Vitamin, mineral, and drug absorption following bariatric surgery

Ronald Andari Sawaya, Jane Jaffe, Lindsay Friedenberg, Frank K Friedenberg, Ronald Andari Sawaya, Jane Jaffe, Lindsay Friedenberg, Frank K Friedenberg

Abstract

The prevalence of obesity continues to rise throughout the world. Increasingly, bariatric surgery is used for those with morbid obesity as a pivotal approach to achieve weight loss. Along with substantial weight loss, malabsorption of essential vitamins, minerals, and drugs also occurs. Therefore, more than ever, a better understanding of the physiology and mechanisms by which these deficiencies occur is essential. We review the normal physiology of vitamin, mineral, and drug absorption. This is followed by a description of currently performed bariatric surgeries in the United States. A detailed review of specific nutrient and mineral deficiency states is presented, based on the most significant studies published in the last two decades. Of note, screening and supplementation recommendations have been included. Drug absorption data after these procedures is presented and discussed. Studies were identified by searching the Cochrane Registry and MEDLINE using relevant search terms, as well as through review of the reference section of included manuscripts.

Conclusions: Bariatric surgery can be effectively used to achieve sustainable weight-loss in morbidly obese patients. It simultaneously brings forth important functional consequences on nutrient deficiencies and drug absorption that clinician's must be aware of. Further prospective, randomized research on specific procedures and deficiencies is required.

Figures

Figure 1
Figure 1
Biopharmaceutical Drug Disposition Classification System (BDDCS),
Figure 2
Figure 2
Bariatric Surgery Procedures. With permission from DeMaria EJ.

References

    1. Ogden CL, Carroll MD, Flegal KM. Epidemiologic trends in overweight and obesity. Endocrinology & Metabolism Clinics of North America. 2003;32:741–760.
    1. Ogden CL, Carroll MD, Curtin LR, Lamb MM. Prevalence of High Body Mass Index in US Children and Adolescents, 2007–2008. JAMA. 2010;303:242–247.
    1. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861–7.
    1. National institutes of health. Clinical guidelines on the identification, evaluation, and treatment of over- weight and obesity in adults: the evidence report. Obes Res. 1998;6(suppl 2):51S–209S.
    1. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547–559.
    1. Mattar SS, Velcu LM, Rabinovitz M, Demetris AJ. Surgically-Induced Weight Loss Significantly Improves Nonalcoholic Fatty Liver Disease and the Metabolic Syndrome. Annals of surgery. 2005;242:610–620.
    1. North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Vol. 200. Bethesda, Md: National Institutes of Health; NIH publication 00–4084.
    1. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes. 2007;31:1248–61.
    1. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.
    1. Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950–2000. Obes Surg. 2002;12:705–717.
    1. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075–1079.
    1. Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002;6:855–60. discussion 861.
    1. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909–1917.
    1. Livingston EH. The incidence of bariatric surgery has plateaued in the U. S Am J Surg. 2010;200:378–385.
    1. Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am. 2009;56:1105–1121.
    1. Seaman JS, Bowers SP, Dixon P, Schindler L. Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model. Psychosomatics. 2005;46:250–253.
    1. Mirmiran P, Hosseini-Esfahanil F, Jessri M, Mahan LK, Shiva N, Azizis F. Does dietary intake by Tehranian adults align with the 2005 dietary guidelines for Americans? Observations from the Tehran lipid and glucose study. J Health Popul Nutr. 2011;29:39–52.
    1. Caspary WF. Physiology and pathophysiology of intestinal absorption. Am J Clin Nutr. 1992;55:299S–308S.
    1. Levin RJ. Digestion and absorption of carbohydrates--from molecules and membranes to humans. Am J Clin Nutr. 1994;59:690S–698S.
    1. Murray RK, Kotlikoff MI. Receptor-activated calcium influx in human airway smooth muscle cells. J Physiol. 1991;435:123–144.
    1. Schanker LS. On the mechanism of absorption of drugs from the gastrointestinal tract. J Med Pharm Chem. 1960;2:343–359.
    1. Custodio JM, Wu CY, Benet LZ. Predicting drug disposition, absorption/elimination/transporter interplay and the role of food on drug absorption. Adv Drug Deliv Rev. 2008;60:717–733.
    1. Smith A, Henriksen B, Cohen A. Pharmacokinetic considerations in Roux-en-Y gastric bypass patients. Am J Health Syst Pharm. 2011 Dec 1;68(23):2241–7.
    1. Stenberg P, Luthman K, Artursson P. Virtual screening of intestinal drug permeability. J Control Release. 2000;65:231–243.
    1. Amidon GL, Lennernas H, Shah VP, Crison JR. A theoretical basis for a biopharmaceutic drug classification: the correlation of in vitro drug product dissolution and in vivo bioavailability. Pharm Res. 1995;12:413–420.
    1. Dearden JC. Partitioning and lipophilicity in quantitative structure-activity relationships. Environ Health Perspect. 1985;61:203–228.
    1. Martinez MN, Amidon GL. A mechanistic approach to understanding the factors affecting drug absorption: a review of fundamentals. J Clin Pharmacol. 2002;42:620–643.
    1. Ciarimboli G. Organic cation transporters. Xenobiotica. 2008;38:936–971.
    1. Hagenbuch B, Meier PJ. Organic anion transporting polypeptides of the OATP/ SLC21 family: phylogenetic classification as OATP/ SLCO superfamily, new nomenclature and molecular/functional properties. Pflugers Arch. 2004;447:653–665.
    1. Zimmerman J. Methotrexate transport in the human intestine. Evidence for heterogeneity. Biochem Pharmacol. 1992;43:2377–2383.
    1. Duverne C, Bouten A, Deslandes A, et al. Modification of cefixime bioavailability by nifedipine in humans: involvement of the dipeptide carrier system. Antimicrob Agents Chemother. 1992;36:2462–2467.
    1. Westphal JF, Trouvin JH, Deslandes A, Carbon C. Nifedipine enhances amoxicillin absorption kinetics and bioavailability in humans. J Pharmacol Exp Ther. 1990;255:312–317.
    1. Wang DS, Kusuhara H, Kato Y, Jonker JW, Schinkel AH, Sugiyama Y. Involvement of organic cationtransporter 1 in the lactic acidosis caused by metformin. Mol Pharmacol. 2003;63:844–848.
    1. Bourdet DL, Pritchard JB, Thakker DR. Differential substrate and inhibitory activities of ranitidine and famotidine toward human organic cation transporter 1 (hOCT1; SLC22A1), hOCT2 (SLC22A2), and hOCT3 (SLC22A3) J Pharmacol Exp Ther. 2005;315:1288–1297.
    1. Mouly S, Paine MF. P-glycoprotein increases from proximal to distal regions of human small intestine. Pharm Res. 2003;20:1595–1599.
    1. Saitoh H, Aungst BJ. Possible involvement of multiple P-glycoprotein-mediated efflux systems in the transport of verapamil and other organic cations across rat intestine. Pharm Res. 1995;12:1304–1310.
    1. Benet LZ, Zia-Amirhosseini P. Basic principles of pharmacokinetics. Toxicol Pathol. 1995;23:115–123.
    1. Wu CY, Benet LZ. Predicting drug disposition via application of BCS: transport/absorption/ elimination interplay and development of a biopharmaceutics drug disposition classification system. Pharm Res. 2005;22:11–23.
    1. Requarth JA, Burchard KW, Colacchio TA, Stukel TA. Long-term morbidity following jejunoileal bypass. The continuing potential need for surgical reversal. Arch Surg. 1995 Mar;130:318–25.
    1. Mole DR, Tomson CR, Mortensen N, Winearls CG. Renal complications of jejuno-ileal bypass for obesity. QJM. 200;94:69–77.
    1. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11:41–50.
    1. Fontana MA, Wohlgemuth SD. The surgical treatment of metabolic disease and morbid obesity. Gastroenterol Clin North Am. 2010;39:125–133.
    1. Nocca D, Krawczykowsky D, Bomans B, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg. 2008;18:560–565.
    1. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007;356:2176–2183.
    1. Franco JVA, Ruiz PA, Palermo M, et al. A Review of Studies Comparing Three Laparoscopic Procedures in Bariatric Surgery: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and Adjustable Gastric Banding. Obesity Surgery. 2011;21:1458–1468.
    1. Gumbs AA, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obes Surg. 2007;17:962–969.
    1. Ward M, Prachand V. Surgical treatment of obesity. Gastrointest Endosc. 2009;70:985–990.
    1. Smith BR, Schauer P, Nguyen NT. Surgical approaches to the treatment of obesity: bariatric surgery. Endocrinol Metab Clin North Am. 2008;37:943–964.
    1. Truesdell DD, Whitney EN, Acosta PB. Nutrients in vegetarian foods. J Am Diet Assoc. 1984;84:28–35.
    1. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267–282.
    1. Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947–954.
    1. DeMeester TR, Fuchs KH, Ball CS, Albertucci M, Smyrk TC, Marcus JN. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg. 1987;206:414–426.
    1. Kant AK. Consumption of energy-dense, nutrient-poor foods by adult Americans: nutritional and health implications. The third National Health and Nutrition Examination Survey, 1988–1994. Am J Clin Nutr. 2000;72:929–936.
    1. Puglisi MJ, Fernandez ML. Modulation of C-reactive protein, tumor necrosis factor-alpha, and adiponectin by diet, exercise, and weight loss. J Nutr. 2008;138:2293–2296.
    1. O’Rourke RW. Inflammation in obesity-related diseases. Surgery. 2009;145:255–259.
    1. Morinigo R, Casamitjana R, Delgado S, et al. Insulin resistance, inflammation, and the metabolic syndrome following Roux-en-Y gastric bypass surgery in severely obese subjects. Diabetes Care. 2007;30:1906–1908.
    1. Munoz M, Mazure RA, Culebras JM. Obesity and the immune system. Nutr Hosp. 2004;19:319–324.
    1. Schweiger C, Keidar A. Nutritional deficiencies in bariatric surgery patients: prevention, diagnosis and treatment. Harefuah. 2010;149:715–20. 748.
    1. Gracia JA, Martinez M, Aguilella V. Postoperative morbidity of biliopancreatic diversion depending on common limb length. Obes Syrg. 2007;17:1306–1311.
    1. Xanthakosa SA, Thomas IH. Nutritional consequences of bariatric surgery. Curr Opin Clin Nutr Metab Care. 2006;9:489–96.
    1. Rudnicki SA. Prevention and treatment of peripheral neuropathy after bariatric surgery. Curr Treat Options Neurol. 2010;12:29–36.
    1. Chaston TB, Dixon JB, O’Brien PE. Changes in fat-free mass during significant weight loss: a systematic review. Int J Obes (Lond) 2007;31:743–750.
    1. Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10:1033–1037.
    1. Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone. 2002;30:771–777.
    1. Seres DS. Surrogate nutrition markers, malnutrition, and adequacy of nutrition support. Nutr Clin Pract. 2005;20:308–313.
    1. Fuhrman MP. The albumin-nutrition connection: separating myth from fact. Nutrition. 2002;18:199–200.
    1. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009 Apr;17(Suppl 1):S1–70.
    1. Aills L, Blankenship J, Buffington C. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4:S73–108.
    1. Amaral JF, Thompson WR, Caldwell MD, Martin HF, Randall HT. Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity. Ann Surg. 1985;201:186–93.
    1. Halverson JD, Zuckerman GR, Koehler RE, et al. Gastric bypass for morbid obesity: a medical-surgical assessment. Ann Surg. 1981;194:152–60.
    1. Ruz M, Carrasco F, Rojas P, Codoceo J. Iron absorption and iron status are reduced after Roux-en-Y gastric bypass. Am J Clin Nutr. 2009;90:527–532.
    1. Kushner RF. Micronutrient deficiencies and bariatric surgery. Curr Opin Endocrinol Diabetes Obes. 2006;13:405–411.
    1. Davies DJ, Baxter JM, Baxter JN. Nutritional deficiencies after bariatric surgery. Obes Surg. 2007;17:1150–1158.
    1. Avgerinos DV, Llaguna OH, Seigerman M, Lefkowitz AJ, Leitman IM. Incidence and risk factors for the development of anemia following gastric bypass surgery. World J Gastroenterol. 2010;16:1867–1870.
    1. Rhode BM, Shustik C, Christou NV, et al. Iron absorption and therapy after gastric bypass. Obes Surg. 1999;9:17–21.
    1. Bal B, Koch TR, Finelli FC, Sarr MG. Managing medical and surgical disorders after divided Roux-en-Y gastric bypass surgery. Nat Rev Gastroenterol Hepatol. 2010;7:320–334.
    1. Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care. 2004 Sep;7(5):569–75.
    1. Avgerinos DV, Llaguna OH, Seigerman M, Lefkowitz AJ. Incidence and risk factors for the development of anemia following gastric bypass surgery. World J Gastroenterol. 2010;16(15):1867–1870.
    1. Goldner WS, Stoner JA, Thompson J, et al. Prevalence of vitamin D insufficiency and deficiency in morbidly obese patients: a comparison with non-obese controls. Obes Surg. 2008;18:145–150.
    1. Gemmel K, Santry HP, Prachand VN, Alverdy JC. Vitamin D deficiency in preoperative bariatric surgery patients. Surg Obes Relat Dis. 2009;5:54–59.
    1. Brouwer DA, van Beek J, Ferwerda H, et al. Rat adipose tissue rapidly accumulates and slowly releases an orally-administered high vitamin D dose. Br J Nutr. 1998;79:527–532.
    1. Bell NH, Epstein S, Shary J, Greene V, Oexmann MJ, Shaw S. Evidence for alteration of the vitamin D–endocrine system in obese subjects. J Clin Invest. 1985;76:370–3.
    1. Lin E, Armstrong-Moore D, Liang Z, Sweeney JF, Torres WE, Ziegler TR. Contribution of adipose tissue to plasma 25-hydroxyvitamin D concentrations during weight loss following gastric bypass surgery. Obesity (Silver Spring) 2011 Mar;19(3):588–94. Epub 2010 Oct 14.
    1. Slater GH, Ren CJ, Seigel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48–55.
    1. Newbury L, Dolan K, Hatzifotis M, Fielding G. Calcium and vitamin D depletion and elevated parathyroid hormone following bilio- pancreatic diversion. Obes Surg. 2003;13:893–5.
    1. Ducloux R, Nobecourt E, Chevallier JM, Ducloux H, Elian N, Altman JJ. Vitamin D deficiency before bariatric surgery: should supplement intake be routinely prescribed? Obes Surg. 2011;21:556–560.
    1. Sakhaee K, Bhuket T, Adams-Huet B, Rao DS. Meta-analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate. Am J Ther. 1999;6:313–21.
    1. Marcuard SP, Sinar DR, Swanson MS, Silverman JF, Levine JS. Absence of luminal intrinsic factor after gastric bypass surgery for morbid obesity. Dig Dis Sci. 1989;34:1238–1242.
    1. Behrns KE, Smith CD, Sarr MG. Prospective evaluation of gastric acid secretion and cobalamin absorption following gastric bypass for clinically severe obesity. Dig Dis Sci. 1994;39(2):315–20.
    1. Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg. 2002;6:195–203. discussion 204–5.
    1. Ledoux S, Msika S, Moussa F, Larger E. Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass. Obes Surg. 2006 Aug;16(8):1041–9.
    1. Rhode BM, Arseneau P, Cooper BA, Katz M. Vitamin B-12 deficiency after gastric surgery for obesity. Am J Clin Nutr. 1996;63(1):103–9.
    1. Provenzale D, Reinhold RB, Golner B, Irwin V. Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients. J Am Coll Nutr. 1992;11(1):29–35.
    1. Skroubis G, Sakellaropoulos G, Pouggouras K, Mead N, Nikiforidis G. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg. 2002;12(4):551–8.
    1. Gasteyger C, Suter M, Calmes JM, Gaillard RC, Giusti V. Changes in body composition, metabolic profile, and nutritional status 24 months after gastric banding. Obes Surg. 2006;16:243–50.
    1. Sobieraj DM, Wang F, Kirton OC. Warfarin resistance after total gastrectomy and Roux-en-Y esophagojejunostomy. Pharmacotherapy. 2008;28:1537–1541.
    1. Griffiths TM, Thomas P, Campbell IA. Antituberculosis drug levels after jejunoileal bypass. Br J Dis Chest. 1982;76:286–289.
    1. Mallory GN, Macgregor AM. Folate status following gastric bypass surgery (the Great Folate Mystery) Obes Surg. 1991;1:69–72.
    1. Boylan LM, Sugerman HJ, Driskell JA. Vitamin E, vitamin B-6, vitamin B-12, and folate status of gastric bypass surgery patients. J Am Diet Assoc. 1988;88:579–85.
    1. Hatizifotis M, Dolan K, Newbury L, Fielding G. Symptomatic vitamin A deficiency following biliopancreatic diversion. Obes Surg. 2003;13:655–657.
    1. Quaranta L, Nascimbeni G, Semeraro F, Quaranta CA. Severe corneoconjunctival xerosis after biliopancreatic bypass for obesity (Scopinaro’s operation) Am J Ophthalmol. 1994;118:817–818.
    1. Van Mieghem T, Van Schoubroeck D, Depiere M, Debeer A. Fetal cerebral hemorrhage caused by vitamin K deficiency after complicated bariatric surgery. Obstet Gynecol. 2008;112(2 Pt 2):434–6.
    1. Kang L, Marty D, Pauli RM, Mendelsohn NJ, Prachand V. Chondrodysplasia punctata associated with malabsorption from bariatric procedures. Surg Obes Relat Dis. 2010;6(1):99–101.
    1. Moize V, Geliebter A, Gluck ME, Yahav E, Lorence M, Colarusso T, et al. Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass. Obes Surg. 2003 Feb;13(1):23–8.
    1. Scopinaro N, Marinari GM, Pretolesi F, Papadia F, Murelli F, Marini P, et al. Energy and nitrogen absorption after biliopancreatic diversion. Obes Surg. 2000 Oct;10(5):436–41.
    1. Skroubis G, Anesidis S, Kehagias I, Mead N, Vagenas K, Kalfarentzos F. Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population: prospective comparison of the efficacy and the incidence of metabolic deficiencies. Obes Surg. 2006 Apr;16(4):488–95.
    1. Nanni G, Balduzzi GF, Capoluongo R, et al. Biliopancreatic diversion: clinical experience. Obes Surg. 1997;7:26–29.
    1. Malone M. Altered drug disposition in obesity and after bariatric surgery. Nutr Clin Pract. 2003;18:131–135.
    1. Kennedy MC, Wade DN. Phenytoin absorption in patients with ileojejunal bypass. Br J Clin Pharmacol. 1979;7:515–518.108.
    1. Peterson DI. Phenytoin absorption following jejunoileal bypass. Bull Clin Neurosci. 1983;48:148–149.
    1. Prince RA, Pincheira JC, Mason EE, Printen KJ. J Clin Pharmacol. 1984;24:523–527.
    1. Kampmann JP, Klein H, Lumholtz B, Molholm Hansen JE. Ampicillin and propylthiouracil pharmacokinetics in intestinal bypass patients followed up to a year after operation. Clin Pharmacokinet. 1984;9:168–176.
    1. Magee SR, Shih G, Hume A. Malabsorption of oral antibiotics in pregnancy after gastric bypass surgery. J Am Board Fam Med. 2007;20:310–313.
    1. Chenhsu RY, Wu Y, Katz D, Rayhill S. Dose-adjusted cyclosporine c2 in a patient with jejunoileal bypass as compared to seven other liver transplant recipients. Ther Drug Monit. 2003;25:665–670.
    1. Kelley M, Jain A, Kashyap R, et al. Change in oral absorption of tacrolimus in a liver transplant recipient after reversal of jejunoileal bypass: case report. Transplant Proc. 2005;37:3165–3167.
    1. Andersen AN, Lebech PE, Sorensen TI, Borggaard B. Sex hormone levels and intestinal absorption of estradiol and D-norgestrel in women following bypass surgery for morbid obesity. Int J Obes. 1982;6:91–96.
    1. Victor A, Odlind V, Kral JG. Oral contraceptive absorption and sex hormone binding globulins in obese women: effects of jejunoileal bypass. Gastroenterol Clin North Am. 1987;16:483–491.
    1. Wills SM, Zekman R, Bestul D, Kuwajerwala N, Decker D. Tamoxifen malabsorption after Roux-en-Y gastric bypass surgery: case series and review of the literature. Pharmacotherapy. 2010;30:217.
    1. Werbin N. Tuberculosis after jejuno-ileal bypass for morbid obesity. Postgrad Med J. 1981;57:252–253.
    1. Marcus FI, Quinn EJ, Horton H, et al. The effect of jejunoileal bypass on the pharmacokinetics of digoxin in man. Circulation. 1977;55:537–541.
    1. Terry SI, Gould JC, McManus JP, Prescott LF. Absorption of penicillin and paracetamol after small intestinal bypass surgery. Eur J Clin Pharmacol. 1982;23:245–248.
    1. Food and Drug Administration. Guidance for Industry: Waiver of In Vivo Bioavailability and Bioequivalence Studies for Immediate Release Solid Oral Dosage Forms Based on a Biopharmaceutics Classification System. Food and Drug Administration; Rockville, MD: 2000.
    1. Skottheim IB, Stormark K, Christensen H, Jakobsen GS. Significantly altered systemic exposure to atorvastatinacid following gastric bypass surgery in morbidly obese patients. Clin Pharmacol Ther. 2009;86(3):311–8.
    1. Skottheim IB, Stormark K, Christensen H, Jakobsen GS. Significant increase in systemic exposure of atorvastatin after biliopancreatic diversion with duodenal switch. Clin Pharmacol Ther. 2010 Jun;87(6):699–705.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe