Gastrointestinal (GI) surgery associated with resection or bypass can affect the absorption and kinetics of certain drugs. The goal of this article is 3-fold: (1) highlight the physiologic changes associated with selected GI surgeries (specifically gastric, small intestine, and colon), (2) review the implications for drug and nutrient absorption, and (3) suggest modifications of the pharmacologic agents, dosing regimens, and routes of delivery. Few large trials are available to use as references, but there is a wealth of individual reports and small series. Understanding the predictable challenges of drug administration in these patients will improve care.
American Gastroenterological Association. Medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003;124:1105-1110.
2.
BakerMT. The history and evolution of bariatric surgical procedures. Surg Clin North Am. 2011;91(6):1181-1201, viii.
3.
MillerADSmithKM. Medication and nutrient administration considerations after bariatric surgery. Am J Health Syst Pharm. 2006;63(19):1852-1857.
4.
EdwardsAEnsomMH. Pharmacokinetic effects of bariatric surgery. Ann Pharmacother. 2012;46(1):130-136.
5.
PadwalRBrocksDSharmaAM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41-50.
6.
The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1997;157(21):2413-2446.
7.
WachterRM. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med. 1987;147(3):556-558.
8.
O’MailiaJJSanderGEGilesTD. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med. 1987;107(2):185-186.
9.
PetersFPde ZwaanCKhoL. Prolonged QT interval and ventricular fibrillation after treatment with sublingual nifedipine for malignant hypertension. Arch Intern Med. 1997;157(22):2665-2666.
10.
MaloneM. Altered drug disposition in obesity and after bariatric surgery. Nutr Clin Pract. 2003;18(2):131-135.
JeejeebhoyK. Nutritional aspects of inflammatory bowel disease. In: JB KirsnerRS, ed. Inflammatory Bowel Disease. Baltimore, MD: Williams & Wilkins; 1995:734-749.
13.
JahnchenEMeinertzTGilfrichHJKerstingFGrothU. Enhanced elimination of warfarin during treatment with cholestyramine. Br J Clin Pharmacol. 1978;5(5):437-440.
14.
BullinghamRENichollsAJKammBR. Clinical pharmacokinetics of mycophenolate mofetil. Clin Pharmacokinet. 1998;34(6):429-455.
KinoKJWittkowskyAK. Influence of bile acid replacement on cyclosporine absorption in a patient with jejunoileal bypass. Pharmacotherapy. 1995;15(3):350-352.
17.
GutzlerFZimmermannRRingGHSauerPStiehlA. Ursodeoxycholic acid enhances the absorption of cyclosporine in a heart transplant patient with short bowel syndrome. Transplant Proc. 1992;24(6):2620-2621.
18.
MizutaKKobayashiEUchidaHFujimuraAKawarasakiHHashizumeK. Influence of tacrolimus on bile acid and lipid composition in continuously drained bile using a rat model: comparative study with cyclosporine. Transpl Int. 1999;12(5):316-322.
19.
KimKYoonIChunILeeNKimTGwakHS. Effects of bile salts on the lovastatin pharmacokinetics following oral administration to rats. Drug Deliv. 2011;18(1):79-83.
20.
MitchellJFMaasLCBargerRCGeizaydEA. Successful oral anticoagulant therapy in a patient with short bowel syndrome. Am J Hosp Pharm. 1977;34(2):171-172.
21.
KearnsPJJrO’ReillyRA. Bioavailability of warfarin in a patient with severe short bowel syndrome. JPEN J Parenter Enteral Nutr. 1986;10(1):100-101.
22.
HankerJP. Gastrointestinal disease and oral contraception. Am J Obstet Gynecol. 1990;163(6):2204-2207.
23.
RobertsRSketrisISAbrahamIGivnerMLMacDonaldAS. Cyclosporine absorption in two patients with short-bowel syndrome. Drug Intell Clin Pharm. 1988;22(7-8):570-572.
24.
GubbinsPOBertchKE. Drug absorption in gastrointestinal disease and surgery: clinical pharmacokinetic and therapeutic implications. Clin Pharmacokinet. 1991;21(6):431-447.
25.
ThielkeJMartinJWeberFLSchroederTJGoretskySHantoDW. Pharmacokinetics of tacrolimus and cyclosporine in short-bowel syndrome. Liver Transpl Surg. 1998;4(5):432-434.
26.
WenzelKWKirschsieperHE. Aspects of the absorption of oral L-thyroxine in normal man. Metabolism. 1977;26(1):1-8.
27.
JeppesenPBHoyCEMortensenPB. Deficiencies of essential fatty acids, vitamin A and E and changes in plasma lipoproteins in patients with reduced fat absorption or intestinal failure. Eur J Clin Nutr. 2000;54(8):632-642.
28.
LepageGLevyERoncoNSmithLGaleanoNRoyCC. Direct transesterification of plasma fatty acids for the diagnosis of essential fatty acid deficiency in cystic fibrosis. J Lipid Res. 1989;30(10):1483-1490.
29.
LaineLAhnenDMcClainCSolciaEWalshJH. Review article: potential gastrointestinal effects of long-term acid suppression with proton pump inhibitors. Aliment Pharmacol Ther. 2000;14(6):651-668.
30.
LahnerEAnnibaleBDelle FaveG. Systematic review: impaired drug absorption related to the co-administration of antisecretory therapy. Aliment Pharmacol Ther. 2009;29(12):1219-1229.
31.
LelawongsPBaroneJAColaizziJL. Effect of food and gastric acidity on absorption of orally administered ketoconazole. Clin Pharm. 1988;7(3):228-235.
32.
BlumRAD’AndreaDTFlorentinoBM. Increased gastric pH and the bioavailability of fluconazole and ketoconazole. Ann Intern Med. 1991;114(9):755-757.
33.
ChinTWLoebMFongIW. Effects of an acidic beverage (coca-cola) on absorption of ketoconazole. Antimicrob Agents Chemother. 1995;39(8):1671-1675.
34.
LimHKimKHanDOhJKimY. Crystal structure of TTC0263, a thermophilic TPR protein from Thermus thermophilus HB27. Mol Cells. 2007;24(1):27-36.
35.
TomiloDLSmithPFOgundeleAB. Inhibition of atazanavir oral absorption by lansoprazole gastric acid suppression in healthy volunteers. Pharmacotherapy. 2006;26(3):341-346.
36.
HughesGSHealdDLBarkerKB. The effects of gastric pH and food on the pharmacokinetics of a new oral cephalosporin, cefpodoxime proxetil. Clin Pharmacol Ther. 1989;46(6):674-685.
37.
GraselaTHJrSchentagJJSedmanAJ. Inhibition of enoxacin absorption by antacids or ranitidine. Antimicrob Agents Chemother. 1989;33(5):615-617.
38.
LebsackMENixDRyersonB. Effect of gastric acidity on enoxacin absorption. Clin Pharmacol Ther. 1992;52(3):252-256.
39.
DerendorfHVanderMaelenCPBricklRSMacGregorTREisertW. Dipyridamole bioavailability in subjects with reduced gastric acidity. J Clin Pharmacol. 2005;45(7):845-850.
40.
OosterhuisBJonkmanJHAnderssonTZuiderwijkPBJedemaJN. Minor effect of multiple dose omeprazole on the pharmacokinetics of digoxin after a single oral dose. Br J Clin Pharmacol. 1991;32(5):569-572.
41.
CohenAFKroonRSchoemakerRHoogkamerHvan VlietA. Influence of gastric acidity on the bioavailability of digoxin. Ann Intern Med. 1991;115(7):540-545.
42.
SoonsPAvan den BergGDanhofM. Influence of single- and multiple-dose omeprazole treatment on nifedipine pharmacokinetics and effects in healthy subjects. Eur J Clin Pharmacol. 1992;42(3):319-324.
43.
BliesathHHuberRSteinijansVWKochHJKunzKWurstW. Pantoprazole does not interact with nifedipine in man under steady-state conditions. Int J Clin Pharmacol Ther. 1996;34(1):S81-S85.
44.
GertzBJHollandSDKlineWF. Studies of the oral bioavailability of alendronate. Clin Pharmacol Ther. 1995;58(3):288-298.
45.
ComoJADismukesWE. Oral azole drugs as systemic antifungal therapy. N Engl J Med. 1994;330(4):263-272.
46.
VanderhoffBTTahboubRM. Proton pump inhibitors: an update. Am Fam Physician. 2002;66(2):273-280.
47.
GolubALFrostRWBetlachCJGonzalezMA. Physiologic considerations in drug absorption from the gastrointestinal tract. J Allergy Clin Immunol. 1986;78(4):689-694.
48.
GubbinsPOBertchKE. Drug absorption in gastrointestinal disease and surgery. Pharmacotherapy. 1989;9(5):285-295.
49.
ThielmanNMNeuHC. Bacterial cell wall inhibitors. In: BrodyBTMLarnerJMinnemanKP, eds. Human Pharmacology. St Louis, MO: Mosby-Year Book; 1998:655-682.
50.
MenardiGGuggenbichlerJP. Bioavailability of oral antibiotics in children with short-bowel syndrome. J Pediatr Surg. 1984;19(1):84-86.
51.
ParsonsRL. Drug absorption in gastrointestinal disease with particular reference to malabsorption syndromes. Clin Pharmacokinet. 1977;2(1):45-60.
52.
MindelACarneyO. Acyclovir malabsorption. Br Med J (Clin Res Ed). 1988;296(6636):1605.
53.
KennedyJMRijiAM. Effects of surgery on the pharmacokinetic parameters of drugs. Clin Pharmacokinet. 1998;35(4):293-312.
54.
UrquhartJ. Internal medicine in the 21st century: controlled drug delivery: therapeutic and pharmacological aspects. J Intern Med. 2000;248(5):357-376.
55.
BernerBCowlesVE. Case studies in swelling polymeric gastric retentive tablets. Expert Opin Drug Deliv. 2006;3(4):541-548.
