About 280,000 patients in the US have bariatric surgery each year.
Be prepared to manage key post-op issues for these patients.
Pain management. Use multimodal pain regimens to reduce opioid needs. For example, schedule oral acetaminophen...or consider rectal administration in patients unable to take po.
But avoid NSAIDs. These increase the risk of GI ulceration or perforation...a common complication in bariatric surgery patients.
If an opioid is needed, avoid extended-release forms. Gastric transit is faster in these patients, leading to poor absorption.
Venous thromboembolism (VTE). Start prophylaxis within 24 hours post-op...generally with a low-molecular-weight heparin (LMWH) or fondaparinux.
If using a LMWH, consider higher doses...such as enoxaparin 40 mg every 12 hours if BMI is 40 or higher, or 60 mg every 12 hours if BMI is above 50.
Think about continuing prophylaxis for up to 4 weeks in high-risk post-op patients...such as those with a previous VTE or limited mobility.
If patients develop a DVT or PE, use warfarin. Don’t generally start a direct oral anticoagulant (rivaroxaban, etc) due to limited data...and absorption concerns with some options.
Med adjustments. Switch home meds to immediate-release crushable tabs...caps that can be opened...or liquids. Patients will need this for about 8 weeks post-op.
Limit sugar-containing liquids or giving crushed meds in high-sugar foods, such as applesauce...to minimize dumping syndrome.
Try to space out med administration instead of giving them all at once...to help improve tolerability.
Evaluate if any chronic meds should be modified post-op to limit adverse effects. For example, stop sulfonylureas...stop or reduce mealtime insulin by at least 50%...and consider reducing basal insulin by 50% to 75%. Patients’ lower caloric intake can raise hypoglycemia risk.
Also consider stopping 1 or more antihypertensives to limit possible hypotension...since BP reductions may be seen immediately post-op.
At discharge, reinforce home blood sugar and BP monitoring.
And educate about new meds patients may be discharged on. For instance, patients with a gallbladder may get ursodiol for 6 months post-op to prevent gallstones due to rapid weight loss.
Emphasize lifelong adherence to vitamin and mineral supplements.
Go to our Bariatric Surgery and Medication Use resource for more post-op considerations and guidance on vitamin and mineral supplementation.
- Ebbitt LM, Kassel LE, McKenzie JJ, et al. The pharmacist's role in optimizing medication management before, during, and after minimally invasive and bariatric surgery. Am J Health Syst Pharm. 2024 Apr 25:zxae111. doi: 10.1093/ajhp/zxae111.
- Aminian A, Vosburg RW, Altieri MS, et al. The American Society for Metabolic and Bariatric Surgery (ASMBS) updated position statement on perioperative venous thromboembolism prophylaxis in bariatric surgery. Surg Obes Relat Dis. 2022 Feb;18(2):165-174.