May the Level of Lithium be Affected After Bariatric Surgery?

Öz

Introduction: In patients with medication for chronic illnesses, using medications for chronic illnesses, the doses of drugs should be adjusted before bariatric surgery. Studies investigating the pharmacokinetics of the oral drugs used after bariatric surgery are limited. We will present a young bipolar male obese patient who should continue to use lithium after bariatric surgery. Case: Twenty-six-year-old male was applied to our clinics with the complaint of weight gain of 20 kg in a year. This patient was reported to have taken risperidone 2 mg tb 1x1 and lithium capsule 1x3 due to bipolar disorder (BPD). Also, the patient who had previously been diagnosed with asthma did not take any inhaler medication for it. On physical examination; body weight was 195 kg, height 184 cm, body mass index 57.5 kg/m2 and vital findings were stable. Respiratory examination revealed rhonchus, and the examination of other organ systems was unremarkable. Laboratory evaluation revealed that glucose was 480 mg/dL, creatinine: 0.9 mg/dL, ALT: 65 U/L, AST: 28 U/L, Na: 143 mmol/L, K: 4 mmol/L, HDL: 26 mg/dL, LDL: 165 mg/dL, Triglyceride: 200 mg/dL, HbA1c: 8.5%.With the diagnosis of type 2 diabetes, exenatide 5 mcg 2x1 subcutaneous and metformin 1000 mg 2x1 tb were given, and hyperglycemia was regulated.The patient was examined by psychiatry, and BPD was found to be stable. Serum level of lithium was 0.5 mEq/L. Laparoscopic Roux-n-Y gastric bypass (RYGB) surgery was planned after bariatric surgery council. To decrease postoperative pulmonary complications, perioperative inhaler beta2 agonist was given. Metformin and exenatide was discontinued after RYGB. The patient was given bariatric surgery diet, but he could not tolerate oral lithium or risperidone. Sublingual olanzapin 10 mg was given. Later, in postoperative 1st month, risperidon im 25 mg each 2 weeks was initiated to be taken in every 2 weeks. Because of intolerance, it was not given until postoperative 6th month. Lithium capsule 1x1 was started at postoperative 6th month, and increased gradually up to 1x3 capsule. The level of lithium was 0.21 and 0.129 mEq/L, in the first and 6th month of the initiation of lithium, respectively. Effective level could not be achieved. Conclusion: Due to nausea, postoperative use of lithium may become difficult. Lithium could be given to our patient regularly after 6th postoperative month, but the reference level could not be achieved. Large studies investigating the use of lithium in patients with BPD after bariatric surgery will clarify this issue.

Anahtar Kelimeler

• Bariatric surgery
• Lithium,
• Lithium level
• Obesity
• Bipolar disorder

Bariatrik Cerrahi Sonrasında Lityum Düzeyi Etkilenir mi?

Öz

Giriş: Kronik hastalık sebebiyle ilaç kullanımı olan hastalarda, bariatrik cerrahi sonrasında ilaç dozları ayarlanmalıdır. Bariatrik cerrahi sonrası oral alınan ilaçların farmakokinetiği ile ilgili çalışmalar sınırlıdır. Biz de bariatrik cerrahi sonrasında lityum kullanımına devam etmesi gereken genç bipolar erkek obez hastamızı sunacağız. Olgu: 26 yaşında erkek hasta son 1 yılda 20 kilo alımı sebebiyle başvurdu. Hasta 2 yıldır bipolar bozukluk (BPB) tanısıyla, risperidon 2 mg 1x1 tablet ve lityum 1x3 kapsül kullanıyordu. Astım tanısı olan hastanın düzenli inhaler kullanımı yoktu. Fizik bakıda; vücut ağırlığı: 195 kg, boy: 184 cm, vücut kütle indeksi: 57.5 kg/m2 ve vital bulgular stabil saptandı. Akciğer muayenesinde ronkuslar saptandı; diğer sistem muayeneleri normal sınırlardaydı. Laboratuar bulgularında; glukoz: 480 mg/dL, kreatinin: 0.9 mg/dL, ALT: 65 U/L, AST: 28 U/L, Na: 143 mmol/L, K: 4 mmol/L, HDL: 26 mg/dL, LDL: 165 mg/dL, Trigliserid: 200 mg/dL, HbA1c: %8.5 saptandı. Tip 2 diyabet tanısıyla, eksenatid 5 mcg 2x1 subkütan ve metformin 1000 mg 2x1 tb başlandı ve kan şekeri regülasyonu sağlandı. Psikiyatri tarafından değerlendirilen hasta BPB açısından stabil seyretti ve serum lityum düzeyi: 0.5 mEq/L saptandı. Bariatrik cerrahi konseyinde değerlendirildi ve laparoskopik Roux-n-Y gastrik bypass (RYGB) cerrahisi planlandı. Postoperatif pulmoner komplikasyonları azaltmak için perioperatif beta2 agonist inhaler tedavi başlandı. RYGB uygulanan hastaya postoperatif dönemde metformin veya eksenatid verilmedi. Bariatrik cerrahi diyeti verilen hastanın kan şekeri regülasyonu antidiyabetik bir ajana ihtiyaç duyulmadan sağlandı. Hasta postoperatif dönemde lityum ve risperidonu tolere edemedi ve bu sebeple hastaya sublingual olanzapin 10 mg başlandı. Daha sonra postoperatif 1.ayda risperidon im 25 mg 2 haftada bir uygulanmaya başlandı. İntolerans sebebiyle postoperatif 6. aya kadar lityum verilmedi. Postoperatif 6. ayda lityum 1x1 kapsül başlandı, doz haftada bir tedricen 1x3 kapsüle çıkıldı. Tedavinin 1. ayında bakılan lityum düzeyi 0.21 mEq/L, 6. ayında 0.129 mEq/L ölçüldü. Efektif lityum düzeyi sağlanamadı. Sonuç: Bulantı sebebiyle postoperatif lityum kullanımı zorlaşmaktadır. Hastamızda postoperatif 6. aydan sonra lityum düzenli verilebildi ancak serum lityum düzeyi referans aralığına ulaşmadı. BPB’de bariatrik cerrahi sonrasında lityum kullanımı ile ilgili geniş çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• bariatrik cerrahi
• lityum
• lityum düzeyi
• obezite
• bipolar bozukluk

Kaynakça

1. 1. Leff DR, Heath D. Surgery for obesity in adulthood. Br Med J. 2009;339:740–6.
2. 2. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical complications. Obes Rev. 2010;11:41–50.
3. 3. MacGregor AMC, Boggs L. Drug distribution in obesity and following bariatric surgery: A literature review. Obes Surg. 1996; 6:17–27.
4. 4. Malone M. Altered drug disposition in obesity and after bariatric surgery. Nutr Clin Pract. 2003;18:131–5.
5. 5. Miller AD, Smith KM. Medication and nutrient administration considerations after bariatric surgery. Am J Health Syst Pharm. 2006;63:1852–57.
6. 6. Yska JP, van der Meer DH, Dreijer AR, Eilander W, Apers JA, Emous M, Totté ER, Wilffert B, van Roon EN. Influence of bariatric surgery on the use of medication.. Eur J Clin Pharmacol. 2016 Feb;72(2):203-9.
7. 7. Yska JP, van der Linde S, Tapper VV, Apers JA, Emous M, Totté ER, Wilffert B, van Roon EN. Influence of bariatric surgery on the use and pharmacokinetics of some major drug classes. Obes Surg. 2013 Jun;23(6):819-25.
8. 8. Dahan A, Porat D, Azran C, Mualem Y, Sakran N, Abu-Abeid S. Lithium Toxicity with Severe Bradycardia Post Sleeve Gastrectomy: a Case Report and Review of the Literature. Obes Surg. 2019 Feb;29(2):735-738.

9. 9. Niessen R, Sottiaux T, Schillaci A, Lejeune F. [Lithium toxicity after bariatric surgery]. Rev Med Liege. 2018 Feb;73(2):82-87.
10. 10. Wasserman B, Jiang W. Lithium Toxicity after Roux-en-Y Gastric Bypass is Not Just Limited to Perioperative Period. Psychosomatics. 2018 Mar - Apr;59(2):206.
11. 11. Bingham KS, Thoma J, Hawa R, Sockalingam S. Perioperative Lithium Use in Bariatric Surgery: A Case Series and Literature Review. Psychosomatics. 2016 Nov - Dec;57(6):638-644.
12. 12. Musfeldt D, Levinson A, Nykiel J, Carino G. Lithium toxicity after Roux-en-Y bariatric surgery. BMJ Case Rep. 2016 Mar 18;2016. pii: bcr2015214056.
13. 13. Tripp AC. Lithium toxicity after Roux-en-Y gastric bypass surgery. J Clin Psychopharmacol. 2011 Apr;31(2):261-2.
14. 14. Williams D. Lithium toxicity: risk factors, monitoring, and management. 2014 (updated 1 November, 2014 11/6/2015). http://www.uspharmacist.com/continuing_ education/ceviewtest/lessonid/110716/.
15. 15. Walsh K, Volling J. Lithium toxicity following Roux-en-Y gastric bypass. Bariatr Surg Pract Patient Care 2014;9:77–80.