Antiretroviral considerations in HIV-infected patients undergoing bariatric surgery

Cimino, Christo; Binkley, Amanda; Swisher, Regina; Short, William R.

doi:10.1111/jcpt.12755

Cited by 18 publications

(18 citation statements)

References 34 publications

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“…As a consequence, this may impact the pharmacokinetics of orally administered drugs, mainly absorption and bioavailability [ 25 ]. In the case of subtherapeutic exposure to ARVs, the development of resistance may occur, potentially leading to treatment failure and HIV progression [ 26 , 27 ].…”

Section: Introductionmentioning

confidence: 99%

Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV

et al. 2022

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Bariatric surgery is increasingly applied among people living with HIV to reduce obesity and the associated morbidity and mortality. In people living with HIV, sufficient antiretroviral exposure and activity should always be maintained to prevent development of resistance and disease progression. However, bariatric surgery procedures bring various gastrointestinal modifications including changes in gastric volume, and acidity, gastrointestinal emptying time, enterohepatic circulation and delayed entry of bile acids. These alterations may affect many aspects of antiretroviral pharmacokinetics. Some drug characteristics may result in subtherapeutic exposure and the potential related risk of treatment failure and resistance. Antiretrovirals that require low pH, administration of fatty meals, longer intestinal exposure, and an enterohepatic recirculation for their absorption may be most impacted by bariatric surgery procedures. Additionally, some antiretrovirals can interact with the polyvalent cations in supplements or drugs inhibiting gastric acid, thereby preventing their use as these comedications are commonly prescribed post-bariatric surgery. Predicting pharmacokinetics on the basis of drug characteristics solely proved to be challenging, therefore pharmacokinetic studies remain crucial in this population. Here, we discuss general implications of bariatric surgery on antiretroviral outcomes in people living with HIV as well as drug properties that are relevant for the choice of antiretroviral treatment in this special patient population. Additionally, we summarise studies that evaluated the pharmacokinetics of antiretrovirals post-bariatric surgery. Finally, we performed a comprehensive analysis of theoretical considerations and published pharmacokinetic and pharmacodynamic data to provide recommendations on antiretrovirals for people living with HIV undergoing bariatric surgery.

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Section: Introductionmentioning

confidence: 99%

Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV

et al. 2022

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“…Patients undergoing bariatric surgery will experience physiologic changes, decreased food intake, may be instructed to crush oral medications, and may be prescribed postoperative acid‐suppressing agents or vitamin supplements. Therefore clinicians must consider the patient’s ART in the postoperative setting by evaluating the ARVs site of absorption, ability to be crushed, need to be taken with food, and contraindications or drug interactions with acid‐suppressing agents or supplements …”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Weight‐Loss Pharmacotherapy in Persons Living with HIV: A Review of the Literature and Potential Drug‐Drug Interactions with Antiretroviral Therapy

Cope¹,

Fischetti²,

Kavanagh

et al. 2019

Pharmacotherapy

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The prevalence of obesity among persons living with human immunodeficiency virus (HIV) has increased significantly and may be linked to the use of antiretroviral therapy. Although weight‐loss medications approved by the U.S. Food and Drug Administration are recommended as an adjunct to diet and exercise to treat obesity in the general population, little is known about the safety and efficacy of these drugs specifically in persons living with HIV. We review the available evidence regarding the effective use of weight‐loss pharmacotherapy in persons living with HIV and its potential to interact with antiretroviral therapy. Persons living with HIV are frequently not reported or included in clinical trials for weight‐loss medications; however, treatment efficacy is likely similar to the general population. Several important reported or theoretical drug‐drug interactions exist between antiobesity pharmacotherapy and antiretroviral therapy. Orlistat is a weight‐loss drug available in the United States without a prescription and was linked to HIV viral rebound in several case reports. Clinicians should be aware of the potential for loss of HIV viremia control when certain weight‐loss pharmacotherapies are used in combination with antiretrovirals.

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“…Two common weight-loss surgeries are roux-en-y gastric bypass (RYGB) and sleeve gastrectomy (SG), both of which can be performed laparoscopically. During these procedures, the surface area of the stomach (and intestine in RYGB) is physically altered and the pH of the stomach increases as its size shrinks, becoming closer to that of the small intestine [8].…”

Section: Key Pointsmentioning

confidence: 99%

“…Changes in the pH and surface area of the gastrointestinal (GI) tract after surgery may affect HIV virologic suppression via altered ART absorption. Some antiretrovirals are absorbed in the duodenum, a piece of the intestine that is "bypassed" during RYGB surgery [8]. Additionally, select antiretrovirals depend on an acidic environment for optimal absorption [8], which may be impacted by surgery itself as well as acid suppression prescribed for ulcer prevention post-operatively.…”

Section: Key Pointsmentioning

confidence: 99%

Antiretroviral Therapy Efficacy Post-Bariatric Weight Loss Surgery: A Case Series of Persons Living with Human Immunodeficiency Virus

2022

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Purpose Human immunodeficiency virus (HIV)–related mortality has decreased secondary to advances in antiretroviral therapy (ART), and the incidence of obesity in this population is increasing. Bariatric surgery is an effective method of weight loss, though changes in the gastrointestinal tract may affect ART absorption and virologic suppression. Existing data are limited to case reports studying outdated therapeutic regimens; studies evaluating modern ART regimens are needed. The objective of this study was to determine if undergoing bariatric surgery impacts HIV virologic failure rate at 12 months post-surgery and to characterize the failure population. Materials and Methods This retrospective case series included adults with virologically suppressed HIV on ART who underwent roux-en-y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery between 2000 and 2019 (n=20) at one of three medical centers within one academic medical system. The primary outcome was proportion of patients with ART failure at 12 months post-surgery. Select additional data collected included CD4+ count, metabolic parameters, postoperative complications, and medication non-adherence. Results A total of 18 patients were included in this analysis. Seventeen of 18 patients (94%) maintained virologic suppression within 12 months post-surgery. There were no significant changes in CD4+ counts before and after surgery. The one failure was an African American woman who underwent sleeve gastrectomy surgery. This patient’s baseline viral load was undetectable and CD4+ count was 263 cells/mm3. Conclusion Undergoing bariatric surgery did not increase virologic failure rate in a small cohort of persons living with HIV, and ART non-adherence was associated with virologic failure. Graphical abstract

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Antiretroviral considerations in HIV-infected patients undergoing bariatric surgery

Cited by 18 publications

References 34 publications

Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV

Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV

Safety and Efficacy of Weight‐Loss Pharmacotherapy in Persons Living with HIV: A Review of the Literature and Potential Drug‐Drug Interactions with Antiretroviral Therapy

Antiretroviral Therapy Efficacy Post-Bariatric Weight Loss Surgery: A Case Series of Persons Living with Human Immunodeficiency Virus

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