Research and Reports

Research and Reports Objective

Creation of a Bariatric Surgery Medication Therapy Management Model Michael J. Schuh OBJECTIVE: To describe how pharmacist-provided medication

therapy management (MTM) services can be applied to bariatric surgery. PRACTICE SETTING: A pharmacy MTM consult service located in a multispecialty medical clinic with a bariatric department attached to a hospital where bariatric surgeries are performed. PRACTICE DESCRIPTION: MTM bariatric surgery office practice where patients are seen before surgery by a pharmacist to identify medication problems and determine how best to administer alternative dosage forms post-operatively to patients. PRACTICE INNOVATION: Practice innovations are a creation of a specialized service and accompanying specialized medication database within a pharmacotherapy practice. MAIN OUTCOME MEASURES: Outcome measures are number of patients referred per month and polypharmacy consults scheduled downstream from the bariatric surgery. Improved patient outcomes and prescribing efficiency from usage of the newly developed database of drugs that can be crushed. RESULTS: All bariatric patients are now referred to the pharmacist MTM pharmacotherapy service for medication review before bariatric surgery. CONCLUSION: Bariatric surgery is a source of another useful MTM practice model. Utilizing MTM pharmacists to consult with bariatric patients presurgery helps ease the physician burden of writing alternative dose prescriptions and helps identify medication problems with patients before their surgery. KEY WORDS: Alternative dosage forms, Bariatric surgery, Crushable database, Medication therapy management, MTM. ABBREVIATION: MTM = Medication therapy management. Consult Pharm 2015;30:000-00.

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To describe how pharmacist-provided medication therapy management (MTM) services can be applied to a bariatric surgery before surgery. Little has been published about bariatric applications to MTM pharmacist consultations. Bariatric surgery presents a prime opportunity for pharmacists’ clinical involvement because the number and complexity of the medications used by bariatric patients can be high. These patients also have multiple comorbidities, and MTM can be of great utility to both the patients and an institution’s bariatric surgery team. Bariatric surgery MTM involves an understanding of pharmaceutical dosage forms, nutrition, pharmacology, and pharmacokinetics. Pharmacists have more combined training in these areas than any other health care professionals.

Practice Setting A pharmacy MTM consult service located in a multispecialty medical clinic with a bariatric department attached to a hospital where bariatric surgeries are performed.

Practice Description MTM before bariatric surgery involves an understanding of pharmaceutical dosage forms, nutrition, and pharmacokinetics. These are areas where pharmacists have in-depth training. Combining this knowledge base with their pharmacology background gives pharmacists a potentially important role in bariatric medicine. Bariatric surgery is an operation on the stomach and/ or intestines that helps patients with extreme obesity to lose weight. Bariatric surgery presents a prime opportunity for pharmacist clinical involvement because patients often cannot take standard dosage forms. Because the number and complexity of the medications used by bariatric patients can be high, and these patients have multiple comorbidities, MTM can be of great utility to both bariatric patients and an institution’s bariatric surgery team. Bariatric surgery MTM involves understanding of pharmaceutical dosage forms, nutrition, pharmacology, and pharmacokinetics. Pharmacists have more combined training in these areas than any other health care professionals.

THE CONSULTANT PHARMACIST JULY 2015 VOL. 30, NO. 7

Creation of a Bariatric Surgery MTM Model

Obesity is seen as one of the nation’s largest public health threats; about 72 million Americans are considered obese, with 18 million considered morbidly obese. Obesity has been linked to chronic diseases such as diabetes, hypertension, and heart disease.1 In 2010, bariatric surgeries performed in the United States plateaued at approximately 113,000 cases per year. Complications have fallen from 10.5% in 1993 to 7.6% in 2006.2 Since 2006, major complications have fallen to 4%, and the overall death risk is currently 0.1%.1 Bariatric surgery results in effective management of obesity-related conditions such as diabetes and hypertension, resulting in more inclusion of bariatric procedures in insurance plans.3-8 In the MTM bariatric surgery office practice, the patients are seen before surgery by a pharmacist to identify medication problems and determine how best to administer alternative dosage forms to patients after surgery. Patients are seen on an appointment basis and scheduled through the electronic medical record system, as are other provider visits. The practice emerged because of the number of alternative dosage form requests coming from the new bariatric department at the clinic. The pharmacotherapy service increasingly was being inundated with these requests as the bariatric practice grew. Researching what medications can be crushed is time-consuming because there are no references available that indicate specifically what dosage forms one can crush after bariatric surgery. “No crush” lists are similar and are utilized when researching a new drug for the specialized database. A “can crush” database had to be developed, and to formalize and standardize services, pharmacotherapy visits before surgery were added to the bariatric surgery standard orders. To add a can-crush medication to the database, the practice had to first use other “do not crush” lists first to see if a drug was on them. If it was, an alternative dosage form for that product was sought. If for instance an extended-release formulation was being taken by the patient, we would investigate whether a liquid was available or if there were an immediate-release form that could be crushed and substituted. If the patient was

taking an immediate-release medication and there was no information on crushing, we would have to verify if it could be crushed. If a medication cannot be crushed as an immediate-release drug, it will say so in the product literature, usually in the product insert. If a product can be crushed, the same literature often will not say how the dosage form can be prepared and taken in an alternate way. Other times a product may be bitter, it may taste badly, or the pharmacokinetic properties are changed by crushing or suspending in water, so the MTM service had to determine substitutes for these. Other factors involved were degradation of the product, pH effects on potency, effect of dose-delivery time by inactive ingredients, and flocculation. For example, many levothyroxine preparations may cause choking if allowed to set too long before taken orally. Applesauce is an ideal vehicle for many preparations that can be crushed or capsules that can be emptied into it because of its relatively low acidic pH. Enteric-protected dosage forms such as omeprazole beads can be preserved by being emptied into applesauce before being taken by mouth.9 Sometimes a therapeutic alternative that can be crushed had to be used. While the main objective of patient visits is to modify dosage forms for immediate post-op use, other pharmacist activities result such as consultations on absorptive issues and pharmacokinetics of medications following the immediate post-op period. While conducting the pre-op visit, the pharmacist is also screening patients for possible adverse drug reactions, with emphasis on central nervous depressive drugs and any drug that can increase the risk of bleeding during surgery.

Practice Innovation Two practice innovations evolved: the creation of a specialized MTM service and the development of an accompanying specialized medication database. These were used to modify medication regimens and dosage forms of medications administered following bariatric surgery. They also created a collaborative surgery environment with a department not normally considered closely tied with a pharmacy MTM service. The MTM


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Research and Reports services performed by a pharmacist often were considered to be a primary care activity. This model of MTM service delivery shows a pharmacy MTM service can be adapted to meet specialty medical services. Efficient participation and documentation in this type of practice required development of a “crushable medication” database to assist with departmental prescription writing. There are an abundance of “Do Not Crush” databases; however, no complete databases could be found that specifically indicated which medications could be crushed or were comprehensive in listing alternative dosage forms. It cannot be assumed a medication can be crushed just because it does not appear on a “Do Not Crush” list or that there is a modality to safely and effectively administer a medication in an alternative dosage form in the bariatric patient population. An abbreviated example of the database is included (Table 1).

The database is constantly updated and revised when new information becomes available regarding current entries and when new agents are introduced to the pharmaceutical market.

Main Outcome Measurements Outcome measures are number of patients referred per month and polypharmacy consults scheduled following the bariatric surgery, which were sometimes a significant amount of time after surgery because of other medical problems both related and unrelated to their bariatric surgery. The database is used by the entire pharmacy department—including the hospital inpatient services and palliative services—to assist patients with dysphagia on many medical services. Dysphagia patients are referred now from other departments such as neurology.

Table 1. Crushable Medication Database Medication

Dosage Form

Crushable?

Alternative?

Specific Instructions

Bumetanide

Tablet

Yes

N/A

Crush, place in applesauce

Chloral hydrate

Capsule

No

Yes

Suppository and liquid available

Desvenlafaxine

Tablet

No

Yes

Can prescribe venlafaxine immediaterelease tablets which are crushable, or XR, capsules which can be opened and poured onto applesauce.

Levothyroxine

Tablet

Yes

N/A

Tablets may be crushed and suspended in 5-10 mL of water; solution should be consumed immediately. Administer Levoxyl with full glass of water to prevent gagging (tablet swells). May crush tablets and sprinkle over a small amount of food (i.e., cooked cereal, applesauce).

Abbreviations: N/A = Not applicable, XR = Extended-release. Source: Author’s database.

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Creation of a Bariatric Surgery MTM Model

Results All bariatric patients are now referred via physicians’ orders to the pharmacist MTM pharmacotherapy service for medication review before bariatric surgery. One secondary effect was increased polypharmacy consults post-op because these patients have special needs created by the surgery. Post-bariatric surgery patients now are more achlorhydric, so they may be getting B12 injections and are more prone to mineral deficiencies leading to iron-deficiency anemias, hypomagnesemia, and osteopenia/osteoporosis. They may also have more gastrointestinal issues such as dumping syndrome and vitamin malabsorption issues.10 Some of these patients with time may incur other medical problems and are referred to other MTM pharmacist services. Another outcome was that after multiple pharmacist visits, patients seem to better appreciate the range and depth of a pharmacist’s clinical capabilities. This is usually verbally conveyed after a separate visit, sometimes many years after the initial bariatric-surgery consult.

Conclusion Bariatric surgery is a source of another MTM practice model of care. Utilizing MTM pharmacists to consult with bariatric patients before surgery helps ease the physician burden of researching and writing alternative dose prescriptions. Secondarily, the service also helps identify possible medication problems with patients before their surgery. The newly developed crushable database is widely used within the institution by other departments for patients with dysphagia. Even though this model of practice was originally designed for bariatric surgery, the custom database and principles of dosage form alteration can be used in almost every pharmacy practice. In addition, and to our experience, specialty pharmacist consult services create in the minds of patients an understanding of pharmacists as clinical health care professionals and not just as dispensers of medications.

Michael J. Schuh, PharmD, MBA, is clinical pharmacist and assistant professor of pharmacy, family medicine, and palliative medicine, Mayo Clinic Florida, Jacksonville, Florida, and assistant professor and course coordinator, University of Florida Medication Therapy Management Master of Science Program, University of Florida College of Pharmacy, Department of Pharmacotherapy and Translational Research, Jacksonville. For correspondence: Michael J. Schuh, PharmD, MBA, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224; Phone: 904953-2673; Fax: 904-953-2274; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The author has no potential conflicts of interest. 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.00. References 1. American Society of Metabolic and Bariatric Surgery. Available at http://asmbs.org/2013/04/new-evidence-prompts-update-tometabolic-and-bariatric-surgery-clinical-guidelines/. Accessed August 8, 2014. 2. Livingston EH. The incidence of bariatric surgery has plateaued in the US. Am J Surg 2010;100:378-85. 3. MacDonald KG, Long SD, Swanson MS et al. The gastric bypass operation reduces the progression and mortality of non-insulin dependent diabetes mellitus. J Gastrointest Surg 1997:1213-20. 4. Pories WJ, Swamson MS, Macdonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339-50. 5. Rubino F, Gagner M. Potential for surgery for curing type 2 diabetes mellitis. Ann Surg 2002;236:554-9. 6. Benotti PN, Bistrain B, Binotti JR et al. Heart disease and hypertension in severe obesity: the benefits of weight reduction. Am J Clin Nutr 1992;55:586S-90S. 7. Carson JL, Ruddy ME, Duff AE et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994;154:193-200. 8. Sugarman HJ, Wolfe LG, SIca DA et al. Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Ann Surg 2003;237:751-6. 9. Monzani A, Giuseppina O. Delayed-release oral suspension of omeprazole for the treatment of erosive esophagitis and gastroesophageal reflux disease in pediatric patients: a review. Clin Exp Gastroenterol 2010;3:17-25. 10. Shah M, Vinaya S, Abhimanyu G. Long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. JCEM 2006;91:4223-31.


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