Weighing in: Optimizing medications around weight loss
Obesity is on the rise in America, with, according to CDC, more than one-third of Americans being classified as obese. Obesity can impact many health conditions, including heart disease, type 2 diabetes, hypertension, and certain types of cancer. Bariatric surgery has become a popular option for weight loss in individuals that qualify, as it has demonstrated clinically meaningful weight loss. Although effective, there are several lifestyle- and medication-related modifications that need to be made post-operatively and which providers should be made aware.
Pharmacists have a unique set of skills that they can bring to the team to help patients through this transition. Within our clinic, we offer both non-surgical and surgical weight loss options, and my role is to be the medication expert on our interdisciplinary team. On the non-surgical weight loss team, my job is primarily to help titrate up GLP-1 receptor agonists while titrating down insulin in patients with diabetes. Insulin can cause significant weight gain, so we must find the optimal dose where we are still controlling the patient’s diabetes, but also assisting them in their weight loss efforts. On the surgical team, my responsibilities include obtaining accurate medication histories and answering medication-related questions about pharmacokinetics/dynamics after surgery. I also identify medications that cause weight gain and find alternatives whenever possible.
Here are some tips that all pharmacists can use to care for patients who have undergone bariatric surgery.
For patients undergoing any bariatric procedure, all medications should be given in a liquid dosage form, or be able to be crushed or opened and sprinkled for up to two months following surgery. Additionally, enteric-coated and extended-release medications may not be absorbed properly after bariatric procedures. As medication experts, pharmacists can recommend alternative dosage forms or therapeutic substitutions that would be more appropriate options.
The Institute for Safe Medication Practices (ISMP) “Do Not Crush” list is a good starting point, but pharmacists can also reference package inserts or drug databases to determine which products can be crushed, split, or opened and sprinkled. If a tablet must be used and cannot be crushed or split, aim to keep solid dosage forms smaller than an M&M’s candy.
Bariatric surgeries can be categorized into malabsorptive procedures, restrictive procedures, or both. All patients who have had bariatric surgery are at high-risk for vitamin deficiencies, especially malabsorptive procedures. Therefore, there are many vitamins a patient should take after surgery. The American Society for Metabolic and Bariatric Surgery provides guidance for vitamin supplementation.
Pharmacists should guide patients toward selecting vitamins that have had third-party testing completed to verify the quality of that product. Some common seals of approval are NSF, USP, or Consumer Lab. Don't forget about the dosage form here, too!
Medications to avoid
Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are known to cause ulcers and other GI effects that are detrimental in the post-surgical period. Avoid NSAIDs with all surgery types, recommend acetaminophen instead, and limit the use of corticosteroids if possible. Pharmacists should also monitor for medications that cause weight gain, such as sulfonylureas, insulin, certain antipsychotics, and corticosteroids. Minimizing and substituting these medications, when possible, will help ensure patients are reaching their weight loss goals. Finally, avoid products containing sorbitol, sucrose, mannitol, or other sugars as they can lead to dumping syndrome (more common with Roux-en-Y gastric bypass).
Following my passion
Pharmacists can play an important role when it comes to managing both surgical and non-surgical weight loss patients. It is not common for pharmacists to work directly on these teams, but I have always been passionate about diabetes management, weight loss, and helping patients achieve their goals. I was able to develop a service centered around my interests and identify gaps in care. I encourage other New Practitioners to pursue their passions to expand pharmacy practice into new, exciting areas.
Abby Fornes, PharmD, is an assistant professor of pharmacy practice at Shenandoah University in Fairfax, VA, and an ambulatory care pharmacist at Inova Health System. In her free time, she enjoys hiking, biking, skiing, traveling, and playing board games.