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Folsom Gal

SSRIs and RNY gastric bypass

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Greetings! I am new to this site and can't figure out how to search anything, so if this has been addressed, by apologies. I have had dysthymia pretty much all my life but this was well controlled with SSRIs. After RNY I have been struggling to find one that works, and I wonder if absorption could be the problem. Any one that you might suggest that are absorbed well after GBS? Thanks in advance for your help with this.

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You've asked a great question. Unfortunately there is very little information in the medical literature that addresses it. You will probably want to work with your MDs to adjust your dosage to get the desired affect. You may want to find out if blood levels of your med can be measured so that your dosage can be optimized. Finally, you and your docs will want to make sure that you don't develop symptoms of over dosage. If the drug isn't working, you might up the dose and still not get an effect. This could be because the drug simply isn't working for you, not that you are not absorbing it.

Here are a couple of references. The first abstract refers to "bypassing major portions of the small intestine". This may be an overstatement since many surgeons bypass relatively short portions of the small bowel these days. Find out from your surgeon who much was bypassed and if he thinks it will have an effect. The normal length of the small bowel is about 600 cm. Also note that the small bowel adapts over time. When it is shortened a lot it reacts by gradually thickening and enlarging. It thus becomes more absorbent.

Am J Health Syst Pharm. 2006 Oct 1;63(19):1852-7.

Medication and nutrient administration considerations after bariatric surgery.

Miller AD, Smith KM.

Department of Pharmacy Services, University of Kentucky Health Care, Lexington, 40536-0293, USA.

Comment in:

* Am J Health Syst Pharm. 2007 Feb 1;64(3):241; author reply 241.

Abstract

PURPOSE: Medication and nutrient administration considerations after bariatric surgery are discussed.

SUMMARY: Bariatric surgery is categorized by surgical technique (i.e., restrictive procedure or a combination of restrictive and malabsorptive procedures). Roux-en-Y gastric bypass is the most frequently performed bariatric surgery in the United States. Patients who have undergone this surgery are at risk for nutrient deficiencies. Several factors, such as pH and absorption sites, should be considered when providing these patients with appropriate supplementation. Drug solubility and surface area for absorption are also affected by gastric bypass procedures. By bypassing major portions of the small intestine, Roux-en-Y procedures drastically reduce the surface area for absorption. These changes may warrant manipulation in drug route or dose to ensure adequate delivery. Drugs with long absorptive phases that remain in the intestine for extended periods are likely to exhibit decreased bioavailability in these patients. The reduced size of the stomach after surgery can place patients at risk for adverse events associated with some medications. Medications implicated in such adverse events include nonsteroidal antiinflammatory drugs, salicylates, and oral bisphosphonates. Drugs that are rapidly and primarily absorbed in the stomach or duodenum are likely to exhibit decreased absorption in patients who have had combination restrictive-malabsorptive procedures. Because reduced drug absorption may result in decreased efficacy rather than toxicity, increased patient monitoring for therapeutic effects can help detect potential absorption problems.

CONCLUSION: Selection of appropriate nutrient salts can improve nutrient replacement in patients who have undergone bariatric surgery. Changes in dosage forms based on drug characteristics can improve bioavailability.

Psychosomatics. 2005 May-Jun;46(3):250-3.

Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model.

Seaman JS, Bowers SP, Dixon P, Schindler L.

Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73151, USA. jeff-seaman@ouhsc.edu

Abstract

Large numbers of Roux-en-Y gastric bypass (RYGB) surgery patients have psychiatric illnesses that are in part treated with medication preoperatively, but there are no objective data to guide psychiatric drug dosing postoperatively. An in vitro drug dissolution model was developed to approximate the gastrointestinal environment of the preoperative (control) and post-RYGB states. Medication tablets were placed in the two environments, and the median calculated weights of the dissolved portions were compared. Ten of 22 psychiatric medication preparations had significantly less dissolution and two had significantly greater dissolution in the post-RYGB environment, compared with the control environment. The results suggest a need for an in vivo study of serum drug levels after RYGB surgery in patients taking psychiatric medications. Differences in the pharmacokinetics of the postoperative RYGB patient may necessitate adjustments in dosing.

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