A 47-year-old man presents to the outpatient clinic after a referral from his bariatric surgeon. He had gastric bypass surgery one year ago and has lost 120 lbs with a current weight of 280 lbs. He reports worsening depression since gastric bypass surgery. He took Prozac in high school for depression and is wondering if he can restart this medication. What considerations would need to be made given gastric bypass history for this patient when administering Prozac? Is there another medication that may better address depression in a patient with a history of gastric bypass? Is there any additional monitoring that would be recommended?  Use of Fluoxetine in an Obese Patient Essay Example

Use of Fluoxetine (Prozac) in an Obese Patient Who Has Undergone Bariatric or Gastric Bypass Surgery

It is known that patients that are morbidly obese often suffer from depressive and mood disorders. Fr this reason, it is not uncommon to find that they are on some sort of antidepressant medication. One class of these medications is the serotonin reuptake inhibitor or SRI whose example is fluoxetine or Prozac (Stahl, 2017). However, according to De Jonge et al. (2017); it has been observed that when these obese patients undergo bariatric or gastric bypass surgery they relapse. This relapse to depression occurs despite still being on the antidepressant at the same therapeutic dose. The purpose of this paper is to address what needs to be done in this situation and to provide an alternative solution.

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Worsening Depression in a 47 Year-Old Male One Year Post Bariatric Surgery

The man has undergone gastric bypass surgery and says he took fluoxetine (Prozac) before and would like to continue with the same. Fluoxetine is a serotonin reuptake inhibitor or SRI. Studies have shown that in obese patients on SRIs who undergo Roux-en-Y gastric bypass operation, there is relapse of psychiatric symptoms because of reduced bioavailability of the medication (De Jonge et al., 2017; Hamad et al., 2012).  Use of Fluoxetine in an Obese Patient Essay Example  According to Hamad et al. (2012), this has been determined to be due to reduced solubility (lack of gastric acid due to resection of the stomach) and reduced absorption (due to less intestinal surface for absorption secondary to resection). Therefore, the considerations to be made given this patient’s history of gastric bypass surgery when administering fluoxetine (Prozac) are that (i) he needs to be monitored after surgery to see if he will not be experiencing any more the therapeutic benefits of the Prozac as he did before; and (ii) the development of depressive symptoms after the initial pre-operative positive response should warrant a change in medication class (Brandão et al., 2015).

Indeed, there is another class of medications that may better address depression in a patient with a history of gastric bypass surgery such as this 47 year-old male. These are serotonin norepinephrine reuptake inhibitors or SNRIs (Stahl, 2017). An example of these drugs that the patient in this case can use is desvenlafaxine (Pristiq). Additional monitoring that could be recommended is serum blood levels of the antidepressant being taken for a while after bariatric surgery.

References

Brandão, I., Fernandes, A.L., Osório, E., Calhau, M.C., & Coelho, R. (2015). A psychiatric perspective view of bariatric surgery patients. Archives of Clinical Psychiatry, 42(5). http://dx.doi.org/10.1590/0101-60830000000062

De Jonge, L., Petrykiv, D., Fennema, J., & Arts, M. (2017). The effects of bariatric surgery on pharmacokinetics of antidepressants: A systematic review. European Psychiatry, 41(Suppl.), S232-S233. https://doi.org/10.1016/j.eurpsy.2017.01.2244

Hamad, G.G., Helsel, J.C., Perel, J.M., Kozak, G.M., McShea, M.C., Hughes, C., Confer, A.L., Sit, D.K., McCloskey, C.A. & Wisner, K.L. (2012). The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. American Journal of Psychiatry, 169(3), 256-253. https://doi.org/10.1176/appi.ajp.2011.11050719

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.    Use of Fluoxetine in an Obese Patient Essay Example