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Bioavailability of Orally Administered Drugs After Bariatric Surgery

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Abstract

Purpose of Review

Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery.

Recent Findings

The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred.

Summary

The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.

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Abbreviations

AUC:

Area under the curve

ASA:

Acetylsalicylic acid

BMI:

Body mass index

BAV:

Bioavailability

BCS:

Biopharmaceutical classification system

BS:

Bariatric surgery

CL :

Clearance

C max :

Peak concentration

DOAC:

Direct oral anticoagulant

GIP:

Gastric inhibitory polypeptide

GIT:

Gastrointestinal tract

INR:

International normalized ratio

IR:

Immediate release

IUDs:

Intrauterine devices

H2 :

Histamine H2 receptor

k a :

Absorption rate constant

NSAIDs:

Non-steroidal anti-inflammatory drugs

OAGB:

Mini-gastric bypass

PPI:

Proton pump inhibitor

RYGB:

Roux-en-Y gastric bypass

SG:

Sleeve gastrectomy

T 1/2 :

Biological half-life

TDM:

Therapeutic drug monitoring

T max :

Time to peak concentration

TSH:

Thyroid-stimulating hormone

Vd:

Volume of distribution

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Acknowledgements

The article was written in the framework of the Working Group on Pharmacotherapy in Obesity of the Czech Professional Society of Clinical Pharmacy (member of the Czech Medical Association of J.E. Purkyně, www.coskf.cz).

Funding

This study was supported by research initiatives of the Ministry of Health of Czech Republic RVO-VFN 64165 and Ministry of Education, Czech Republic grant COOPERATIO 207034 Internal Disciplines and Pharmaceutical sciences.

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Authors and Affiliations

  1. Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic

    Eliška Dvořáčková, Alena Pilková, Ondřej Slanař & Jan Miroslav Hartinger

  2. Department of Clinical Pharmacy, Hospital Na Františku, Prague, Czech Republic

    Eliška Dvořáčková

  3. Third Internal Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic

    Martin Matoulek

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Dvořáčková, E., Pilková, A., Matoulek, M. et al. Bioavailability of Orally Administered Drugs After Bariatric Surgery. Curr Obes Rep 13, 141–153 (2024). https://doi.org/10.1007/s13679-023-00548-7

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