012;169(3):256-263. doi:10.1176/appi.ajp.2011.11050719
12. Angeles PC, Robertsen I, Seeberg LT, et al. The influence of bariatric surgery on oral drug bioavailability in patients with obesity: a systematic review. Obes Rev. 2019;20(9):1299-1311. doi:10.1111/obr.12869
13. Laparoscopic Sleeve Gastrectomy. University of California San Francisco Department of Surgery. Accessed April 1, 2021. https://surgery.ucsf.edu/conditions--procedures/laparoscopic-sleeve-gastrectomy.aspx
14. Brethauer S, Schauer P. Laparoscopic Sleeve Gastrectomy: A Newcomer to Bariatric Surgery. Obesity Action Coalition. 2007. Accessed May 15, 2021. https://www.obesityaction.org/community/article-library/laparoscopic-sleeve-gastrectomy-a-newcomer-to-bariatric-surgery/
15. Roerig JL, Steffen K. Psychopharmacology and bariatric surgery. Eur Eat Disord Rev. 2015;23(6):463-469. doi:10.1002/erv.2396
16. Bland CM, Quidley AM, Love BL, et al. Long-term pharmacotherapy considerations in the bariatric surgery patient. A J Health Syst Pharm. 2016;73(16):1230-1242. doi:10.2146/ajhp151062
17. Lin YH, Liu SW, Wu HL, et al. Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: a case report and review of literature. Medicine (Baltimore). 2020;99(28):e21122. doi:10.1097/MD.0000000000021122
18. Lorico S, Colton B. Medication management and pharmacokinetic changes after bariatric surgery. Can Fam Physician. 2020;66(6):409-416.
19. Homan J, Schijns W, Aarts EO, et al. Treatment of vitamin and mineral deficiencies after biliopancreatic diversion with or without duodenal switch: a major challenge. Obes Surg. 2018;28(1):234-241. doi:10.1007/s11695-017-2841-0
20. Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207. doi:10.1016/S2213-8587(17)30437-0
Ms. B, age 60, presents to the clinic with high blood pressure, hyperlipidemia, type 2 diabetes mellitus, depression, and anxiety. Her blood pressure is 138/82 mm Hg and pulse is 70 beats per minute. Her body mass index (BMI) is 41, which indicates she is obese. She has always struggled with her weight and has tried diet and lifestyle modifications, as well as medications, for the past 5 years with no success. Her current medication regimen includes lisinopril 40 mg daily, amlodipine 5 mg daily, atorvastatin 40 mg daily, metformin 500 mg twice daily, dulaglutide 0.75 mg weekly, lithium 600 mg daily, venlafaxine extended-release (XR) 150 mg daily, and alprazolam 0.5 mg as needed up to twice daily. Due to Ms. B’s BMI and because she has ≥1 comorbid health condition, her primary care physician refers her to a gastroenterologist to discuss gastric bypass surgery options.
Ms. B is scheduled for Roux-en-Y gastric bypass surgery. You need to determine if any changes should be made to her psychotropic medications after she undergoes this surgery.
There are multiple types of bariatric surgeries, including Roux-en-Y gastric bypass, sleeve gastrectomy, laparoscopic adjustable gastric band, and biliopancreatic diversion with duodenal switch (BPD/DS) (Figure1-4). These procedures all restrict the stomach’s capacity to hold food. In most cases, they also bypass areas of absorption in the intestine and cause increased secretion of hormones in the gut, including (but not limited to) peptide-YY (PYY) and glucagon-like peptide 1 (GLP-1). These hormonal changes impact several factors, including satiety, hunger, and blood sugar levels.5
Roux-en-Y is commonly referred to as the gold standard of weight loss surgery. It divides the top of the stomach into a smaller stomach pouch that connects directly to the small intestine to facilitate smaller meals and alters the release of gut hormones. Additionally, a segment of the small intestine that normally absorbs nutrients and medications is completely bypassed. In contrast, the sleeve gastrectomy removes approximately 80% of the stomach, consequently reducing the amount of food that can be consumed. The greatest impact of the sleeve gastrectomy procedure appears to result from changes in gut hormones. The adjustable gastric band procedure works by placing a band around the upper portion of the stomach to create a small pouch above the band to satisfy hunger with a smaller amount of food. Lastly, BPD/DS is a procedure that creates a tubular stomach pouch and bypasses a large portion of the small intestine. Like the gastric bypass and sleeve gastrectomy, BPD/DS affects gut hormones impacting hunger, satiety, and blood sugar control.
How bariatric surgery can affect drug absorption
As illustrated in the Table,6-19 each type of bariatric surgery may impact drug absorption differently depending on the mechanism by which the stomach is restricted.
Drug malabsorption is a concern for clinicians with patients who have undergone bariatric surgery. There is limited research measuring changes in psychotropic exposure and outcomes following bariatric surgery. A 2009 literature review by Padwal et al7 found that one-third of the 26 studies evaluated provided evidence of decreased absorption following bariatric surgery in patients taking medications that had intrinsic poor absorption, high lipophilicity, and/or undergo enterohepatic recirculation. In a review that included a small study of patients taking selective serotonin reuptake inhibitors or venlafaxine, Godini et al8 demonstrated that although there was a notable decrease in drug absorption closely following the surgery, drug absorption recovered for some patients 1 month after Roux-en-Y surgery. These reviews suggest patients who have undergone any form of bariatric surgery must be observed closely because drug absorption may vary based on the individual, the medication administered, and the amount of time postprocedure.
Until more research becomes available, current evidence supports recommendations to assist patients who have a decreased ability to absorb medications after gastric bypass surgery by switching from an extended-release formulation to an immediate-release or solution formulation. This allows patients to rely less on gastric mixing and unpredictable changes in drug release from extended- or controlled-release formulations.
Continue to: Aside from altered...
Aside from altered pharmacokinetics after bariatric surgery, many patients experience an increased risk of self-harm and suicide.20 Therefore, a continued emphasis on and reinforcement of proper antidepressant use and adjustment in these patients is important. This can be facilitated through frequent follow-up visits, either in-person or via telehealth.
Understanding the effect of bariatric surgery on drug absorption is critical to identifying a potential need to adjust a medication dose or formulation after the surgery. Available evidence and data suggest it is reasonable to switch from an extended- or sustained-release formulation to an immediate-release formulation, and to monitor patients more frequently immediately following the surgery.
CASE CONTINUED
Related Resources
- Colvin C, Tsia W, Silverman AL, et al. Nothing up his sleeve: decompensation after bariatric surgery. Current Psychiatry. 2021;20(4):15-19. doi:10.12788/cp.010
Drug Brand Names
Alprazolam • Xanax
Amlodipine • Norvasc
Atorvastatin • Lipitor
Dulaglutide • Trulicity
Lisinopril • Zestril, Prinivil
Lithium • Eskalith, Lithobid
Metformin • Glucophage
Olanzapine • Zyprexa
Venlafaxine • Effexor
Ms. B, age 60, presents to the clinic with high blood pressure, hyperlipidemia, type 2 diabetes mellitus, depression, and anxiety. Her blood pressure is 138/82 mm Hg and pulse is 70 beats per minute. Her body mass index (BMI) is 41, which indicates she is obese. She has always struggled with her weight and has tried diet and lifestyle modifications, as well as medications, for the past 5 years with no success. Her current medication regimen includes lisinopril 40 mg daily, amlodipine 5 mg daily, atorvastatin 40 mg daily, metformin 500 mg twice daily, dulaglutide 0.75 mg weekly, lithium 600 mg daily, venlafaxine extended-release (XR) 150 mg daily, and alprazolam 0.5 mg as needed up to twice daily. Due to Ms. B’s BMI and because she has ≥1 comorbid health condition, her primary care physician refers her to a gastroenterologist to discuss gastric bypass surgery options.
Ms. B is scheduled for Roux-en-Y gastric bypass surgery. You need to determine if any changes should be made to her psychotropic medications after she undergoes this surgery.
There are multiple types of bariatric surgeries, including Roux-en-Y gastric bypass, sleeve gastrectomy, laparoscopic adjustable gastric band, and biliopancreatic diversion with duodenal switch (BPD/DS) (Figure1-4). These procedures all restrict the stomach’s capacity to hold food. In most cases, they also bypass areas of absorption in the intestine and cause increased secretion of hormones in the gut, including (but not limited to) peptide-YY (PYY) and glucagon-like peptide 1 (GLP-1). These hormonal changes impact several factors, including satiety, hunger, and blood sugar levels.5
Roux-en-Y is commonly referred to as the gold standard of weight loss surgery. It divides the top of the stomach into a smaller stomach pouch that connects directly to the small intestine to facilitate smaller meals and alters the release of gut hormones. Additionally, a segment of the small intestine that normally absorbs nutrients and medications is completely bypassed. In contrast, the sleeve gastrectomy removes approximately 80% of the stomach, consequently reducing the amount of food that can be consumed. The greatest impact of the sleeve gastrectomy procedure appears to result from changes in gut hormones. The adjustable gastric band procedure works by placing a band around the upper portion of the stomach to create a small pouch above the band to satisfy hunger with a smaller amount of food. Lastly, BPD/DS is a procedure that creates a tubular stomach pouch and bypasses a large portion of the small intestine. Like the gastric bypass and sleeve gastrectomy, BPD/DS affects gut hormones impacting hunger, satiety, and blood sugar control.
How bariatric surgery can affect drug absorption
As illustrated in the Table,6-19 each type of bariatric surgery may impact drug absorption differently depending on the mechanism by which the stomach is restricted.
Drug malabsorption is a concern for clinicians with patients who have undergone bariatric surgery. There is limited research measuring changes in psychotropic exposure and outcomes following bariatric surgery. A 2009 literature review by Padwal et al7 found that one-third of the 26 studies evaluated provided evidence of decreased absorption following bariatric surgery in patients taking medications that had intrinsic poor absorption, high lipophilicity, and/or undergo enterohepatic recirculation. In a review that included a small study of patients taking selective serotonin reuptake inhibitors or venlafaxine, Godini et al8 demonstrated that although there was a notable decrease in drug absorption closely following the surgery, drug absorption recovered for some patients 1 month after Roux-en-Y surgery. These reviews suggest patients who have undergone any form of bariatric surgery must be observed closely because drug absorption may vary based on the individual, the medication administered, and the amount of time postprocedure.
Until more research becomes available, current evidence supports recommendations to assist patients who have a decreased ability to absorb medications after gastric bypass surgery by switching from an extended-release formulation to an immediate-release or solution formulation. This allows patients to rely less on gastric mixing and unpredictable changes in drug release from extended- or controlled-release formulations.
Continue to: Aside from altered...
Aside from altered pharmacokinetics after bariatric surgery, many patients experience an increased risk of self-harm and suicide.20 Therefore, a continued emphasis on and reinforcement of proper antidepressant use and adjustment in these patients is important. This can be facilitated through frequent follow-up visits, either in-person or via telehealth.
Understanding the effect of bariatric surgery on drug absorption is critical to identifying a potential need to adjust a medication dose or formulation after the surgery. Available evidence and data suggest it is reasonable to switch from an extended- or sustained-release formulation to an immediate-release formulation, and to monitor patients more frequently immediately following the surgery.
CASE CONTINUED
Related Resources
- Colvin C, Tsia W, Silverman AL, et al. Nothing up his sleeve: decompensation after bariatric surgery. Current Psychiatry. 2021;20(4):15-19. doi:10.12788/cp.010
Drug Brand Names
Alprazolam • Xanax
Amlodipine • Norvasc
Atorvastatin • Lipitor
Dulaglutide • Trulicity
Lisinopril • Zestril, Prinivil
Lithium • Eskalith, Lithobid
Metformin • Glucophage
Olanzapine • Zyprexa
Venlafaxine • Effexor
1. Obesity Treatments: Gastric Bypass Surgery. UCLA Health. Accessed April 4, 2021. http://surgery.ucla.edu/bariatrics-gastric-bypass
2. Thomas L. Gastric bypass more likely to require further treatment than gastric sleeve. News Medical. January 15, 2020. Accessed April 4, 2021. https://www.news-medical.net/news/20200115/Gastric-bypass-more-likely-to-require-further-treatment-than-gastric-sleeve.aspx
3. Lap Adjustable Gastric Banding. Laser Stone Surgery & Endoscopy Centre. September 5, 2016. Accessed April 4, 2021. http://www.laserstonesurgery.org/project/lap-adjustable-gastric-banding/
4. BPD/DS Weight-Loss Surgery. Johns Hopkins Medicine. Accessed April 4, 2021. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/bpdds-weightloss-surgery
5. Holst JJ, Madsbad S, Bojsen-Møller KN, et al. Mechanisms in bariatric surgery: gut hormones, diabetes resolution, and weight loss. Surg Obes Relat Dis. 2018;14(5):708-714. doi:10.1016/j.soard.2018.03.003
6. Public Education Committee. Bariatric Surgery Procedures. American Society for Metabolic and Bariatric Surgery. Updated May 2021. Accessed September 4, 2021. https://asmbs.org/patients/bariatric-surgery-procedures
7. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41-50. doi:10.1111/j.1467-789x.2009.00614.x
8. Godini L, Castellini G, Facchiano E, et al. Mood disorders and bariatric surgery patients: pre- and post- surgery clinical course- an overview. J Obes Weight Loss Medicat. 2016;2(1). doi:10.23937/2572-4010.1510012
9. Smith A, Henriksen B, Cohen A. Pharmacokinetic considerations in Roux-en-Y gastric bypass patients. Am J Health Syst Pharm. 2011;68(23):2241-2247. doi:10.2146/ajhp100630
10. Brocks DR, Ben-Eltriki M, Gabr RQ, et al. The effects of gastric bypass surgery on drug absorption and pharmacokinetics. Expert Opin Drug Metab Toxicol. 2012;8(12):1505-1519. doi:10.1517/17425255.2012.722757
11. Hamad GG, Helsel JC, Perel JM, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry. 2012;169(3):256-263. doi:10.1176/appi.ajp.2011.11050719
12. Angeles PC, Robertsen I, Seeberg LT, et al. The influence of bariatric surgery on oral drug bioavailability in patients with obesity: a systematic review. Obes Rev. 2019;20(9):1299-1311. doi:10.1111/obr.12869
13. Laparoscopic Sleeve Gastrectomy. University of California San Francisco Department of Surgery. Accessed April 1, 2021. https://surgery.ucsf.edu/conditions--procedures/laparoscopic-sleeve-gastrectomy.aspx
14. Brethauer S, Schauer P. Laparoscopic Sleeve Gastrectomy: A Newcomer to Bariatric Surgery. Obesity Action Coalition. 2007. Accessed May 15, 2021. https://www.obesityaction.org/community/article-library/laparoscopic-sleeve-gastrectomy-a-newcomer-to-bariatric-surgery/
15. Roerig JL, Steffen K. Psychopharmacology and bariatric surgery. Eur Eat Disord Rev. 2015;23(6):463-469. doi:10.1002/erv.2396
16. Bland CM, Quidley AM, Love BL, et al. Long-term pharmacotherapy considerations in the bariatric surgery patient. A J Health Syst Pharm. 2016;73(16):1230-1242. doi:10.2146/ajhp151062
17. Lin YH, Liu SW, Wu HL, et al. Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: a case report and review of literature. Medicine (Baltimore). 2020;99(28):e21122. doi:10.1097/MD.0000000000021122
18. Lorico S, Colton B. Medication management and pharmacokinetic changes after bariatric surgery. Can Fam Physician. 2020;66(6):409-416.
19. Homan J, Schijns W, Aarts EO, et al. Treatment of vitamin and mineral deficiencies after biliopancreatic diversion with or without duodenal switch: a major challenge. Obes Surg. 2018;28(1):234-241. doi:10.1007/s11695-017-2841-0
20. Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207. doi:10.1016/S2213-8587(17)30437-0
1. Obesity Treatments: Gastric Bypass Surgery. UCLA Health. Accessed April 4, 2021. http://surgery.ucla.edu/bariatrics-gastric-bypass
2. Thomas L. Gastric bypass more likely to require further treatment than gastric sleeve. News Medical. January 15, 2020. Accessed April 4, 2021. https://www.news-medical.net/news/20200115/Gastric-bypass-more-likely-to-require-further-treatment-than-gastric-sleeve.aspx
3. Lap Adjustable Gastric Banding. Laser Stone Surgery & Endoscopy Centre. September 5, 2016. Accessed April 4, 2021. http://www.laserstonesurgery.org/project/lap-adjustable-gastric-banding/
4. BPD/DS Weight-Loss Surgery. Johns Hopkins Medicine. Accessed April 4, 2021. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/bpdds-weightloss-surgery
5. Holst JJ, Madsbad S, Bojsen-Møller KN, et al. Mechanisms in bariatric surgery: gut hormones, diabetes resolution, and weight loss. Surg Obes Relat Dis. 2018;14(5):708-714. doi:10.1016/j.soard.2018.03.003
6. Public Education Committee. Bariatric Surgery Procedures. American Society for Metabolic and Bariatric Surgery. Updated May 2021. Accessed September 4, 2021. https://asmbs.org/patients/bariatric-surgery-procedures
7. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41-50. doi:10.1111/j.1467-789x.2009.00614.x
8. Godini L, Castellini G, Facchiano E, et al. Mood disorders and bariatric surgery patients: pre- and post- surgery clinical course- an overview. J Obes Weight Loss Medicat. 2016;2(1). doi:10.23937/2572-4010.1510012
9. Smith A, Henriksen B, Cohen A. Pharmacokinetic considerations in Roux-en-Y gastric bypass patients. Am J Health Syst Pharm. 2011;68(23):2241-2247. doi:10.2146/ajhp100630
10. Brocks DR, Ben-Eltriki M, Gabr RQ, et al. The effects of gastric bypass surgery on drug absorption and pharmacokinetics. Expert Opin Drug Metab Toxicol. 2012;8(12):1505-1519. doi:10.1517/17425255.2012.722757
11. Hamad GG, Helsel JC, Perel JM, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry. 2012;169(3):256-263. doi:10.1176/appi.ajp.2011.11050719
12. Angeles PC, Robertsen I, Seeberg LT, et al. The influence of bariatric surgery on oral drug bioavailability in patients with obesity: a systematic review. Obes Rev. 2019;20(9):1299-1311. doi:10.1111/obr.12869
13. Laparoscopic Sleeve Gastrectomy. University of California San Francisco Department of Surgery. Accessed April 1, 2021. https://surgery.ucsf.edu/conditions--procedures/laparoscopic-sleeve-gastrectomy.aspx
14. Brethauer S, Schauer P. Laparoscopic Sleeve Gastrectomy: A Newcomer to Bariatric Surgery. Obesity Action Coalition. 2007. Accessed May 15, 2021. https://www.obesityaction.org/community/article-library/laparoscopic-sleeve-gastrectomy-a-newcomer-to-bariatric-surgery/
15. Roerig JL, Steffen K. Psychopharmacology and bariatric surgery. Eur Eat Disord Rev. 2015;23(6):463-469. doi:10.1002/erv.2396
16. Bland CM, Quidley AM, Love BL, et al. Long-term pharmacotherapy considerations in the bariatric surgery patient. A J Health Syst Pharm. 2016;73(16):1230-1242. doi:10.2146/ajhp151062
17. Lin YH, Liu SW, Wu HL, et al. Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: a case report and review of literature. Medicine (Baltimore). 2020;99(28):e21122. doi:10.1097/MD.0000000000021122
18. Lorico S, Colton B. Medication management and pharmacokinetic changes after bariatric surgery. Can Fam Physician. 2020;66(6):409-416.
19. Homan J, Schijns W, Aarts EO, et al. Treatment of vitamin and mineral deficiencies after biliopancreatic diversion with or without duodenal switch: a major challenge. Obes Surg. 2018;28(1):234-241. doi:10.1007/s11695-017-2841-0
20. Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207. doi:10.1016/S2213-8587(17)30437-0
