Margaret Malone

Gastric Bypass and Vertical Banded Gastroplasty- a Prospective Randomized Comparison and 5-Year Follow-up

Background: a prospective randomized study was undertaken to compare the outcome of vertical banded gastroplasty (VBG) and gastric bypass (GBP) in patients with clinically severe obesity. Methods: eligibility criteria included Class IV obesity, <50 years old and a history of at least one attempt of non-operative weight loss. Patients were managed conservatively for 3 months prior to surgery. Patients were followed post-operatively and monitored for early and late complications and their weight loss outcome for up to 5 years. Results: 44 patients were recruited. Two patients withdrew within 4 weeks and were excluded. Twenty subjects had a GBP and 22 a VBG. There were no significant differences with respect to age, gender, maximum or pre-operative weight between the groups (p > 0.05). Patients who underwent GBP demonstrated significantly greater post-operative weight loss (p < 0.05) which was apparent from 6 months onwards. There were no deaths, pulmonary emboli, post-operative leaks or wound dehiscence. There were no instances of staple-line disruption. Symptomatic ulcer disease, confirmed endoscopically, developed in 25% of GBP patients. Nine patients developed gallstones post-operatively of whom five were in the VBG and four in the GBP group. Conclusions: weight loss following GBP was maintained, while VBG patients slowly regained.

Glutathione in Health and Disease: Pharmacotherapeutic Issues

Objective: To review the current research and importance of glutathione (GSH) therapy in health and disease and to provide a basic overview of the widespread use and interest in this compound. Data Identification: Articles were obtained via a MEDLINE search of the term glutathione in conjunction with specific disease states mentioned, and via extensive review of references found in articles identified by computer search. Study Selection: Emphasis was placed on the most recent research, human research, and in discussing multiple disease states. Data Extraction: The literature was reviewed for methodology, quality, and practical aspects of interest to clinical pharmacists. Data Synthesis: GSH is a tripeptide of extreme importance as a catalyst, reductant, and reactant. It continues to be investigated in diverse areas such as acute respiratory distress syndrome, toxicology, AIDS, aging, oncology, and liver disease. Despite the widespread clinical interest in GSH, we were not able to identify an in-depth review of this compound in the pharmacy literature. Conclusions: The list of potential indications for modulation of GSH is extensive and broad. This review introduces clinicians to what GSH is, its basic chemistry, and some areas of active research.

Recommended Nutritional Supplements for Bariatric Surgery Patients

Objective: To review nutritional supplements commonly required after bariatric surgery to provide a practical guide and reference source for generalist healthcare providers. Data Sources: A PubMed literature search (1968–July 2008) was conducted, using the search term nutritional deficiency after bariatric surgery, and was limited to English-language literature on adult (aged >19 y) human subjects. Additional references from the selected literature were also included. Study Selection and Data Extraction: Data were extracted from large clinical series and practice guidelines whenever possible. Case reports were used only when they were the sole information source. Data Synthesis: Nutritional deficiencies that occur after bariatric surgery depend significantly on the type of surgery performed. Restrictive procedures such as gastric banding are the least likely to cause nutritional deficits, since none of the Intestine is bypassed. Malabsorptive procedures such as biliopancreatic diversion or mixed restrictive/malabsorpive procedures (eg, Roux-en-Y gastric bypass) can result in serious nutritional problems when patients do not take required supplements after surgery. Vitamins and minerals that are commonly deficient in this circumstance include vitamin B12, calcium, vitamin D, thiamine, folic acid, iron, zinc, and magnesium. Rare ocular complications have been reported with hypovitaminosis A. Conclusions: Healthcare professionals, especially those who practice outside large bariatric centers, must be aware of the supplements required by patients who have had bariatric surgery. Many patients fail to follow up with the surgery centers and are managed by their primary care teams and community pharmacists, especially in the selection of multivitamin and nutritional supplements.

Medications Associated with Weight Gain

OBJECTIVE To review available literature regarding weight gain associated with commonly prescribed drugs and adjunctive therapy used to limit weight gain. DATA SOURCES Information was retrieved from a MEDLINE English-literature search between 1995 and July 2005, with a major subject heading of weight gain/drug effects excluding complementary alternative medicines. Other limits applied included human subjects and individuals >19 years of age. Additionally, references from retrieved articles were reviewed to identify other literature sources. STUDY SELECTION AND DATA EXTRACTION Changes in weight are generally reported as a primary or secondary outcome of many studies. Where possible, prospective, randomized, controlled trials were preferred; however, many studies were retrospective or open label. Meta-analyses and recent reviews, especially those providing a detailed description of the proposed mechanism involved in weight gain beyond the scope of this article, were included. Limited information was available from case reports. Studies were categorized by therapeutic area including psychiatry, neurology, diabetes, and other miscellaneous drug therapy. Medications used to intentionally stimulate appetite for weight gain, such as megesterol acetate, were not included. DATA SYNTHESIS Weight gain with medication is usually associated with individual agents within a class. The tendency to cause weight gain is often related to differential specificity and sensitivity of binding to receptors involved with appetite regulation. CONCLUSIONS Clinically significant weight gain is associated with some commonly prescribed medicines. There is wide interindividual variation in response and variation of the degree of weight gain within drug classes. Where possible, alternative therapy should be selected, especially for individuals predisposed to overweight and obesity.

Longitudinal assessment of outcome, health status, and changes in lifestyle associated with long-term home parenteral and enteral nutrition

BACKGROUND The purpose of this study was to assess the health status, frequency of therapy-related symptoms, and impact of home parenteral and enteral nutrition (HPEN) on lifestyle in patients who were stable and had nonmalignant diagnoses. Assessments were made at 2 time points, 3 years apart. METHODS Institutional review board approval was obtained. Adult HPEN patients self-completed a general health status questionnaire (SF-36) and a lifestyle-symptom questionnaire in 1993 and 1996. Demographic data relating to underlying disease state and infusion regimen were also collected. RESULTS Seventeen patients (7 men, 10 women; 13 receiving home parenteral nutrition [HPN] and 4 receiving home enteral nutrition [HEN]) participated in the study. The mean (SEM) duration of HPEN therapy at the start of the study was 7.1 (1.6) years. Although health status as assessed by SF-36 scores was lower in all categories when compared with age- and gender-matched control data from the general US population (p < .05), there was no significant difference in SF-36 scores between the 2 time periods (p > .05). Sleep, travel, and social activities were the most affected aspects of the patients lifestyle. CONCLUSIONS These data suggest that patients with nonmalignant underlying disease receiving HPEN maintain a stable health status over a prolonged period.

Altered Drug Disposition in Obesity and After Bariatric Surgery

The purpose of this review is to evaluate the effect of obesity and gastric bypass on drug disposition. A Medline search was conducted of literature from 1980 onward. All types of literature were included because of the limited data published on this subject. Very few prospective randomized controlled studies are available that have evaluated changes in drug pharmacokinetics and pharmacodynamics in patients who have a body mass index (BMI) >40 kg/m(2) or who have undergone gastric restrictive surgery. Dosing recommendations have been based on general pharmacokinetic principles where specific drug data have not been assessed. Given the increasing prevalence of overweight and obesity in the population, studies that evaluate the impact of obesity on drug disposition, especially related to drugs released in the past 10 years, should be conducted.

Serotonin Syndrome Induced by Fluvoxamine and Mirtazapine

OBJECTIVE: To document a case of serotonin syndrome associated with the combined use of fluvoxamine and mirtazapine, and to discuss the pharmacodynamic and pharmacokinetic interactions that were the likely causes of this potentially serious adverse drug reaction (ADR). CASE SUMMARY: A 26-year-old white woman with a 12-year history of anorexia nervosa was being treated with fluvoxamine. After mirtazapine was added to her therapy, she developed tremors, restlessness, twitching, flushing, diaphoresis, and nausea, symptoms that are consistent with serotonin syndrome. DISCUSSION: The possible causes of this ADR are discussed, including the effects of fluvoxamine and mirtazapine alone, the possible pharmacodynamic and pharmacokinetic interactions of these two drugs, and the patients underlying anorexia nervosa. CONCLUSIONS: An increasing number of drugs that affect serotonin are available and are indicated for various disorders. Since there is a significant likelihood of these agents being prescribed concomitantly, clinicians must be aware of possible interactions that could lead to serotonin syndrome.

The Lifestyle Challenge Program: A Multidisciplinary Approach to Weight Management

BACKGROUND The increasing prevalence of overweight and obesity in the US has received widespread attention and is highlighted in recent government-issued health priorities. While there are many weight loss programs in different settings, few include pharmacist involvement in spite of pharmacists’ recognized easy accessibility to the public. OBJECTIVE To provide insight into a successful, collaborative, multidisciplinary approach to weight management and to encourage pharmacists and other healthcare professionals to adopt a similar approach to patient management. METHODS Adult patients >18 years of age were recruited from an outpatient university-based setting to participate in a weight management program. The principles of the program included diet, exercise, and behavior modification. The program was conducted through weekly one-hour group sessions held over a 20-week period. Faculty involved in the program included an attending physician specializing in nutrition, a pharmacist, and a behavioral psychologist. All data are expressed as mean ± SD unless otherwise specified. RESULTS Ninety participants (74 female, mean age 48 ± 10 y) entered the program between April 2001 and April 2004. Participants had multiple obesity-related comorbid diseases. The weight of completers (n = 59) decreased from 100.9 ± 20 kg at baseline to 97.3 ± 19.5 kg at 10 weeks and 95.9 ± 20 kg at 20 weeks. Thirty-nine patients completed both baseline and final assessments, which showed improvement in health-related quality of life, binge-eating behavior, and depressive symptoms (p < 0.05). CONCLUSIONS This program is a successful multidisciplinary model for the management of overweight and obese patients in an outpatient-based hospital setting.

Assessment of Drug-Related Problems in Clinical Nutrition Patients

BACKGROUND Medication use in clinical nutrition patients is affected by concomitant disease states and alterations in medication administration and delivery. The purpose of this evaluation was to document the number and type of drug-related problems that occurred and to evaluate the effect pharmacists had on the care of nutrition patients. METHODS Patients were evaluated by a pharmacist who was part of the clinical nutrition team. Drug-related problems were identified and recommendations were made to resolve them. Acceptance of the recommendations and patient outcomes were documented. RESULTS After the evaluation of 440 patients, 220 pharmacist interventions were made. Interventions included 35 drug information requests and 185 recommendations made to solve identified drug-related problems in 126 patients. The most frequent drug-related problems were drug interactions (33/185) and untreated indications (24/185). Of 185 recommendations, 166 were accepted, and 19 were accepted with a modification. A total of 132 of 155 recommendations that were accepted or accepted with modification had a positive outcome: 45 patients responded, and 87 patients developed no complications. Six patients did not respond to the recommendation, and in 17 patients the outcome was unknown. Fifty-eight recommendations avoided potential adverse drug events. CONCLUSIONS Pharmacist intervention identified drug-related problems in almost 30% of clinical nutrition patients. The identification and resolution of the problems had a positive effect on patient care, as indicated by patient outcome and the avoidance of adverse drug events. The drug-related problem approach identified areas in which pharmacists can educate the health care team and ensure proper medication use in this patient population.

Drug-food interactions in hospitalised patients. Methods of prevention.

SummaryDrug-food interactions in hospitalised patients may result in decreased drug efficacy or increased drug toxicity. The increasing complexity of drug therapy regimens has increased the potential for drug-food interactions to occur, reinforcing the need to develop methods to prevent clinically significant drug-food interactions.Before selecting the optimal method, in terms of feasibility of implementation and successful outcome, drugs with the potential for clinically significant interactions with food must be identified. From an analysis of the literature, 6 methods to prevent drug-food interactions have been suggested as useful tools. Each method has its own advantages and disadvantages. Most have been developed in response to guidelines from the most well recognised agency for quality review in the US, the Joint Commission on Accreditation of Healthcare Organisations (JCAHO). Based on those recommendations, an ideal programme to prevent drug-food interactions would be a combined patient counselling and label system to select the most appropriate drug administration times and increase nurse and patient awareness of the potential for drug-food interactions. However, because of time constraints and limited resources, a label system or the provision of a drug-food interaction pamphlet to the patient before discharge would be a more practical method. Newsletters and educational inservices combined with patient counselling or a label system would be a valuable method to prevent drug-food interactions in hospitalised patients.