Transcript Care of the Post-Bariatric Patient

Care of the PostBariatric Patient
Fall Update in Family Medicine
l
October 20-21, 2016 l Andrew Kraftson, MD
Clinical Tips and Pearls
from the Post-Bariatric
Surgery Clinic
Fall Update in Family Medicine
l
October 20-21, 2016 l Andrew Kraftson, MD
Disclosure(s):
• co-investigator for a clinical
study sponsored by Nestle
(Optifast).
Fall Update in Family Medicine
l
October 20-21, 2016 l Andrew Kraftson, MD
How is follow-up of the bariatric
patient structured?
How is follow-up of the bariatric
patient structured?
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At my institution?
At yours?
Post-Bariatric Endocrinology Clinic
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Goal: provide structured life-long follow-up
for all the post-bariatric patients of the
University of Michigan and act as a referral
center for patients from other institutions.
•
Team: 3 endocrinologists, 2 dieticians, 4
bariatric surgeons, 2 physician assistants (&
close referral contact with 2 therapists, 3
gastroenterologists and 3 plastic surgeons as
well as physical therapy and exercise
physiology)
However, offering long-term
follow-up is atypical for many
local/area bariatric centers.
For most, long-term follow-up
occurs with the local primary
care physician/provider.
What types of
surgery will we
be discussing?
Selection of the Bariatric
Patient
Remember that effective
pre-bariatric work will
make your post-bariatric
job easier.
Beyond meeting NIH/ insurance
criteria, is the patient...
Beyond meeting NIH/ insurance
criteria, is the patient...
• motivated to change?
• demonstrating change, already?
• aware of the post-surgical
requirements (diet/exercise/vitamins)?
• able to keep post-bariatric visits?
• capable of understanding the
process?
• able to afford the required food &
vitamins?
If NOT...
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motivated to
change?
demonstrating
change, already?
aware of the postsurgical
requirements
(diet/exercise/
vitamins)?
able to keep postbariatric visits?
capable of
understanding the
process?
able to afford the
required food &
vitamins?
Then…
•
NO surgery.
•
Postpone surgery &
develop action plan.
Provide education of
expectations.
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Address the
underlying issue(s).
NO surgery until
addressed.
Involve social
work/financial
planning.
Some bariatric programs will do a
good job of addressing these
issues, others will not.
You will know the patient better
than the bariatric program – make
sure these issues are addressed!
Post-Bariatric Complications
Many are possible…
A well-structured visit will
help you screen for
problems.
Here is an example of my
workflow.
Weight Management
*recidivism prevention
Weight Management
Prior to walking in the room
• Determine the Pre-surgical
weight (Peak)
• Determine the “Ideal Body
Weight” (IBW)
• Determine the “Excess Body
Weight” (EBW) =
• EBW = Peak - IBW
Weight Management
Prior to walking in the room
• Obtain the current weight.
• Determine the % EBW lost =
(Peak) – (current)
EBW
Weight Management
Prior to walking in the room
• Compare to projections*:
• At 6 months post: expect
~30-40% EBW loss**
• At 12 months post: expect
• RYGB: 55-70%
• Sleeve: 45-60%
*Can be guided by Michigan Bariatric
Surgery Collaborative database comparison
**Note: 100% EBW loss is NOT the
expectation!
Weight Management
Prior to walking in the room
• This assessment will help
direct the visit:
• Is weight loss too rapid and
concerning?
• Is the rate of weight loss
meeting projections?
• Is the weight loss rate wellbelow projections?
Weight Management
Once with the patient
• The patient’s self-assessment
of weight progress should be
obtained prior to discussing
your assessment of the weight
trajectory.
• This provides information
about insight and can help
with the feedback process.
Weight Management
Once with the patient
Diet:
• You may not have time to
conduct a complete dietary
assessment.
• If you have concerns about
under/over-nutrition, refer the
patient to a dietician.
Weight Management
Once with the patient
Diet:
• Otherwise, if weight loss
meets projections, try to do a
general assessment of dietary
composition (well-balanced or
not?)
Weight Management
Once with the patient
Diet: General composition
guidelines
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70 - 80 gm of protein
• Protein > vegetables > fruit > carbs
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64 oz of water/equivalents
NO carbonation
Avoid: bread/rice/pasta
Avoid sweetened beverages
Weight Management
Once with the patient
Diet: General calorie guidelines
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Six months post: should be consuming at
least 800 cal/day but typically no more
than 1200 (avg: ~1000)
Twelve months post: typical range from
800-1500 cal/day
Weight Management
Once with the patient
Diet: Red Flags
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Slow rate of loss from 2 months post- to 6
months post-op.
Ill-defined/unrestricted snacking on: carbheavy snacks (eg: crackers), nuts (HIGH
caloric density), sweetened beverages.
Lack of vegetables/fruit.
Prolonging meals to “get around” the
physical barriers/restrictions.
Resumption of old habits.
*But also watch for under/malnutrition!
Vitamin Management
*deficiency prevention
If your patient had
surgery with the goal of
getting off all “pills”, s/he
is in for a
disappointment…
The next step in the visit
is to assess the degree of
adherence to vitamin
supplementation
recommendations.
Sample RYGB vitamin regimen:
1st Meal
1st Snack
2nd Meal
• MVI (with iron) • Cal Citrate • Cal Citrate
• B12 SL
500mg
500mg
2nd Snack
• Cal Citrate
500mg
3rd Meal
• MVI (with iron)
Sample Sleeve vitamin regimen:
1st Meal
1st Snack
• MVI (with iron) • Cal Citrate
• B12 SL*
500mg
2nd Meal
2nd Snack
• Cal Citrate
500mg
3rd Meal
Biochemical Monitoring:
Quick Tips:
For your self-study – we do not have
time to cover them in the
presentation, today.
SELF-STUDY
Quick Tips:
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Calcium:
• Please do not discontinue supplements
just because the lab results are normal.
We are trying to prevent problems!
• Calcium type:
• Carbonate (eg: Caltrate): < 10% is
absorbed and it can increase the
risk of kidney stones.
• Citrate (eg: Citracal): USE this!
• ~40-50% is absorbed
• Should not increase stone risk
• Does not require food or gastric
acid for absorption
• There are formulation options –
but need to watch that they are
not taking carbonate.
SELF-STUDY
Quick Tips:
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Calcium:
• Reasons to discontinue:
• Frank hypercalcemia
• Complete intolerance to all
formulations
• (unable to afford them) – though
some insurers (and some medicaid
options??) may provide coverage
for calcium.
• NOT reasons to discontinue:
• Normal calcium levels
• Kidney stones: most post-bariatric
stones are cal-oxalate. Holding
calcium may cause calcium
deficiency and this will precipitate
oxalate!
SELF-STUDY
Quick Tips:
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Vitamin D:
• Many will obtain adequate amounts
through: diet and the calcium + D
(combination) supplements.
• However, for a significant number of
patients, deficiency will occur despite
these efforts (especially in Michigan!)
SELF-STUDY
Quick Tips:
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Vitamin D:
• Common supplementation regimens:
• Mild deficiency: Cal+D plus OTC D3
1000 intl units daily
• Moderate:
• Cal+D plus OTC D3 2000-10,000
intl units daily
• Cal+D plus RX ergocalciferol
50,000 intl units 1x/week
• Severe:
• Cal+D plus RX ergocalciferol
50,000-100,000 2-7x/week
• Alternate forms:
• Liquid vitamin D
• Light/sun-exposure: 10-15 min
of uncovered arms/legs =
~20,000 intl units
SELF-STUDY
Quick Tips:
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Vitamin D:
• Example of a common replacement
error I see made:
• “Jane Smith” was deficient despite
being on Cal+D and vit D3 1000 intl
units daily.
• Her PCP decides to raise her level
by prescribing ergo 50,000 intl
units weekly x 8 weeks.
• However, after completion she is
then advised to go back to the old
D3 1000 for maintenance.
• This will usually result in a return to
the problem.
• RAISE the maintenance dose after
you have “tanked her up”!
SELF-STUDY
Quick Tips:
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Vitamin D:
• Example of a common lab
interpretation error I see:
• “Jane Smith” has labs drawn and
was found to have elevated PTH
levels.
• Her physician jumps to the
conclusion that she has pathologic
hyperparathyroidism.
• Remember: interpret in the
CONTEXT of calcium and 25hydroxyvitamin D
SELF-STUDY
Quick Tips:
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Vitamin D:
• Remember: interpret in the CONTEXT
of calcium and 25- hydroxyvitamin D:
• Normal calcium with low 25HD =
appropriate secondary
hyperparathyroidism = need to
replace D
• Low calcium with normal 25HD =
appropriate secondary
hyperparathyroidism = need to
take/replace calcium.
• Low/normal calcium –orlow/normal 25HD = try to increase
the levels and see the effect on the
PTH
• HIGH calcium and high PTH = PTHdependent hyperparathyroidism
SELF-STUDY
Quick Tips:
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B12:
• You cannot become B12 toxic so there
is generally no need to intervene when
levels are elevated – let them continue
on the regimen.
• Use sublingual B12 instead of oral B12
to avoid issues with gut absorption.
• Sublingual B12 is CHEAP!
(~$1/MONTH)
• Q: Why do I recommend sleeve
patients take B12?
• A: We analyzed our patient population
data and saw a general trend of falling
B12 levels – some to frankly low.
Therefore, we made the programmatic
decision to institute prophylactic
therapy.
SELF-STUDY
Quick Tips:
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B12:
• IM injections:
• For deficiency despite SL B12
• To improve adherence
• Per patient preference
• I often teach my patients to selfadminister.
• However, you can bring them to
the clinic for injections.
SELF-STUDY
Quick Tips:
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Iron:
• I encourage patients to take ironcontaining MVIs
• Most senior (eg: centrum silver) MVIs
do NOT contain iron
• If deficient despite dietary iron and
iron-containing MVI, then I move to
replacement.
• I start with oral iron and encourage
patients to try different ones if there
are tolerance issues.
SELF-STUDY
Quick Tips:
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Iron:
• Iron infusion therapy should be used in
cases of refractory iron deficiency
anemia (despite oral therapy –or- if
intolerant to oral therapy).
• This is usually facilitated by:
• A post-bariatric physician
• A hematologist
• A gastroenterologist
SELF-STUDY
After assessing the
diet/activity progress and
the vitamin regimen
adherence, I will then move
to specific complication
screening.
“How are you and
others adapting to the
changes you are going
through?”
Screens for:
• Mood disorder
• Sabotage
• Relationship strain
• Feelings of isolation
• Domestic abuse
“How well are your
bowels moving
(frequency,
consistency)? Any
abdominal discomfort?
Any nausea/ vomiting?
Any food intolerances?”
Screens for:
• Constipation (& possibly
related to pelvic floor
dysfunction)
• SIBO
• Biliary disease
• Dumping (if applicable)
“Ever feel episodes of
shakiness, sweating,
anxiety – particularly
after eating?”
Screens for:
• Post-bariatric
hypoglycemia
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Can occur in up to 30% of
malabsorptive surgeries
(like RYGB)
Typical onset is > 1 year
post-surgery
Post-bariatric
hypoglycemia:
Detection
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Whipple’s triad
Get objective evidence
with glucose meter
Symptoms and values
must correlate
Post-bariatric hypoglycemia: My glucose testing instructions
Hypoglycemia (aka: low blood sugar) Testing:
I have asked you to start checking your blood sugars as a 'homework' assignment as we
investigate the cause of your symptoms.
Note: the days do NOT have to be consecutive (ie: it is ok if you have some non-testing days in
between the days you test your blood sugar).
Please test as indicated, below:
1. Day 1 - Day 2: check your blood sugar after waking up in the morning and before eating or
drinking anything. Record the values, below:
 Day 1: _________
 Day 2: _________
2. Day 3 & Day 4: pick the meal that typically occurs PRIOR to the episodes you experience.
Check blood sugars as follows:
Day 3:
 Immediate BEFORE eating the meal: ________
 60 minutes AFTER eating the meal: _________
 120 minutes AFTER eating the meal: ________
Day 4:
 Immediate BEFORE eating the meal: ________
 60 minutes AFTER eating the meal: _________
 120 minutes AFTER eating the meal: ________
3. Other: check during any SYMPTOMATIC episode:
 Episode value: _______
 Episode value: _______
 Episode value: _______
Post-bariatric
hypoglycemia:
Detection
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“Dynamic” testing can be
performed for
confirmation (eg: mixedmeal tolerance testing but NOT
oral glucose tolerance testing)
Post-bariatric
hypoglycemia:
Detection
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Patient should NOT have
fasting or fastingnocturnal episodes.
If s/he does, need to rule
out other causes (insulinoma)
Post-bariatric
hypoglycemia:
Management
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Dietary changes =
cornerstone of therapy
Medications can be
considered if this is
insufficient
Post-bariatric
hypoglycemia:
Management
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Dietary changes:
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AVOID simple carbs. Carbs
consumed should be complex.
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Have protein with each meal/snack
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Eat ~3 meals + 3 snacks per day (reg
spaced)
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Can try corn-starch 1-3x/day
Post-bariatric
hypoglycemia:
Management
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Medications:
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Acarbose: first line
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Verapamil: as monotherapy or
added to acarbose
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Diazoxide: less tolerable for elderly
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Octreotide
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Other (anecdotal experiences)
Post-bariatric
hypoglycemia:
Management
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Surgical management (ie:
“reversal” and/or partial
pancreatectomy) had been
considered as “last resort” but
has, itself, fallen out-of-favor;
even for severe cases.
“Regarding diabetes,
are you still taking any
medications? Are you
checking your blood
sugars? Have you had
any symptoms of high
and/or low sugars?”
Diabetes & Bariatric
Surgery
• Many patients will experience
a “remission” of diabetes –
there is NO CURE.
• A1c <=7 at 3 years post-op:
• RYGB: 65% of patients
• Sleeve: 65% of patients
• A1c <= 7 and OFF medications
at 3 years post-op:
• RYGB: 58% of patients
• Sleeve: 33% of patients
Schauer P et al. Bariatric surgery versus intensive medical therapy for diabetes – 3 year outcomes. N Engl J Med (2014), DOI: 10.1056/NEJMoa1401329
Diabetes & Bariatric
Surgery
• IF your patient has poor
glycemic control after surgery,
you should analyze WHY.
Schauer P et al. Bariatric surgery versus intensive medical therapy for diabetes – 3 year outcomes. N Engl J Med (2014), DOI: 10.1056/NEJMoa1401329
Other Issues (beyond the scope of
this talk):
Risk of addiction
transference
Other Issues (beyond the scope of
this talk):
Risk of bone thinning/
osteoporosis
Other Issues (beyond the scope of
this talk):
Risk of excess skin-related
issues.
Summary:
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Fall Update in Family Medicine
Screen patients carefully.
Familiarize yourself with the
post-surgical
recommendations.
If the bariatric program does
not provide lifetime follow-up,
conduct a visit dedicated to
post-bariatric care.
Be aware of possible
complications and screen.
l
October 20-21, 2016 l Andrew Kraftson, MD
Thank you for
your attention!
Questions?
Fall Update in Family Medicine
l
October 20-21, 2016 l Andrew Kraftson, MD