Many patients will have bariatric surgery which will likely shorten the length of the GI tract.  It is important to remember what impact this will have on the use of medications and many clinicians will forget this critical fact.  Bariatric surgery can lead to long acting medications not being adequately absorbed.

Of highest importance is oral long acting medications.  Let’s say you have a patient who is having gastric bypass surgery and is on Toprol XL for hypertension.  Here’s the two standard options that I have seen used the most.

1. Leave it alone. I’ve seen this strategy used and sometimes the blood pressure has remained the same or very close.  It is always challenging to consult on a case later on after they have been on it for a long time and the blood pressure is well managed.  Is it being absorbed or not is the million $$$ question?  Depending upon the indication and vital signs, you could make the argument to try to reduce it as maybe a potential weight loss or healthier lifestyle since the surgery has helped bring down the blood pressure.  It may also be important to keep an eye on vital signs at different times of the day when the long acting medication may wear off as it goes through the gut too quickly to be slowly absorbed.
2. Change it to short acting. For metoprolol, this option isn’t too bad.  Going from a once a day drug (metoprolol succinate) to a twice a day (metoprolol tartrate) drug generally isn’t going to be a huge burden for patients.  However, this may get more burdensome for other medications.  Diltiazem (immediate release) is the classic example that is usually dosed up to four times per day.  This is obviously a pain in the butt for virtually all patients and may sabotage our adherence rates.

Have you seen any other options taken to address bariatric surgery and long acting medications?

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