1. No category

January 2015
What is Gluten?
What is the Big Deal
About Gluten?
Shirin Madzhidova, PharmD
Pediatric Pharmacotherapy Fellow
Nova Southeastern University
Protein found in wheat, and related
grains (barley, rye)
Gives dough elasticity, shape, and
chewy texture
Formed by combination of proteins
gliadin and glutenin
Added to foods as a source of
protein, worldwide
Learning Objectives
Review the pathophysiology of gluten
on celiac disease
Identify sources of gluten in a
common diet
Discuss current theories on the
application of gluten-free diet
Evaluate the evidence behind gluten
sensitivity
Image from: http://aestheticalpha.com/gluten/
Before We Begin…
https://www.youtube.com/watch?v=
AdJFE1sp4Fw
Products Containing Gluten
Flour products (eg.
breads, pastas)
Beer
Cereals (unless
gluten free)
Soy sauce
Food additives
(flavorings, malt)
Gravies
Some lunch meats
Some sports drinks
Some teas
Some cosmetic
products
Some medications
1
January 2015
When Gluten is a
Problem?
Celiac disease (CD)
Non-celiac gluten sensitivity (NCGS)
Wheat allergy
Celiac Disease
Autoimmune disorder
Genetic predisposition
Immune response to gluten proteins
Leads to damage of villi in small
intestine
Impaired absorption of nutrients
Affects 1 in 133 people in the US
(1% of population)
Clinical Presentation of
CD
In children: diarrhea, malabsorption,
growth failure, anemia, etc.
In adults: atypical presentation
Gastrointestinal manifestations
Headache, depression, neuropathies
Osteoarthritis
Iron deficiency
Metabolic bone disease
Kidney disease
Complications of Celiac
Disease
Associated with other autoimmune
disorders
Gastrointestinal manifestations
Metabolic abnormalities
Neuropsychiatric disease
Risk of malignancy
Treatment: gluten-free diet (GFD)
Image from: http://fixyourdigestion.com/celiac-gluten-free-and-still-having-symptoms-2/
Non-Celiac Gluten Sensitivity
New syndrome of gluten intolerance
Symptoms similar to celiac disease
Irritable Bowel Syndrome-like symptoms
Headache, joint and muscle pain
Chronic fatigue, depression
Image from: http://gastro.ucla.edu/body.cfm?id=20
Cause and prevalence not known
Must rule out CD and wheat allergy
Symptoms improve with GFD
No validated diagnostic tests exist
2
January 2015
Associated Disorders
Irritable Bowel Syndrome
May be associated with NCGS
Patients with diarrhea-predominant IBS
may benefit from GFD
Autism spectrum disorder and
schizophrenia
Opioid peptide theory
Symptom improvement from glutenfree, casein-free diet
Efficacy not established
Wheat Allergy
IgE and non-IgE mediated response
Occurs in 0.5% of population
Mainly affects children
Associated with atopic dermatitis and
enterocolitis
May present with hives, rash, and in
severe cases, anaphylaxis
Often outgrown by age three
Increased Prevalence
Theories
Wheat containing baby formula
Increase in caesarian deliveries
Increased use of vital gluten
Argonomic practices (fertilizers, etc.)
Poor overall diets (change in gut
microbiome)
Changes in the gut microbiome
Media Influence
“Grain Brain” by D. Perlmutter
Claims that 38 different diseases
and symptoms can be cured by
GFD
“Wheat Belly” by W. Davis,
MD
Claims that wheat consumptions
is the main cause of obesity and
diabetes in the US
Images from: http://www.amazon.com/Grain-Brain-Surprising-Sugar-Your-Killers/dp/031623480X
http://www.wheatbellyblog.com
Emerging Research
Athletes and celebrity
endorsement of GFD
~80% of Americans on a GFD do not
have celiac disease
Only 1 in 5 people affected by celiac
disease are diagnosed
Prevalence of celiac disease is
increasing
Four times more common today than in
1950
Images from: www.peacefuldumpling.com, www.self.com, shelflife.ew.com, glutendude.com
3
January 2015
Gluten-Free Diet
Usually higher in fat, sugar, and
calories
Low in fiber, not enriched or fortified
Low in iron, B vitamins, and folate
Average cost of gluten-free products
is 242% more expensive
In 2013, 30% of US adults reported
eliminating gluten from their diet
Overview
1% of population is affected by celiac
disease
Celiac disease is on the rise and
needs improved diagnostic testing
GFD for non-celiac symptoms
requires more research
GFD is not always more nutritious
Exclusion diets must be carefully
monitored
Gluten-Free Marketing
Sales of GF products increased by 63%
since 2012
4,599 new products introduced last year
No. 1 GF snack – Potato chips
Naturally free of gluten
Sales of products with the label increased
456% since 2012
In 2013, twice as many GF pet foods were
launched than breakfast cereals
Beauty, hair, and household cleaning
products carry the label
References
Pietzak, M. Celiac Disease, Wheat Allergy, and Gluten Sesitivity:
When Gluten Free is Not a Fad. J of Parenteral and Enteral
Nutrition. 2012;36(1):68-75.
Aziz I, Sanders DS. Emerging concepts: from coeliac disease to
non-coeliac gluten sensitivity. Proceedings of the Nutrition
Society. 2012;71:576-580.
Nash DT, Slutzky AR. Gluten sensitivity: new epidemic or new
myth? Proc (Bayl Univ Med Cent) 2014;27(4):377-378.
Rubio-Tapia A, Ludvigsson J, et al. The Prevalence of Celiac
Disease in the United States. Am J Gastroenterol 2012;
107:1538–1544.
Schuppan D, Dieterich W. Pathogenesis, epidemiology, and clinical
manifesttions of celiac disease in adults. In: UpToDate, Post TW
(Ed), UpToDate, Waltham, MA. (Accessed on December 25,
2014.)
The Truth About Gluten. The Consumer Report Magazine, January
2015: 37-40.
4
January 2015
Probiotics Origin1
Probiotic Use in GI Disease
Management: Are these Bugs
Good?
Alexandria Cabrera, PharmD, BCPS
PGY-2 Health System Pharmacy Administration Resident
Miami VA Healthcare System
Early 20th century
Elie Metchnikoff
professor at Pasteur Institute, Paris
“father of probiotics”
The Prolongation of Life: Optimistic Studies
Bulgarians drank milk fermented by lactic-acid producing
bacteria
Longer life spans
Lactobacillus is the most commonly studied probiotic to date
Lactic acid lowers stomach pH and inhibits growth of infectious
bacteria
Goals and Objectives
Define probiotics and identify available
products
Probiotic Products1,2
Product Name
Type of Probiotic
VSL#3
Bifidobacterium breve
Bifidobacterium longum
Bifidobacterium infantis
Lactobacillus acidophilus
Lactobacillus plantarum
Lactobacillus paracasei
Lactobacillus bulgaricus
Streptococcus thermophilus
Align
Bifidobacterium infantis
Culturelle
Lactobacillus rhamnosus GG
Florastor
Saccharomyces boulardii
Discuss the proposed mechanisms of
probiotics for use in gastrointestinal disorders
Analyze published evidence regarding the
safety and efficacy of probiotic use in
gastrointestinal disorders
Dosing varies based on product and indication
Side effects: Flatulence, abdominal bloating
Storage: Most require refrigeration, except Culturelle
Probiotics1,2
Food and Agriculture Organization of the United
Nations and World Health Organization
“live microorganisms that confer a health benefit to the
host when administered in adequate amounts”
Similar to those found naturally in the human body
“good bacteria”
Most common strains
Bifidobacterium
Lactobacillus
Saccharomyces boulardii (yeast)
Yogurt Products1,2
Product Name
Type of Probiotic
Activia
Lactobacillus bulgaricus
Streptococcus thermophilus
Bifidobacterium lactis
DanActive
Lactobacillus casei
Stonyfield
Streptococcus thermophilus
Lactobacillus bulgaricus
Lactobacillus acidophilus
Bifidus
Lactobacillus casei
Side effects: Flatulence, abdominal bloating
Storage: Keep refrigerated
FDA has not approved any health claims
1
January 2015
Mechanisms of Action3,4
Enhancement of the epithelial barrier
Modulation of regulation genes
encoding adherence junction proteins
Increased mucin expression
Increased adhesion to intestinal
mucosa
Inhibition of pathogenic adhesion
Production of anti-microorganism
substances
Degradation of bacterial component
into anti-microbial peptide
Release of defensins from epithelial
cells
Disrupt membrane integrity and
promote lysis
Acetic and Lactic acid
Lower intracellular pH
Bacteriocins
Inhibit cell wall synthesis
Immunomodulatory
Effect3,4
Induce protective cytokines
IL-10
TNF-β
Suppress intestinal
inflammation
Downregulation of TLR expression
Suppression of pro-inflammatory
cytokines
Secretion of metabolites that may
inhibit TNF-α
Inhibition of NF-kB signaling
Antibiotic-associated
Diarrhea5
Meta-analysis 2012
63 trials
11,811 patients with diarrhea
Lactobacillus based probiotics
• 42% lower risk of developing antibiotic-associated
diarrhea
• RR 0.58
• NNT 13
Studies were small and utilized different
endpoints
Infectious Diarrhea6
Reduction in duration of infectious diarrhea
Meta analysis 2010
63 randomized controlled trials
• 8,014 adults and children with acute infectious diarrhea
• Lactobacillus GG and Saccharomyces boulardii
Probiotics reduced overall risk of diarrhea lasting 4+
days
RR 0.41
Mean duration of diarrhea decreased by 25 hours
95% CI 16-34 hours
Stool frequency on day 2 reduced by 0.80 stools per day
95% CI 0.45 to 1.14 stools per day
Antibiotic-associated
Diarrhea5
Routine prevention of antibioticassociated diarrhea
Systematic review 2012
82 randomized trials
• 17 trials used Lactobacillus GG
RR 0.64= 36% decreased risk
• 16 trials Saccharomyces boulardii
Infectious Diarrhea7
Meta analysis 2002
9 randomized, double-blind, placebo controlled
Pediatric patients with acute infectious
diarrhea
Lactobacillus GG
Duration of diarrhea reduced by 0.7 days
95% CI 0.3-1.2 days
Frequency reduced to 1.6 stools per day on
day 2
95% CI 0.7-2.6 fewer stools
RR 0.48= 52% decreased risk
2
January 2015
Irritable Bowel
Syndrome12
Constipation8,9
Improvement in frequency and consistency
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Results
Koebnick C,
Wagner I, et
al. (2003)8
Double-blind,
randomized,
placebocontrolled
70 with
symptoms
of chronic
constipation
L. casei
yogurt 65
mL/day
4 weeks
• Improvement in self-reported
severity of constipation and
stool consistency after 1 week of
therapy (p<0.0001)
Meta-analysis 2008
20 randomized, controlled trials
• 1,404 subjects
Median of 54 subjects per study
Global IBS symptoms improvement
• Defecation frequency 3 times or
less per week decreased from
54% to 3% L. casei versus 51%
to 14% placebo (p=0.001)
Nishida S,
Gotou M, et
al. (2004)9
Double-blind,
randomized,
placebocontrolled
35 healthy
adult
females
with
tendency
toward
infrequent
stools
B. lactis
BB-12
yogurt 100
g/day
7 weeks
(3 week
rest
period)
• RR 0.77 (95% CI 0.62-0.94)
• NNT 7.3
• Defecation frequency increased
in all subjects receiving B. lactis
BB-12 (5.7 + 2 to 7.1 + 2.3
times/week, p<0.01) and
placebo (5.7 + 2 to 5.6 +2
times/week, p<0.05)
Less abdominal pain
• RR 0.78 (95% CI 0.69-0.88)
• NNT 8.9
• Defecation frequency increased
in those with constipation
receiving B. lactis BB-12 (4.3 +
1.4 to 7.5 + 2.3 times/week,
p<0.01) and placebo (4.3 + 1.4
to 5.3 +1 times/week, p<0.05)
Constipation10
Systematic review 2010
5 randomized, controlled trials
May increase defecation frequency and improve stool
consistency
Crohn’s Disease2,13-16
Induction of remission
Maintenance of remission
• Adults (3 trials, n=266)
B. lactis
L. casei
E. coli Nissle
• Children (2 trials, n=111)
Available data unable to prove clinical
effectiveness
L. casei rhamnosus
Not L. rhamnosus GG
No adverse events reported
Clinical significance unclear
Irritable Bowel
Syndrome11
Short-term studies
Certain patient subgroups may benefit
Crohn’s Disease13-16
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Results
Schultz M,
Timmer A, et
al. (2004)13
Double-blind,
randomized,
placebocontrolled
11 with
moderate to
active
Crohn’s
disease
L. GG 2
capsules/
day
6 months
• 2/5 L. GG versus 3/6 placebo
relapsed
Guslandi M,
Mezzi G, et al.
(2000)14
Double-blind,
randomized,
controlled
32 with
Crohn’s
disease in
remission
(CDAI <150)
S.
boulardii
1g/day
6 months
• 37.5% mesalamine alone versus
6.25% mesalamine + S.
boulardii had clinical relapses
Bourreille A,
Cadiot G, et
al. (2013)15
Double-blind,
randomized,
placebocontrolled
159 with
Crohn’s
disease
S.
boulardii
1g/day
52 weeks
• 38/80 (47.5%) S. boulardii
versus 42/79 (53.2%) placebo
relapsed (p=0.5)
Magnitude of benefit was modest
Systematic review 2009
16 randomized, controlled trials
• Inadequate blinding, trial length, and sample size
• Lack of intention-to-treat analysis
2 trials using B. infantis showed improvement in
composite score for abdominal pain/discomfort,
bloating/distention, and bowel movement difficulty
(p<0.05)
• Mean time to relapse: 16+4
weeks L. GG versus 12+4.3 in
the placebo (p=0.5)
• Median time to relapse: 40.7
weeks S. boulardii versus 39.0
weeks (p=0.78)
Bousvaros A,
Guandalini
MD, et al.
(2005)16
Double-blind,
randomized,
placebocontrolled
75 pediatrics
(age 5-21)
with Crohn’s
disease in
remission
(PCDAI <10)
L. GG
24
months
• Median time to relapse: 11.6
months L. GG versus 12.8
months placebo (p=0.37)
• 12/39 L. GG versus 6/36
placebo relapsed (p=0.18)
CDAI: Crohn’s Disease Activity Index
PCDAI: Pediatric Crohn’s Disease Activity Index
3
January 2015
Ulcerative Colitis17,18
Pouchitis21,22
Prevention of recurrent pouchitis
Induction of remission
Maintenance of remission
Maintenance of remission
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Results
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Conclusions
Wildt S,
Nordgaard I,
et al. (2011)17
Double-blind,
randomized,
placebocontrolled
32 with leftsided
ulcerative
colitis in
remission
with at least
one relapse
in year prior
L.
Acidophilus
La-5 and
B. animalis
subsp.
Lactis BB12 (ProbioTec AB-25)
52 weeks
• 5/20 Probio-Tec AB-25 versus
1/12 placebo maintained
remission (p=0.37)
Gionchetti P,
Rizzello F,
Venturi A, et
al. (2000)21
Double-blind,
randomized,
placebocontrolled
40 with a
h/o of
chronic,
relapsing
pouchitis
VSL#3
6g/day
9 months
• 3/20 VSL#3 versus 20/20
placebo had flare-ups of chronic
pouchitis (p<0.001)
12
months
36 with
recurrent or
refractory
pouchitis
12
months
L. GG 2
capsules/
day
Double-blind,
randomized,
placebocontrolled
VSL#3
6g/day
187 with
ulcerative
colitis in
remission
for 12
months
Mimura T,
Rizzello F,
Helwig U, et
al. (2004)22
Zocco MA, dal
Verme LZ, et
al. (2006)18
Prospective,
open-label,
randomized
• Median time to relapse was
125.5. days in the probiotic
versus 104 days in the placebo
group (p=0.37)
• 10/65 L. GG alone, 10/62 L.GG
+ mesalazine and 12/60
mesalazine alone relapsed
• Within 3 months of stopping
VSL#3, all patients relapsed
• 17/20 VSL#3 versus 1/20
placebo maintained in remission
(p<0.0001)
• 1 VSL#3 patient dropped out
due to abdominal cramp,
vomiting, and diarrhea
• 85% L. GG alone, 84% L. GG +
mesalazine and 80% mesalazine
alone maintained clinical
remission (p=0.77)
Ulcerative Colitis19,20
Pouchitis23-25
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Results
Study
Study
Design
Number of
Subjects
Probiotic
Duration
Results
Rembacken
BJ, Snelling
AM, et al.
(1999)19
Double-blind,
randomized
116 with
active
ulcerative
colitis
E. coli
(Nissle
1917)
12
months
• 39/57 E. coli versus 44/59
mesalazine attained remission
Gionchetti P,
Rizzello F, et
al. (2003)23
Double-blind,
randomized,
placebocontrolled
40 with a h/o
of pouchitis
VSL#3
3g/day
12
months
• 2/20 VSL#3 versus 8/20 placebo
had an episode of acute
pouchitis (P <0.05)
• 26/57 E. coli versus 32/59
mesalazine relapsed
• Mean duration of remission was
221 days in the E. coli versus
206 days in the mesalazine
group
Tursi A,
Brandimarte
G, et al.
(2004)20
Double-blind,
randomized,
placebocontrolled
144 with
acute
ulcerative
colitis
VSL#3
3g/day
8 weeks
• 41/71 VSL#3 versus 29/73
placebo showed at least 50%
improvement in UCDAI scores
(p=0.01)
• 31/71 VSL#3 versus 23/73
placebo attained remission
(p=0.069)
• 8 VSL#3 and 9 placebo reported
mild side effects (dizziness,
abdominal bloating and
discomfort, flu-like syndrome)
UCDAI: Ulcerative Colitis Disease Activity Index
Pouchitis21,22
Acute or chronic inflammation of the ileal reservoir
• IBDQ score significantly
improved for VSL#3 (p<0.001)
• No side effects reported
Shen B,
Brzezinski A,
et al. (2005)24
Kuisma J,
Mentula S, et
al. (2003)25
Open-label
Double-blind,
randomized,
placebocontrolled
31 with
antibiotic
dependent
pouchitis in
remission
VSL#3
6g/day
20 with a h/o
pouchitis and
endoscopic
inflammation
L. GG 2
capsules/
day
8 months
• 6/31 (19.4%) remained on
VSL#3 at end of 8 months
• 23 discontinued due to
recurrence of symptoms and 2
due to side effects (bloody bowel
movements and severe
constipation)
3 months
• 4/10 L. GG became colonized
• Changes in total PDAI score
were not significantly different
• Inefficient for clinical
improvement of pouchitis
IBDQ: Inflammatory Bowel Disease Questionnaire
PDAI: Pouchitis Disease Activity Index
Recommendations
Clinical trials using probiotics have yielded inconsistent
results
Underlying ulcerative colitis
Restorative proctocolectomy
Long term efficacy yet to be established
• Surgical removal of the colon and rectum
Ileal pouch-anal anastomosis
• Creation of a pouch of small intestine to recreate removed rectum
• Reestablishes gastrointestinal continuity
Antibiotic-associated diarrhea
Larger studies are needed prior to recommendation for use as routine
prevention
Infectious diarrhea
Studies suggest probiotics may be considered in adults and children
Constipation
Current data is insufficient
Larger studies warranted
4
January 2015
Recommendations
Irritable Bowel Syndrome
Studies have not provided clear evidence and only modest
benefit
Crohn’s disease
Lack of evidence to prove any benefit
Ulcerative colitis
References
10.
Chmielewska A, Szajewska H. Systematic review of randomised controlled trials: probiotics for functional
constipation. World J Gastroenterol 2010; 16:69.
11.
Ringel Y, Carroll IM. Alterations in the intestinal microbiota and functional bowel symptoms. Gastrointest
Endosc Clin N Am 2009; 19:141.
12.
McFarland LV, Dublin S. Meta-analysis of probiotics for the treatment of irritable bowel syndrome. World J
Gastroenterol 2008; 14:2650.
13.
Schultz M, Timmer A, Herfarth HH, et al. Lactobacillus GG in inducing and maintaining remission of Crohn’s
disease. BMC Gastroenterol. 2004 Mar;38(3):293.
14.
Guslandi M, Mezzi G, Sorghi M, et al. Saccharomyces boulardii in maintenance treatment of Crohn’s disease.
Dig Dis Sci. 2000 Jul; 45(7):1462.
15.
Bourreille A, Cadiot G, Le Dreau G, et al. Saccharomyces boulardii does not prevent relapse of Crohn's
disease. Clin Gastroenterol Hepatol 2013; 11:982.
16.
Bousvaros A, Guandalini S, Baldassano RN, et al. A randomized, double-blind trial of Lactobacillus GG versus
placebo in addition to standard maintenance therapy for children with Crohn’s disease. Inflamm Bowel Dis.
2005 Sep; 11(9):833.
17.
Wildt S, Nordgaard I, Hansen U, et al. A randomised double-blind placebo-controlled trial with Lactobacillus
acidophilus La-5 and Bifidobacterium animalis subsp. lactis BB-12 for maintenance of remission in ulcerative
colitis. J Crohns Colitis 2011; 5:115.
Studies have not proven any statistical or clinical significance
Pouchitis
Data suggests there may be benefit from VSL#3
VSL#3 may be reasonable in addition to standard therapy
Quiz
T/F: Lactobacillus is the most studied
probiotic to date.
TRUE
T/F: Most probiotics require refrigeration
upon storage.
TRUE
T/F: Clinical trials using probiotics have
yielded very consistent and easily
interpretable data.
References
18.
Zocco MA, dal Verme LZ, Cremonini F, et al. Efficacy of Lactobacillus GG in maintaining remission of
ulcerative colitis. Aliment Pharmacol Ther 2006; 23:1567.
19.
Rembacken BJ, Snelling AM, Hawkey PM, et al. Non-pathogenic Escherichia coli versus mesalazine for the
treatment of ulcerative colitis: a randomised trial. Lancet 1999; 354:635.
20.
Tursi A, Brandimarte G, Giorgetti GM, et al. Low-dose balsalazide plus a high-potency probiotic preparation
is more effective than balsalazide alone or mesalazine in the treatment of acute mild-to-moderate ulcerative
colitis. Med Sci Monit 2004; 10:PI126.
21.
Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with
chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000; 119:305.
22.
Mimura T, Rizzello F, Helwig U, et al. Once daily high dose probiotic therapy (VSL#3) for maintaining
remission in recurrent or refractory pouchitis. Gut 2004; 53:108.
23.
Gionchetti P, Rizzello F, Helwig U, et al. Prophylaxis of pouchitis onset with probiotic therapy: a double-blind,
placebo-controlled trial. Gastroenterology 2003; 124:1202.
24.
Shen B, Brzezinski A, Fazio VW, et al. Maintenance therapy with a probiotic in antibiotic-dependent
pouchitis: experience in clinical practice. Aliment Pharmacol Ther 2005; 22:721.
25.
Kuisma J, Mentula S, Jarvinen H, et al. Effect of Lactobacillus rhamnosus GG on ileal pouch inflammation
and microbial flora. Aliment Pharmacol Ther 2003; 17:509.
FALSE
References
1.
Hibberd P, Klein M, Duffy L, et al. "Oral Probiotics: An Introduction." National Center for Complementary and
Alternative Medicine. 1 Jan 2007. Web. 18 Dec 2014.
<http://nccam.nih.gov/health/probiotics/introduction.htm>.
2.
Sartor RB. (2014). Probiotics for gastrointestinal disorders. In J. Lamont (Ed), UpToDate. Waltham, Mass.:
UpToDate. Retrieved from www.uptodate.com
3.
Boirivant M and Strober W. The mechanism of action of probiotics. Curr Opin Gastroenterol. 2007
Nov;23(6):679.
4.
Bermudez-Brito M, Plaza-Diaz J, Munoz-Quezada S, et al. Probiotic mechanisms of action. Ann Nutr Metab.
2012;61(2):160.
5.
Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated
diarrhea: a systematic review and meta-analysis. JAMA 2012; 307:1959.
6.
Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane
Database Syst Rev 2010; :CD003048.
7.
Van Niel CW, Feudtner C, Garrison MM, Christakis DA. Lactobacillus therapy for acute infectious diarrhea in
children: a meta-analysis. Pediatrics 2002; 109:678.
8.
Koebnick C, Wagner I, Leitzmann P, et al. Probiotic beverage containing Lactobacillus casei Shirota improves
gastrointestinal symptoms in patients with chronic constipation. Can J Gastroenterol 2003; 17:655.
9.
Nishida S, Gotou M, Akutsu S, et al. Effect of yogurt containing Bifidobacterium lactis BB-12 on improvement
of defecation and fecal microflora of healthy female adults. Milk Science 2004; 53:71.
5
January 2015
PPI’s Versus H2 Receptor
Antagonists ,
1 2
Proton Pump Inhibitors
Appropriate Use Of
Proton Pump Inhibitors
Shut down the cell
pumps that maintain the
acidic environment in
the stomach
Delayed onset of action
(approx. 2 hours)
Work for a longer period
of time; most last up to
24 hours, and the
effects may last up to
three days
BY: KIMBERLY REGIS
PHARMACY RESIDENT 2014-2015
BROWARD HEALTH MEDICAL CENTER
1.
2.
H2 Receptor Antagonists
Block signals generated
by histamine receptors
on cells that are
responsible for acid
secretion
Begin working within an
hour
Usually only work up to
12 hours
Vanderhoff, BT., Tahboub, RM. Proton Pump Inhibitors: An update. Am Fam Physician. 2002 Jul 15; 66(2):273-281.
Katz, PO., Gerson, BL., Vela, MF. Guidelines for the diagnosis and management of Gastroesophageal Reflux Disease. Am J
Gastroenterol 2013; 108:308 – 328; doi: 10.1038/ajg.2012.444; published online 19 February 2013.
PPI’s Versus H2 Receptor
Antagonists
OBJECTIVES
1
Proton Pump Inhibitors
Identify basic principles of proton pump inhibitors
Explain the difference between H2 receptor
antagonists and proton pump inhibitors
Describe the suitable uses of proton pump inhibitors
in a clinical practice setting
Discuss the indications where intravenous therapy is
recommended over oral treatment
Review duration of treatment for applicable
indications
Review indications for gastrointestinal prophylaxis
Explain potential complications of long-term therapy
Considered more potent
than H2 receptor
antagonists
Promote healing of
ulcers in a greater
percentage of people in
a shorter amount of
time
1.
Introduction
1
H2 Receptor Antagonists
Considered as first line
for mild cases that need
acid suppression (eg.
Initial stages of
heartburn)
Less long-term
complications than
proton pump inhibitors
Katz, PO., Gerson, BL., Vela, MF. Guidelines for the diagnosis and management of Gastroesophageal Reflux Disease. Am J
Gastroenterol 2013; 108:308 – 328; doi: 10.1038/ajg.2012.444; published online 19 February 2013.
When Should A Proton Pump
Inhibitor (PPI) Be Used?
1
Proton pump inhibitors (PPIs) are a class of
medications that block the acid secretion from parietal
cells in the stomach; provides relief from acid related
disorders
Long duration of action (>12h-24h); once daily dosing
is sufficient
Bioavailability is reduced by food (given one hour
before meal)
Metabolized in the liver by CYP450 (primarily CYP2C19
and CYP3A4)
1. Lexi-Comp OnlineTM (Lexi-Drugs), Hudson, Ohio: Lexi-Comp, Inc; Accessed September 20th, 2014.
Proton pump inhibitors are used for prophylaxis and
treatment of gastric related conditions, including:
Treatment of gastroesophageal reflux disease
Healing and maintenance of erosive esophagitis
Hypersecretory conditions (eg; Zollinger-Ellison
syndrome)
Short term treatment and maintenance of duodenal
ulcers
Risk reduction for gastric ulcer associated with NSAIDS
Helicobacter pylori eradication in combination with
antibiotics
1. Uptodate.com. Overview and comparison of the proton pump inhibitors for the treatment of acid related disorders. [online] Available at:
http://www.uptodate.com/contents/overview-and-comparison-of-the-proton-pump-inhibitors-for-the-treatmet-of-acid-related-disorders [Accessed:
18 Sep 2014].
1
January 2015
Criteria for IV Usage
1
Patient must be NPO (nothing by mouth)
AND
One of the following conditions:
Bleeding or severe erosive esophagitis
Hypersecretion associated with Zollinger-Ellison
Syndrome
Clinical signs of upper GI bleed before diagnostic
confirmation in high risk patients
Contraindication to using H2 receptor antagonist for
stress ulcer prophylaxis (eg; intolerable side effects, H2
receptor antagonist related thrombocytopenia)
1. Nasser, SC., Nassif, JG., Dimassi HI. Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients. World J
Gastroenterol. Feb 29, 2010; 16(8): 982-986. Published online Feb 28, 2010.
Intravenous PPI
Availability1
IV dosage form available
Esomeprazole
(Nexium®)
Pantoprazole
(Protonix®)
IV dosage form not
available
Dexlansoprazole
(Dexilant®)
Omeprazole (Prilosec®)
Rabeprazole (Aciphex®)
Lansoprazole
(Prevacid®)
Omeprazole/Sodium
Bicarbonate (Zegerid®)
1. Lexi-Comp OnlineTM (Lexi-Drugs), Hudson, Ohio: Lexi-Comp, Inc; Accessed September 20th, 2014
Duration of Treatment
Gastroesophageal reflux
disease (GERD)1
4-8 weeks
May repeat an
additional 8 weeks if
not healed
Peptic ulcer disease
(PUD)2
2-8 weeks
H. Pylori eradication3
7-14 days as
combination therapy
Zollinger-Ellison
syndrome4
4-8 weeks
May repeat an
additional 8 weeks if
not healed
1. Katz, PO., Gerson, BL., Vela, MF. Guidelines for the diagnosis and management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013; 108:308 –
328; doi: 10.1038/ajg.2012.444; published online 19 February 2013.
2. Thompson, EG., Simon, JB. Proton Pump Inhibitors for Peptic Ulcer Disease. WebMD. Available at: http://www.webmd.com/digestive-disorders/proton-pumpinhibitors-for-peptic-ulcer-disease
3. Yuan, Y., Padol, IT., Hunt, RH. Peptic Ulcer Disease Today. Medscape. Available at: http://www.medscape.com/viewarticle/522900_4.
4. Roy, PK., Katz, J. Zollinger-Ellison Syndrome Medication. Medscape. Available at: http://emedicine.medscape.com/article/183555-medication#2
GI Prophylaxis Review
1
Major Risk Factors (One major risk factor indicates
treatment initiation)
Mechanical Ventilation
Coagulopathy (INR > 1.5, platelets < 50)
Minor Risk Factors (Two minor risk factors indicates
treatment initiation)
Hepatic or renal dysfunction
Multiple trauma
History of GI bleeds
Burns (> 35% of BSA)
Shock
Head or spinal injury with Glascow Coma Score < 10
1. Grube, RR, et.al. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health System. 2007 Jul 1;64(13): 1396-400
Complications of LongTerm Use
1
Malabsorption
Hypomagnesemia and Hypocalcemia (may lead to
osteoporosis/bone fractures)
Vitamin B12 deficiency
Drug interaction with Plavix
Predominantly omeprazole
Increased risk of infections
Clostridium dificile
Community Acquired Pneumonia
1. O’neil, LW., Culpepper, BL., Galdo, JA. Long-term consequences of chronic proton pump inhibitor use. US Pharm. 2013; 38(12): 38-42
PPI Complication:
Malabsorption (Hypocalcemia)
Mechanism1
Dietary calcium absorption is dependent upon an acidic environment
PPI’s suppress gastric acid secretion
Reduction in calcium absorption leads to decreased osteoclastic
activity (decreases bone mineral density and increases fracture risk)
2013 ACG guidelines: unless patients with osteoporosis have
another risk factor for hip fractures, there is no contraindication to
PPI therapy 2
FDA: “If calcium supplementation is indicated, use of calcium
citrate is the preferred calcium supplement in patients taking
PPIs, as it can be absorbed in the absence of an acidic
environment” 3
1. O’Neil, LW., Culpepper, BL., Galdo, JA. Long-term consequennces of proton pump inhibitor use. US Pharm. 2013;38(12):38-42.
2. Wolfe M. Overview and comparison of proton pump inhibitors for the treatment of acid-related disorders. In: Basow DW, ed. UpToDate. Waltham, MA: UpToDate; 2013.
3. FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. FDA. March 28, 2011.
2
January 2015
PPI Complication:
Malabsorption
(Hypomagnesemia)
PPI Complication: Plavix
Interaction
1
1
Mechanism:
Plavix is a prodrug and inhibition of platelet aggregation
is due to an active metabolite
The metabolism of clopidogrel to its active metabolite
can be impaired by concomitant medications that
interfere with CYP2C19
Avoid concomitant use of Plavix and strong or
moderate CYP2C19 inhibitors (Omeprazole and
Esomeprazole)
Consider using agents with less CYP2C19 inhibitory
effects (Pantoprazole, Rabeprazole, and
Dexlansoprazole)
1. Drepper, MD., Spahr, L., Frossard, JL. Clopidogrel and proton pump inhibitors- where do we stand in 2012?. World J Gastroenterol. May
14, 2012; 18(18): 2161–2171. Published online May 14, 2012
1. O’Neil, LW., Culpepper, BL., Galdo, JA. Long-term consequennces of proton pump inhibitor use. US Pharm. 2013;38(12):38-42.
PPI Complication: Malabsorption
(Hypomagnesemia)1
Hypomagnesemia generally resolves with the
discontinuation of the PPI but also reoccurs soon after the
PPI is re-challenged
Monitoring: providers should obtain serum magnesium
levels prior to initiation of therapy and periodically
thereafter for patients on long-term treatment and for
patients who take other magnesium lowering medications
PPI Complication: Infection
(Clostridium Dificile)
1
Mechanism
Gastric juices kill Clostridium Dificile and
neutralizes its toxin in a dose dependent manner
PPI’s neutralize the gastric juices, thereby
increasing the chances of acquiring a Clostridium
Dificile infection
Patients should use the lowest dose and shortest
duration of therapy for the condition being treated
Patients who present with clinically significant
hypomagnesemia:
May require discontinuation of PPI therapy
Magnesium replacement via oral or IV methods
Treatment with an alternative class of drugs for GI conditions
1. O’Neil, LW., Culpepper, BL., Galdo, JA. Long-term consequennces of proton pump inhibitor use. US Pharm. 2013;38(12):38-42
1. Hand, L. Do Proton Pump Inhibitors Raise the Risk for C diff Infection? JAMA Intern Med. 2013;173:1359-1367, 1367-1368.
PPI Complication:
Malabsorption
(Vitamin B12 Deficiency)
1
PPI Complication: Infection
(Community Acquired
Pneumonia)
Mechanism
Mechanism
Vitamin B12 absorption is dependent upon acid secretion
PPI’s suppress acid secretion, causing the Vitamin B12 found in food
to not properly absorb into the body
This reduction in Vitamin B12 leads to tiredness, weakness,
constipation and a loss of appetite; a more serious deficiency can
cause balance problems, memory difficulties and nerve problems
Testing for Vitamin B12 deficiency should occur annually for
those on long term treatment
Consuming animal products rich in Vitamin B12 is recommended
A Vitamin B12 supplement may be required
1. Heidelbaugh, JJ. Proton Pump Inhibitors and Risk of Vitamin and Mineral Deficiency. Ther Adv in Drug Safe. 2013;4(3):125-133.
The normal pH of stomach contents promotes a sterile
environment
PPIs increase intragastric pH, which allows for several
species of bacteria to grow in the stomach
The increase in gastric bacteria may lead lung
colonization with a potential for causing pneumonia
Providers should analyze risk vs benefit in prescribing
or continuing PPI therapy, especially in patients at
high risk for developing CAP (elderly, Astham/COPD
patients, etc.)
1. Giuliano, C., Wilheml, SC., Kale-Pradhan, PB. Are Proton Pump Inhibitors associated with the development of community acquired
pneumonia? A meta-analysis. Expert Rev Clin Pharmacol. 2012 May;5(3):337-44.
3
January 2015
Overutilization of PPI’s
1
Primarily result from reasons listed below:
Lack of re-evaluation of the need for continuation
of therapy
Insufficient counseling of step-down therapy
Failure to discontinue stress ulcer prophylaxis
therapy post discharge from the hospital
Chronic outpatient treatment for acute GI
symptoms
Literature Sources
Lexi-Comp OnlineTM (Lexi-Drugs), Hudson, Ohio: LexiComp, Inc; Accessed September 20th, 2014.
Vanderhoff, BT., Tahboub, RM. Proton Pump
Inhibitors: An update. Am Fam Physician. 2002 Jul
15; 66(2):273-281.
Katz, PO., Gerson, BL., Vela, MF. Guidelines for the
diagnosis and management of Gastroesophageal
Reflux Disease. Am J Gastroenterol 2013; 108:308 –
328; doi: 10.1038/ajg.2012.444; published online 19
February 2013.
1. Heidelbaugh, JJ., Kim, AH., Chang, R., Walker, PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap
Adv Gastroenterol. Jul 2012; 5(4): 219–232
Role of a Pharmacist
1
Educate healthcare professionals regarding
GI prophylaxis in the hospital setting
Risks of inappropriately prescribed PPI’s
Re‐evaluation of PPI need post discharge
Provide counseling and education to patients
regarding
Appropriate uses for acid suppression therapy
Proper follow-up requirements with a physician
De-escalation of treatment if appropriate
Literature Sources
Douglas IJ, Evans SJ, Hingorani AD, Grosso AM, Timmis A,
Hemingway H, et al.Clopidogrel and interaction with proton
pump inhibitors: comparison between cohort and within
person study designs. BMJ. 2012;345:e4388. [PMID:
22782731]
Gray SL, LaCroix AZ, Larson J, et al. Proton pump inhibitor
use, hip fracture, and change in bone mineral density in
postmenopausal women: results from the Women’s Health
Initiative. Arch Intern Med 2010;170:765–771
Eom CS, Park SM, Myung SK, Yun JM, Ahn JS. Use of acidsuppressive drugs and risk of fracture: a meta-analysis of
observational studies. Ann Fam Med. 2011;9:257-67.
[PMID: 21555754]
1. Heidelbaugh, JJ., Kim, AH., Chang, R., Walker, PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap
Adv Gastroenterol. Jul 2012; 5(4): 219–232
Questions: True or False
Literature Sources
Proton pump inhibitors are metabolized through the
kidneys
Cunningham R, Dale B, Undy B, et al. Proton pump
inhibitors as a risk factor for Clostridium difficile
diarrhea. J Hosp Infect 2003;54:243–5
It is appropriate to use an IV PPI for a comatose
patient in a non- ICU setting with a prior history of GI
bleeds
Gill JM, Player MS, Metz DC. Balancing the risks and
benefits of proton pump inhibitors [Editorial]. Ann
Fam Med. 2011;9:200-2. [PMID: 21555747]
Omeprazole is available in the injection dosage form
Lodato F, Azzaroli F, Turco L, et al. Adverse Effects of
Proton Pump Inhibitors. Best Practice & Research
Clinical Gastroenterology 24 (2010) 193–201.
4
January 2015
Literature Sources
Nasser, SC., Nassif, JG., Dimassi HI. Clinical and cost
impact of intravenous proton pump inhibitor use in
non-ICU patients. World J Gastroenterol. Feb 29,
2010; 16(8): 982-986. Published online Feb 28, 2010.
Heidelbaugh, JJ., Kim, AH., Chang, R., Walker, PC.
Overutilization of proton-pump inhibitors: what the
clinician needs to know. Therap Adv Gastroenterol. Jul
2012; 5(4): 219–232.
Graham, DY., Pang, SH. A clinical guide to using
intravenous proton pump inhibitors in reflux and
peptic ulcers. Therap Adv Gastroenterol. Jan 2010;
3(1): 11–22. v.3(1).
Literature Sources
Bayan, K., Canoruc, F., Dursun, M., Tuzun, Y., Yilmaz,
S. A head to head comparison of oral vs intravenous
omeprazole for patients with bleeding peptic ulcers
with a clean base, flat spots and adherent clots. World
J Gastroenterol 2006 December 28; 12(48): 78377843
5
January 2015
Laparoscopic Band (Lap Band)
Life After Bariatric
Surgery:
Focus on Medications
Meng Fei Lee, Pharm.D.
PGY-1 Pharmacy Practice Resident
Broward Health Medical Center
Objectives
Identify complications associated with
obesity and bariatric surgery
Define short and long treatment goals
for patients who have undergone
bariatric surgery
Discuss pharmacologic treatment options
for post-operative complications
Discuss dietary restrictions and
supplementation options
Types of Bariatric
Surgeries
Laparoscopic Band (Lap Band)
Laparoscopic Band (Lap Band)
Sleeve Gastrectomy
Roux-en-Y Gastric Bypass (RYGB)
1
January 2015
Sleeve Gastrectomy
Roux-en-Y Gastric Bypass
(RYGB)
Sleeve Gastrectomy
Complications
Short Term
PACU, Surgical floor/inpatient
management
• Pain control
• Nausea/vomiting
• Hydration, IV Fluids
• Pressures
VTE
Diabetes Mellitus
Sleeve Gastrectomy
Complications
Short Term
Reoperation
• Sustained tachycardia
• Respiratory distress
• Persistent vomiting
Infection
Activity Restrictions
Long Term
2
January 2015
Complications
Short term
Long Term
Absorption issues
Nutrition deficiencies
GERD
Gallstones
Pain
Depression
Pregnancy & fertility
Absorption
Decreased surface area
Roux-en-Y gastric bypass
Sleeve gastrectomy
Food aversions (decreased intake of
food)
Roux-en-Y
Sleeve gastrectomy
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Diet (Short Term)
Diet (Post-op)
RYGB & Sleeve Gastrectomy
• First 2 weeks:
Limit oral intake to clear liquids (64 oz)
• Next 2 weeks:
Full liquids or pureed diet
• Next 2 months:
Soft diet
• 3rd postoperative month: Regular diet*
UCSF Medical Center Specialists. Life After Bariatric Surgery. (n.d.). (Retrieved September 8, 2014.)
Diet (Short Term)
Diet (Post-op)
LAGB
• First week: clear liquids
• Reassess & proceed each week: full/pureed
liquids, then soft diet for a week, then
regular diet*
Diet Restrictions
Avoid carbonation
Avoid concentrated sweets
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Vitamin deficiency
Supplementation:
Calcium 500 mg PO twice daily
• Use calcium citrate > calcium carbonate
• Combinations with vitamin D 800 units daily
• Do not take together with iron supplements
Vitamin B1 (thiamine) 1.2 mg PO daily
Vitamin B9 (folic acid) 400 mcg PO daily
Vitamin B12 (cyanocobalamin) 500 mcg
PO daily or 1000 mcg IM monthly, or
3000 mcg IM every 6 months
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Vitamin deficiency
Vitamin C 500 mg PO daily (with
iron)
Ferrous sulfate 325 mg PO daily
•Elemental iron
40 to 65 mg daily for premenopausal
women
18 to 27 mg daily for all others
•Take with vitamin C
•Avoid taking same time as calcium
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
3
January 2015
Gastroesophageal Reflux
Disorder (GERD)
Vitamin deficiency
Fat soluble vitamin complexes
• Fat malabsorption (RYGB)
• Vitamins A, D, E, K
PPI
Omeprazole (Prilosec) 20 mg PO daily
Pantoprazole (Protonix) 40 mg PO daily
Lansoprazole (Prevacid) 15 mg PO daily
Esomeprazole (Nexium) 20 mg PO daily
Vitamin A 500 mcg (1600 units) PO
daily
Vitamin D3 800 units PO daily
Vitamin E 10 mg PO daily
Vitamin K 120 mcg PO males, 90 mcg
PO females
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; January 7, 2015.
Gastroesophageal Reflux
Disorder (GERD)
Vitamin deficiency
Trace Elements
Copper 2 mg PO daily
Selenium 55 mcg PO daily
Zinc 11mg PO males, 8 mg PO females
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Drug
Dose
(PO)
Drug Interactions
Omeprazole
(Prilosec)
20 mg
daily
Amphetamines, Bisphosphonates, Fever, headache,
CYP2C19 Inducers, clozapine,
abdominal pain,
azole antifungals, clopidogrel
nausea
Pantoprazole
(Protonix)
40 mg
daily
Amphetamines, Bisphosphonates, Headache, abdominal
CYP2C19 Inducers, azole
pain, diarrhea,
antifungals, clopidogrel
nausea, vomiting
Lansoprazole
(Prevacid)
15 mg
daily
Amphetamines, Bisphosphonates, Abdominal pain,
CYP2C19 Inducers, CYP 3A4
constipation,
inducers, azole antifungals,
diarrhea, headache
clopidogrel, aripiprazole
Esomeprazole
(Nexium)
20 mg
daily
Amphetamines, Bisphosphonates, Diarrhea, headache,
CYP2C19 Inducers, azole
abdominal pain
antifungals, clopidogrel
Drug Facts & Comparisons. St. Louis, MO. Facts & Comparisons.; January 7, 2015
Gastroesophageal Reflux
Disorder (GERD)
Acid reduction
Gastric reflux-experienced with most
bariatric procedures
If experience with Lap Band, suggest
loosening of band
• patients still experience weight loss
UCSF Medical Center Specialists. Life After Bariatric Surgery. (n.d.). (Retrieved September 8, 2014.)
Adverse Effects
(common >4%)
Pain management
Dosage forms
Tablet/capsule vs. liquid
Immediate release vs. extended release
Avoid
NSAIDS
• Increased risk of ulcer development
• Masked by gastric reflux or mechanical
restriction of procedure
UCSF Medical Center Specialists. Life After Bariatric Surgery. (n.d.). (Retrieved September 8, 2014.)
4
January 2015
Cholelithiasis
Increase risk of development of
gallstones
PMH: does patient have a gallbladder?
Ursodiol 300 mg PO BID
MOA: reduces secretion of cholesterol
from the liver and fractional
reabsorption of cholesterol by the
intestines
decreasing cholesterol
contents of bile & bile stones
Nephrolithiasis
Dietary restrictions (oxalate
containing foods)
Beets, spinach, nuts, wheat bran
All dry beans (fresh, canned or cooked)
• Excluding lima and green beans
Strawberries
Chocolate
Tea
Large doses of Vitamin C
Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; January 7, 2015.
Cholelithiasis
Ursodiol 300 mg PO BID
Adverse Reactions: Headache,
dizziness, back pain, hyperglycemia,
cholecystitis, increased serum creatinine
GI effects: diarrhea, constipation,
dyspepsia, nausea
Duration: 6 months post surgery
Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; January 7, 2015.
Nephrolithiasis
RYGB types of surgery may increase
risk of nephrolithiasis
Approximately 8% of RYGB patients
with reported nephrolithiasis
Increased production of oxaluria
Oxalate nephropathy and renal failure
Marion, DW. Bariatric Surgery: Postoperative and long-term management of the uncomplicated patient.
Management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Women: Pregnancy &
Fertility
Recommendation: contraception for
minimum of 1-2 years post surgery
Delay pregnancy
Nutritional deficiencies
Gestational weight gain
Miscarriage
Decreased fertility associated with
obesity
UCSF Medical Center Specialists. Life After Bariatric Surgery. (n.d.). (Retrieved September 8, 2014.)
Depression
History of mental illness
Exacerbation of disease
Dosage forms of medications
Decreased bioavailability
Post operative manifestation
Depressive symptoms
Treatment options
Marion, DW. Bariatric Surgery: Postoperative and long-term management of the uncomplicated patient.
Management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
5
January 2015
Diet (Long term)
Caloric intake & restrictions
Portion of meals
Avoid foods containing excessive:
Sugar
Spice or acid
Caffeinated beverages
Avoid chewing gum, raw vegetables,
meats that are not easily chewed
Marion, DW. Bariatric Surgery: Postoperative and long-term management of the uncomplicated patient.
Management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
Questions
All bariatric surgery patients should be treated
with Ursodiol to prevent cholelithiasis
True
False
A restrictive oxalate diet is recommended for
patients undergoing the sleeve gastrectomy
procedure
True
False
Women who have undergone bariatric surgeries
should delay pregnancy for 12 to 24 months
True
False
References
1.
2.
3.
4.
5.
6.
Marion, DW. Bariatric Surgery: Postoperative Nutritional Management. In:
UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on
September 8, 2014.)
Marion, DW. Bariatric Surgery: Postoperative and long-term management
of the uncomplicated patient. Management. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on September 8, 2014.)
UCSF medical center post op management
Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp,
Inc.; September 19, 2014.
Drug Facts & Comparisons. St. Louis, MO. Facts & Comparisons.; January
7, 2015
UCSF Medical Center Specialists. Life After Bariatric Surgery. (n.d.).
(Retrieved September 8, 2014.)
6