Background Clinical pharmacist consultations play a vital role in optimizing medication management for bariatric patients. However, postdischarge implementation remains largely unknown. Objectives The aim of this work was to characterize the different types of recommendations made by clinical pharmacists in bariatric patients, and to assess adherence to these recommendations in the ambulatory-care setting. Methods A retrospective analysis was conducted at Herzliya Medical Center, where patients were operated, and Clalit Health Services, the largest Health Maintenance Organization (HMO) in Israel. A total of 210 bariatric patients received clinical pharmacist consultation and a letter to the community clinics between 2013 and 2019. In phase one, we analyzed the types and frequency of recommendations provided. In phase two, adherence in the community was evaluated using HMO medical records over 6 months postdischarge. Results In the first analysis of 210 patients, there was a mean of 9 recommendations per patient. The most common were drug discontinuation (40.9%) and new medication addition (14.8%). Recommendations often addressed chronic conditions, mainly diabetes (36.9%) and hypertension (31.8%). In total, 153 Clalit HMO patients were analyzed for adherence. The overall adherence rate was 77.7%. No significant correlations were found with age, comorbidities, or preoperative medication count to adherence rate. A significant negative correlation was observed between adherence and the number of recommendations (P = 0.007). Conclusion The high adherence rate to hospital clinical pharmacist's recommendations highlights the value of specialized clinical pharmacist consultation in bariatric care. These consultations may improve implementation of treatment plans among both patients and health care providers.

Metabolic bariatric surgery is the most effective long-term treatment for patients with obesity and obesity-related comorbidities. However, despite substantial health benefits, these procedures also pose a significant risk of nutrient imbalances. It is well established that postoperative patients are prone to vitamin and mineral deficiencies. Conversely, excessive supplementation may result in elevated levels of certain micronutrients, which can also produce adverse effects. Patients may self-treat with different supplements, e.g., for hair loss, and may not be aware of possible duplications with their bariatric vitamins. The objective of this work was to examine the potential risk of dermatologic manifestations associated with the use of inappropriate vitamin formulations and overlapping supplementation in a post-bariatric patient. We present a 45-year-old post-bariatric female patient, who developed new onset-acne. Clinical pharmacist intervention identified inappropriate use of a multivitamin containing provitamin A instead of retinol and a relatively high amount of vitamin B1, along with an additional "hair-growth" multivitamin rich in vitamin B6, leading to overlapping supplementation. After initiating an appropriate multivitamin regimen, the dermatologic condition completely resolved with no need for acne medications. An overview of the literature relevant to dietary supplementation-related acne is provided as well. In conclusion, this case highlights the essential need for monitoring and education of bariatric patients regarding appropriate use of vitamins. Through proactive questioning of supplement use, detection of nutrient imbalances, and patient education, clinical pharmacists and other healthcare professionals can prevent and reduce the risk of complications after surgery.

Currently, GLP-1RAs are peptide drugs, typically administered by injection due to insufficient absorption, and only one GLP-1RA, semaglutide, is available as an orally administered drug. To overcome the absorption challenges of oral peptides, this drug product contains the absorption enhancer SNAC. As the tablet is eroded in the stomach, SNAC neutralizes the acidic gastric environment, thereby protecting the semaglutide from enzymatic degradation. Then, SNAC fluidizes the stomach lipidic membrane to increase semaglutide transcellular permeability across the gastric epithelium. It is necessary to realize that the use of such a unique drug product, that relies solely on the stomach for absorption, is expected to be affected by the extreme gastric anatomy/physiology changes post-MBS. Hence, we analyzed the key mechanisms that may affect the bioavailability of oral semaglutide post-MBS. Several mechanisms appear to potentially reduce oral semaglutide absorption post-MBS, including decreased inner gastric surface area, decreased gastric contractility, and faster gastric emptying. Hence, the effectiveness of the complex formulation, that relies solely on the stomach for the SNAC activity and semaglutide absorption, may be severely hampered post-MBS; clinicians should be aware of the potential malabsorption of oral GLP-1RA post-MBS, and preferably consider subcutaneous therapy until specific pharmacokinetic/clinical data are available.

Metabolic Bariatric Surgery (MBS) is highly effective in promoting weight loss and weight loss maintenance in patients with obesity. Worldwide, the predominant MBS was sleeve gastrectomy (SG), followed by the Roux-en-Y bypass, while One-anastomosis gastric bypass (OAGB, mini-gastric bypass) only accounted for 4.3

INTRODUCTION:Metabolic bariatric surgery induces significant anatomical and physiological changes in the gastrointestinal tract that may substantially affect the pharmacokinetics of orally administered drugs. These changes include, among others, reduced gastric volume, increased gastric pH, bypass of absorption segments in the small intestine, alterations in drug metabolism, as well as rapid weight loss and changes in body composition. Many neuropsychiatric medications are characterized by a narrow therapeutic window; therefore, the effects of metabolic bariatric surgery may lead either to reduced drug absorption and therapeutic failure or, conversely, to increased drug levels with a risk of toxicity. Interindividual variability is considerable, making it difficult to predict pharmacokinetic responses in individual patients. This review presents the impact of metabolic bariatric surgery on commonly used neuropsychiatric medications, aiming to promote safe and optimal pharmacotherapy in this population. The article includes a literature review, recommendations for therapeutic drug monitoring, and guidance for clinical and laboratory follow-up. Given the complexity of this issue, a proactive approach is recommended, including assessment of drug levels prior to surgery and close monitoring in the early postoperative period until clinical and laboratory stability is achieved, followed by periodic monitoring based on drug characteristics, patient factors, and the specific surgical procedure performed. A multidisciplinary approach involving a neurologist and/or psychiatrist, along with a clinical pharmacist, is essential to optimize neuropsychiatric treatment in patients undergoing metabolic bariatric surgery.

Objectives: Bariatric surgery, the most effective treatment for obesity and type 2 diabetes, may alter the absorption and overall bioavailability of orally administered drugs. In this case series, we present three patients undergoing one-anastomosis gastric bypass (OAGB) and their treatment with the anticonvulsant and mood stabilizer lamotrigine. Key Findings: Various mechanisms may be involved in the changes in lamotrigine blood levels following OAGB; some may lead to increased drug exposure, while others to its decrease. It was found that low and insufficient (case 1), higher (case 3), or unchanged (case 2) lamotrigine plasma levels are all possible after the surgery. Conclusion: This case series shows the complexity of drug treatment after bariatric surgery. The potentially large variability among patients in the effect of the surgery on the bioavailability of lamotrigine, a highly prescribed, life-saving medication, highlights the special care that must be taken with post-bariatric pharmacotherapy in general, and epilepsy treatment in particular.

Objective: We analyzed refractory hypertensive (refHTN) patients, i.e. patients whose blood pressure is above goal despite being on 5-7 different antihypertensive drug classes. Our goal was to delineate prescription habits of the 5th-7th antihypertensive medications, adherence rates, and BP control. Design and method: In this real-life observational study we utilized the Maccabi Healthcare Services (MHS) database during 2023. MHS is a nationwide Health Maintenance Organization (HMO), providing health services to about one quarter of the Israeli population. In order to describe adherence rates we compared refractory hypertensive patients who were fully adherent (at least six prescriptions and purchases of each medication during 2023) to partially adherent patients (at least one purchase of each medication). Blood pressure control was strictly defined as 80% or more BP measurements during 2023 at goal, meaning 130mmHg systolic BP or less and 80mmHg diastolic BP or less. Results: Out of 1,821,685 adult members of Maccabi HMO during 2023, 361,721 patients were defined as hypertensive (20%). Only 0.5% (1750) of the hypertensive population were at some stage during 2023 on at least 5 anti-hypertensive medications (i.e., apparent refHTN). Of these only 264 patients (15%) were adherent to their medications during the whole year. There was no significant difference between adherence to the different drug classes: 15% were fully adherent to alpha blockers and central alpha 2 agonists, 16% to beta blockers and 17% to direct vasodilators. Practically all (99%) prescriptions given to fully adherent patients were of medications acting on the sympathetic nervous system, correlating with our understanding of refHTN (figure 1). Of the fully adherent patients’ group, only 58 patients (22%) were well controlled during 2023 on a stable 5-7 drug regimen, with 1 patient adherent to 8 drugs. The remaining 78% (205 patients) of the fully adherent group were not optimally controlled and were therefore defined as true refHTN. There was a non-significant trend towards better control of blood pressure with beta blockers vs. alpha blockers (26% vs. 23% of patients, respectively). Conclusions: Novel antihypertensive medications are needed in order to manage this most challenging subgroup of hypertensive patients.

BACKGROUND:Patients undergoing bariatric surgery are prone to changes in absorption, improvement in their chronic diseases and other pharmacokinetic/pharmacodynamic alteration which can affect continuation and the required doses of their chronic medications.OBJECTIVES:To examine the effect of a clinical pharmacist's consultation on the rate of complications, re-hospitalizations and mortality among patients who underwent bariatric surgery.METHODS:In this retrospective cohort study, results of bariatric patients who were consulted by a clinical pharmacist between the years 2013-2019 were compared with the results of a wider group of bariatric patients with chronic diseases who were recorded in the Israeli General Bariatric Registry during the same years. The intervention cohort included bariatric patients members of Clalit Health Services, who were treated at the Herzliya Medical Center and who were identified by the treating staff as complex cases requiring drug counseling. The primary outcomes measured in the study included: rates of surgical complications, re-hospitalizations, and death up to one year after surgery.RESULTS:The intervention group included 165 patients; the 12 month rate of re-hospitalization in the intervention group was 10.9% vs. 19.5% in the comparison group (p=0.005). The rate of documented postoperative complications was 2.7% vs. 3.9% (p=0.462) and mortality was null vs. 0.16%.CONCLUSIONS:Although the intervention population was identified in advance as more complex in terms of age and background morbidity, the rate of re-hospitalization and mortality was significantly lower in the intervention group than in the general bariatric surgery population in Israel. These results demonstrate the importance of referring to a specialized clinical pharmacist around bariatric surgery for improving patient safety, especially in complex patients.

PURPOSE:In Israel, a public committee advises which new medications should be reimbursed subject to an annual budget allocation. The committee considers clinical trial outcomes, professional societies' preferences, projected budget impacts, and other social and ethical aspects. The Israeli oncologists' society places a strong emphasis on prioritizing adjuvant therapies because of their potential to advance cure. In 2023, several novel adjuvant therapies were suggested for national funding. Our objective was to ascertain whether Israeli decision makers have embraced the practice of prioritizing budgets for therapies with curative intent over late-disease therapy. METHODS:We collected data on all proposed cancer therapies for the 2023 update: indications, treatment settings, European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) score, and whether accepted for reimbursement. The rates of acceptance were compared between drugs in curative and noncurative settings. Data were extracted from the official Israeli Ministry of Health publications and ESMO-MCBS website. RESULTS:Seven of the eight proposed therapies with curative intent received reimbursement approval (88%), in contrast to 11 of the 55 therapies for advanced/metastatic stages (20%). Among all advanced disease therapies with a high ESMO-MCBS score of 4, only four of 16 (25%) secured reimbursement approval. CONCLUSION:Our analysis revealed that during the 2023 reimbursement deliberations, Israeli policymakers embraced the prioritization of potentially curative therapies over treatments for incurable cancers, including several interventions that have demonstrated significant improvements in overall survival and/or quality of life. Introducing objective cost-effectiveness measures as a guiding framework for comparing competing medications may offer some resolution to this complex challenge.

The purpose of this work was to investigate the effect of clinical pharmacist consultation on the long-term morbidity and mortality outcomes among patients undergoing bariatric surgery. In this retrospective cohort study, 165 bariatric patients at Herzliya Medical Center who were identified as complex cases and were consulted by a clinical pharmacist (2013–2019) were compared with a wider group of bariatric patients with chronic diseases who were recorded in the Israeli General Bariatric Registry during the same years. The primary outcomes were rates of surgical complications, re-hospitalizations, and death up to one year after surgery. The secondary outcome was the rate of re-hospitalizations in different time periods. The twelve (12)-month rate of re-hospitalization in the intervention group was 10.9% vs. 19.5% in the comparison group (p = 0.005); the rate of documented postoperative complications was 2.7% vs. 3.9% (p = 0.462), and mortality was null vs. 0.16%, respectively. As for the secondary outcomes, the rates of re-hospitalizations in the periods of 0–30, 31–90, 91–180, and 181–365 days after surgery were 1.8% vs. 5.3% (p = 0.046), 2.4% vs. 4.1% (p = 0.278), 3.6% vs. 4.8% (p = 0.476), and 7.3% vs. 9.9% (p = 0.256) in the intervention vs. comparison cohorts, respectively. In conclusion, this study demonstrates the importance and benefit of referring to a specialized clinical pharmacist around bariatric surgery for improving patient safety, especially in complex patients. This is the first study to look at the long-term effects of clinical pharmacist consultation on re-hospitalization and mortality among bariatric patients, and our encouraging outcomes should hopefully stimulate more studies to show the invaluable role of specialized clinical pharmacists.

Objective: Refractory hypertension (refHTN) is defined as blood pressure that remains uncontrolled on maximal therapy, which is defined as the use of 5 or more antihypertensive agents of different drug classes. We aimed to define the prevalence of apparent and true refHTN in a real life national registry of an Health Maintenance Organization (HMO). Design and method: In this real-life observational study we utilized the Maccabi Healthcare Services (MHS) database during 2023. Data includes pharmacy prescriptions and purchases. Apparent refHTN was defined as patients included in the Maccabi “Hypertension Registry” during 2023 and taking 5 different antihypertensive medications of different classes, of which four were from pre-specified groups (diuretics, CCB, RAAS inhibitors and MRAs). True refHTN (unlike apparent refHTN) was defined as being fully adherent to the antihypertensive medication regimen with at least 6 prescriptions and purchases (refills) during 2023 as well as blood pressure which was not optimally controlled during the year (less than 80% of blood pressure measurements equal or below the well-defined target of 130/80mmHg). Results: Out of 1,821,685 adult members of Maccabi HMO during 2023, 361,721 patients were defined as hypertensive patients (20%) and included in the registry. 0.5% (1750) of the hypertensive population were at some stage during 2023 on at least 5 anti-hypertensive medications (i.e., apparent refHTN). Of those only 264 patients (15%) were adherent to their medications during the whole year. Mean age was 71.3 years. Of the well adherent group, 205 patients (77%) were not optimally controlled and thus regarded as true refHTN. Therefore in total, true refHTN was evident in 0.056% of hypertensive population in Maccabi HMO. Conclusions: In an “optimal world” which lacks physician inertia, four medication regimen is prescribed (Diuretics, CCB, RAAS inhibitors and MRAs) and there is willingness to prescribe a fifth and a sixth medication, if needed (alpha blockers, beta blockers, central alpha-2 agonists or direct vasodilators). In the unlikely case of full adherence to all medications, true refHTN is extremely rare (0.056% of hypertensive patients). This suggests that most hypertensive patients can be well controlled using the current anti hypertensive armamentarium.

e18599 Background: The Israeli National Insurance Law determines a uniform benefits package ('the Health Basket') for all residents. A public committee advises each year on which new medications should be added to the Health Basket, subject to the fixed annum budget allocated by the government for this purpose. The clinical benefit of the proposed health technologies is the committee's prime consideration; however, the committee also considers the professional medical societies' prioritizations, the expected budget impact, and other social and ethical aspects. Towards the annual discussions for 2023, 63 new indications for 41 cancer drugs were proposed for the annual update. Of those, 8 were for novel neo-adjuvant/ adjuvant indications, all given high priority ranks by the Israeli Oncologists Society based on the significant disease-free survival (DFS) figures from the phase III clinical trials. Varying the adjuvant treatment practice patterns based solely on DFS figures without available overall survival (OS) data has been in much debate recently between global key opinion leaders. We, therefore, aimed to evaluate whether the Israeli decision-makers have de-facto accepted the attitude of prioritizing budgets for adjuvant/neo-adjuvant therapies as the Israeli Oncologists Society recommended. Methods: We collected data on all cancer therapies proposed for inclusion in the 2023 Health Basket update; drug name, indication, treatment setting (curative intent vs. metastatic disease therapy), ESMO-MCBS grade, and whether or not accepted for reimbursement. All data were extracted from the official Israeli Ministry of Health website publications and press releases. Results: 20% of the allocated budget for updating the National Health basket for 2023 was provided to treat solid tumor cancers. 7 out of the 8 candidate therapies in the neo-adjuvant/adjuvant settings received reimbursement approval (88%) vs. 11 out of 55 therapies for advanced/ metastatic stages of disease (20%). 13 of the 16 candidate metastatic disease therapies that had a high ESMO-MCBS score (4 or 5) were not approved for reimbursement in the 2023 annual committee discussions. Conclusions: Our retrospective evaluation of the Israeli reimbursement prioritization process reveals that decision-makers have accepted the approach of prioritizing potentially curative adjuvant therapies over treatments for patients with incurable cancer. In an era of prosperity of adjuvant therapies in a range of tumor types, concerns might arise regarding restrictions on access to novel therapies for metastatic cancer, even those with proven benefits of significantly improving patients' OS and quality of life. Future analysis should determine the impact of this trend adopted by decision-makers in Israel on disease progression and overall survival in the real-world setting.

Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications. Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss. During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19–72) and 40.6 ± 5.9 kg/m2 (range 35–71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7–78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018). Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Background: Many health benefits of bariatric surgery are known and well-studied, but there is scarce data on the benefits of bariatric surgery on the thyroid function. Objective: We aimed to make a meta-analysis regarding the impact of bariatric surgery on thyroid-stimulating hormone (TSH) levels, levothyroxine dose, and the status of subclinical hypothyroidism. Setting: Systematic review and meta-analysis. Methods: PubMed, EMBASE, and Cochrane Library were searched up to December 2020 for relevant clinical studies. Random-effects model was used to pool results. Network meta-analysis was performed, incorporating direct and indirect comparisons among different types of bariatric surgery. Meta-regression analysis was performed to evaluate the impact of moderator variables on TSH levels and required levothyroxine dose after surgery. We followed the PRISMA guidelines for data selection and extraction. PROSPERO registry number: CRD42018105739. Results: A total of 28 studies involving 1284 patients were included. There was a statistically significant decrease in TSH levels after bariatric surgery (mean difference = -1.66 mU/L, 95%CI [-2.29, -1.03], P < .0001). In meta-regression analysis, we found that the following moderator variables: length of follow-up, mean age, baseline TSH, and preoperative thyroid function, could explain 1%, 43%, 68%, and 88% of the between-study variance, respectively. Furthermore, subclinical hypothyroidism was completely resolved in 87% of patients following bariatric surgery. In addition, there was a statistically significant decrease of levothyroxine dose in frank hypothyroid patients following bariatric surgery (mean difference = -13.20 mcg/d, 95%CI [-19.69, -6.71]). In network meta-analysis, we found that discontinuing or decreasing levothyroxine dosewas significant following Roux-en-Y gastric bypass, 1 anastomosis gastric bypass, and sleeve gastrectomy, (OR = 31.02, 95%CI [10.34, 93.08]), (OR = 41.73, 95%CI [2.04, 854.69]), (OR = 104.03, 95%CI [35.79, 302.38]), respectively. Conclusions: Based on our meta-analysis, bariatric surgery is associated with the resolution of subclinical hypothyroidism, a decrease in TSH levels, and a decrease in levothyroxine dose. (C) 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Bariatric surgery is an effective treatment of obesity and related comorbidities. With surgery, the stomach undergoes major anatomical/physiological changes that may affect the oral exposure of drugs, especially marginally soluble weak bases, such as lamotrigine. The aim of this work was to study the solubility/dissolution of lamotrigine in conditions simulating the stomach before vs. after bariatric surgery. Lamotrigine solubility was studied in-vitro, as well as ex-vivo in gastric content aspirated from patients before vs. after bariatric surgery. We then compared the dissolution kinetics of various marketed lamotrigine products in pre- vs. post-operative stomach conditions, different in volume, pH, agitation strength and speed. Decreased lamotrigine solubility with increasing pH (from 1.37 ± 0.09 (pH = 1) to 0.22 ± 0.03 mg/mL (pH = 7)) was obtained. Twelve-fold higher lamotrigine solubility was revealed in gastric content aspirated before vs. after surgery (8.5 ± 0.7 and 0.7 ± 0.01 mg/mL, respectively). Dissolution studies showed that only the lowest dose (25 mg) fully dissolved in the post-surgery stomach conditions, while at higher doses, lamotrigine tablet dissolution was impaired. Neither fast-dissolving tablet, nor tablet crushing, helped resolving this problem. Based on these results, and given that dissolution of the drug dose governs the subsequent absorption, close monitoring of this essential drug is advised after bariatric surgery.

Bariatric surgery may alter the absorption and overall bioavailability of oral drugs. Lamotrigine is a major antiepileptic and mood stabilizer, that its use after bariatric surgery has not yet been studied. In this article, we provide a thorough mechanistic analysis of the effects of bariatric surgery on multiple mechanisms important for the absorption, bioavailability and overall pharmacokinetics of lamotrigine. Attributable to its pharmacokinetic properties and drug characteristics, the use of lamotrigine after bariatric surgery may be challenging. The complex situation in which some mechanisms may lead to increased drug exposure (e.g., decreased metabolism, weight loss) while others to its decrease (e.g., hampered dissolution/solubility, decreased gastric volume), may result in lowered, unchanged, or enhanced lamotrigine plasma levels after the surgery. We conclude with a set of clinical recommendations for lamotrigine treatment after bariatric surgery, aiming to allow better patient care, and emphasizing the extra caution that needs to be taken with these patients.

Clinical pharmacists have advanced training that enables them to manage medication therapy, including prescribing, titrating, and discontinuing medications, in order to achieve therapeutic goals. In some countries, such as the United States, advances in training, responsibility, legal frameworks, and public acceptance of new roles have proceeded in parallel to expand the scope and contribution of clinical pharmacists over several decades. In this manuscript, we detail seven discrete key parameters of professional advancement for clinical pharmacists, corresponding to the seven areas in which they must advance in order to contribute fully to delivering high-quality medical care. For each key parameter, we briefly summarize the progress made in the United States to date, as well as goals for future progress. We then compare this to the development of the analogous key parameter in Israel. We found that on some key parameters, the development of clinical pharmacy in Israel lags behind the United States. This manuscript can provide a roadmap for the future advancement of clinical pharmacy in Israel, toward its full realization as a profession that can contribute to delivering high-quality medical care.

Background Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. Methods A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Results Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. Conclusion This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

Bariatric surgery is increasingly performed in morbidly obese HIV patients. Limited data exist regarding antiretroviral drug exposure after bariatric surgery. We report a case of a morbidly obese HIV patient who underwent sleeve gastrectomy. Abacavir, lamivudine, and dolutegravir therapeutic drug monitoring was performed at several time points pre- and postsurgery. Significantly increased levels were measured, particularly for abacavir, whose levels increased ∼12-fold. Several mechanistic explanations for these findings are discussed.

As COVID-19 has been expanding rapidly around the world, the types of patients and their backgrounds vary. The substantially altered GI anatomy/physiology after bariatric surgery presents new challenges to the field of oral drug therapy. In this report we highlight issues for consideration when treating COVID-19 patients who previously underwent bariatric surgery and provide practical tools to allow optimal care of these patients. Post-bariatric absorption/pharmacokinetic changes may warrant dose adjustment, as well as the use of liquid oral dosage forms or parenteral routes of administration, if available. Realizing the potentially altered pharmacokinetics of various drugs after bariatric surgery is essential for providing optimal pharmacological therapy and overall patient care.