Just had Lap Band to RNY Revision...Antidepressant metabolism question...

[CyclicalLoser 155]

Hello everyone, I have not been on here a while, but I had my revision from lap band to RNY surgery on July 9th. I was about 280 day of surgery and left 2 days later at 287 (?). Today I'm down to 274. I was out for 5 hours, the surgeon said there was a lot of scar tissue. I thought it was kind of cool because the surgery was robot assisted, which I haven't seen used much for bariatric procedures.

Anyways, the root of my post...Lately I've been having strange dizzyness and head compression feelings. I strongly do not think this is related to the RNY because I've actually been able to get 60g Protein and about 48oz of liquid per day. I've found I can drink more than 1oz per 15 minutes without feeling poorly, and my urine color is not dark yellow. BP is normal and blood sugar is normal (I checked it even though I'm not a diabetic)

Also, I've had these kinds of dizziness/pulsed-compression feelings before when I tapered onto or off of antidepressants. I'm almost positive that's what I'm feeling.

I take 75mg in the morning of lamictal for cyclothymic disorder (Essentially a version of bipolar-II where I don't have mania, but instead have atypical depression). I am on a very small dose, in the past, small doses worked very well for me. I believe the normal bipolar-2 dose is about 150mg. Anyways, I take 3x25mg tablets in the morning. I've done some reading and found that lamictal is poorly metabolized post RNY, so I was wondering if anyone here had to change theirs, and if so, by what multiple? (e.g. 4x amount, 2x, etc..). I know my psychiatrist is very willing to work with me on it, but I'd like to have a general idea before I go see him. I should have had them check for blood levels post surgery, but alas, I didn't.

I also have panic disorder/General Anxiety and that was "more or less" under control with 2x25mg Luvox in the morning and 2x25MG Luvox in the evening. Luvux is also supplied in a very small tablet. (Both Luvix and lamictal are smaller than a claratin). I haven't seen much on Luvox directly since it is an older SSRI that everyone has pretty much forgot about, but for me it worked much better than the newer ones like Lexapro. Typically, with me, I get abnormal yawning reflexes when my Serotonin is being affected by an SSRI, and I'm not seeing it, so I suspect the metabolism of the lamictal is more the culprit (Although the wierd dizziness happens with SSRI taper as well).

My doc told me that I did not need to crush any tablets smaller than an M&M, so I have not been crushing them.

Thanks for any thoughts and I'm excited to be part of the RNY club.

[Missouri-Lee's Summit 1,256]

My surgeon uses the DaVinci robotic-assisted laparoscopic technique. In fact, he recently flew to Sweden to give a talk on it.

My daughter is a PharmD. She insists that I use the generic name instead of the brand name. There are several reasons why it's better to use the generic name instead of the brand name, but I don't want to bore you with the reasons why.

Hardly any information is available regarding the absorption of most drugs after a bariatric procedure. Unfortunately, and because the Roux-en Y gastric bypass (RYGB) is a malabsorptive procedure, it's particularly disappointing to find next to nothing in the research literature. This information is so important!

Fluvoxamine (Luvox) -- Found almost nothing.

Lamotrigine (Lamictal)-The impact of bariatric surgery on psychiatric pharmacotherapy has not received much attention, and few specific recommendations exist to optimize medication regimens for this population. Based on the potential for decreased absorption, it has been suggested that patients taking lamotrigine be monitored for decreased efficacy.

Unfortunately, you'll most likely have to put up with being a guinea pig when it comes to finding the dose that gives you the result you need to feel "good".

By the way, lamotrigine comes in chewable tabs, the largest dose being 25mg. For the regular tabs, 25mg is the smallest dose!

Also, why do you take 2x/25mg tabs of fluvoxamine instead of one 50mg tab (which is also available)?

Edited July 18, 2018 by Missouri-Lee's Summit

[KimTriesRNY 1,853]

6 hours ago, Missouri-Lee's Summit said:

My daughter is a PharmD. She insists that I use the generic name instead of the brand name. There are several reasons why it's better to use the generic name instead of the brand name, but I don't want to bore you with the reasons why.

Curious. Go on and bore us lol.

I was told by my doctor this depends on the medication.

The active ingredient in both generic and name brand medications is supposed to be the same but many times it is the inactive ingredients that are different.

Other than cost difference why prefer a generic?

[Missouri-Lee's Summit 1,256]

@KimTriesRNY When I say generic drug name, I don't mean generic in the sense of "lesser" or "off-brand". This is more like it's pharmaceutical name. It's real name. Think about the common acetaminophen. Many people refer to it as Tylenol, which is well-known but it's really just a brand name for acetaminophen. Many drug stores (CVS, Walgreen's, Wal-Mart) carry there own brands of acetaminophen with more obscure brand names like CVSHealth or Equate. What if someone went to the hospital and when asked what they take for pain relief they answered. "I take Equate." Giving the brand name, in this case, tells the hospital staff nothing. If you're able to remember acetaminophen, however, there is absolutely no mistake. The generic drug name is not always easy to "remember" or even spell or say, so it's a good idea to write down your meds with their generic drug names, if possible. I often have to admit to nurses and other health professionals that I don't speak brand names. For that reason, I get confused when asked, "Do you still take Xanax?" Yes, Xanax is a common brand name, but I only know it as alprazolam.

Likewise, some bariatric patients are given Dilaudid (the brand name) but its generic drug name is hydromorphone. It's not wrong to use a brand name, but there can be confusion. I'm just following the advice of my daughter, and my two sons (who are medical doctors). This is not something I do to appear snooty-toot-toot. I do it because I now understand the difference between a drug's generic drug name and its brand name. If you're not sure what the generic drug name is, describe the pill (color, letters, numbers) and enter into a pill-identifier site this one: https://www.drugs.com/pill_identification.html

Brand names for lisinopril include Prinivil and Zestril. Sites like this one identify over-the-counter medication as well as by-prescription medication.

When I said I didn't want to bore anybody, I didn't intend to appear facetious; I was really just too lazy to continue with my way-after-midnight post and, truthfully, I wasn't sure if anyone gave a flying fig newton.

[Briswife15 889]

LOL! I thought I was the only one who said Flying fig newton!!!

[CyclicalLoser 155]

Missouri-Lee's Summit, thank you for your post and you are most definitely correct, shame on me for using a defacto name I know better than that, I just finished grad school.

My psychiatrist gives me the lowest dosage forms possible because he has given me permission to alter the dose (Slightly mind you) so that I don't have to keep coming back every month. I've been a patient of his for years and based on my unwillingness to take a benzodiazepine medication, he is not worried about addiction issues.

Because of this, my pharmacist probably hates me, but truth is most pharmacies have automated pill fillers anyway.

I was not aware of the chewable lamotrigine, I will definitely ask to switch because the normal ones are extremely bitter and taste awful when crushed. I found some references yesterday that grinding them gave a little bit better bioavailability, so this morning I chewed all three of them and man was it nasty.

Last night, as a test, I took an additional 25mg about an hour before bed. Half an hour later I felt better. Still not normal, but some of the discontinuation symptoms went away. The half life is 29 hours, so I'm wondering how I've been okay for almost a week. I suspect it may be fat soluable, or more likely my mind has been concentrating more on the pain and only now has enough spare time to realize things aren't normal.

I'm going to call my psychiatrist and see if I can get an appointment. I will update this thread as I go so that someone else doesn't have to reinvent the wheel. I'd switch to a different medication, but lamotrigine is an absolutely outstanding medication, the only one I've been happy with over the last 20 years.

[Briswife15 889]

CyclicalLoser, thanks for starting this thread, which I'm watching closely as my psychiatrist told me emphatically not to have RNY because of the drug malabsorption issues. I'm stil pre op, and don't know what to do. I can't do the sleeve because of GERD. Hope you sort your meds out and feel better soon.

[Missouri-Lee's Summit 1,256]

Hey, what's wrong with benzodiazepines? I take two short-acting ones, clonazepam (at bedtime) and alprazolam (for panic attacks.) Don't worry, I understand how and when not to mix my meds, including my opioids and benzos. I also take sertraline (depression) and buspirone (anxiety).

I used to be touchy about the idea of taking addictive medication. As a chronic pain patient, I tried several non-narcotic and holistic approaches to pain relief. My daughter finally explained to me the difference between addiction and dependence. She told me that there is no shame in taking morphine, for example. I am dependent on the drug for pain relief. Yes, I would have withdrawal symptoms if I stopped taking it, but I'm not addicted in the sense that I'm stealing money out of my 19-year-old son's piggy bank because it makes me feel all warm and wonderful. Really, I'm just addicted to not being in around-the-clock pain! And taking morphine for someone who is opioid-tolerant does give one a "high"; it merely takes the edge off the pain so I can function without tears of pain running down my face.

[Missouri-Lee's Summit 1,256]

@Briswife15 That doesn't sound right. The overall health benefits of weight-loss surgery shouldn't be dismissed outright because of an unknown bioavailability issue that most likely can be managed with dose experimentation. There just isn't enough research out there for him to declare, "Don't get surgery!" This puts you in a very fragile and frustrating position. Bariatric medicine is something too few doctors understand, so is it any wonder that they prefer avoidance -- hey, it's easier, right?

"Surgeons and psychiatrists often practice in very different professional circles. There is often no rounding service for inpatient psychiatric consultations available unless patients proclaim suicidal ideations. There is a mutual reticence of psychiatrists to care for perioperative patients who may be having GI symptoms, and surgeon reluctance to manage psychiatric issues when a consultant is not readily available. When patients with significant psychiatric conditions suffer a loss of stability on surgical floors, it can be very difficult, time-consuming, and disconcerting for surgical teams to manage.

Patients are presenting for bariatric evaluation with significant psychiatric disorders with increasing frequency. Existing data do suggest that the benefits of bariatric surgery in terms of weight loss are real, and that surgical outcomes should be good. There is a glaring lack of any information regarding the effect on the person as a whole to guide us as surgeons. The best evidence continues to suggest that in carefully selected patients, bipolar disorder or other Axis 1 disorders are not a contraindication to bariatric surgery. This requires a means and willingness for surgeons and psychiatrists to work closely together to deliver coordinated care and to ensure that recommended follow-up is achieved. Currently, this is not an easy task in most institutions. Lastly, while patients with significant psychiatric conditions may not be contraindicated for bariatric surgery, neither is bariatric surgery a treatment for these conditions, and this fact does not always match up with preoperative patient expectations. This is an area that is ripe for research." See: Clinical Challenges of Bariatric Surgery for Patients with Psychiatric Disorders. Commentary on: “Lithium Toxicity Following Roux-en-Y Gastric Bypass”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063371/

Edited July 18, 2018 by Missouri-Lee's Summit

[Briswife15 889]

@Briswife15 That doesn't sound right. The overall health benefits of weight-loss surgery shouldn't be dismissed outright because of an unknown bioavailability issue that most likely can be managed with dose experimentation. There just isn't enough research out there for him to declare, "Don't get surgery!" This puts you in a very fragile and frustrating position. Bariatric medicine is something too few doctors understand, so is it any wonder that they prefer avoidance -- hey, it's easier, right?
"Surgeons and psychiatrists often practice in very different professional circles. There is often no rounding service for inpatient psychiatric consultations available unless patients proclaim suicidal ideations. There is a mutual reticence of psychiatrists to care for perioperative patients who may be having GI symptoms, and surgeon reluctance to manage psychiatric issues when a consultant is not readily available. When patients with significant psychiatric conditions suffer a loss of stability on surgical floors, it can be very difficult, time-consuming, and disconcerting for surgical teams to manage.
Patients are presenting for bariatric evaluation with significant psychiatric disorders with increasing frequency. Existing data do suggest that the benefits of bariatric surgery in terms of weight loss are real, and that surgical outcomes should be good. There is a glaring lack of any information regarding the effect on the person as a whole to guide us as surgeons. The best evidence continues to suggest that in carefully selected patients, bipolar disorder or other Axis 1 disorders are not a contraindication to bariatric surgery. This requires a means and willingness for surgeons and psychiatrists to work closely together to deliver coordinated care and to ensure that recommended follow-up is achieved. Currently, this is not an easy task in most institutions. Lastly, while patients with significant psychiatric conditions may not be contraindicated for bariatric surgery, neither is bariatric surgery a treatment for these conditions, and this fact does not always match up with preoperative patient expectations. This is an area that is ripe for research." See: Clinical Challenges of Bariatric Surgery for Patients with Psychiatric Disorders. Commentary on: “Lithium Toxicity Following Roux-en-Y Gastric Bypass”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063371/

Hi, Missouri- Lee's Summit, yes, I'm quite upset and concerned! Thanks for your support, and the info you posted. My bariatric surgeon requires a psych evaluation and hopefully the psych he sends me to will be more encouraging and helpful than my personal psych. I have the mindset that I'm going to have the RNY, and get healthy finally (I have a lot of comorbidities). I don't want to be freaking out about possible medication problems.

Sent from my SM-N950U using BariatricPal mobile app

[Missouri-Lee's Summit 1,256]

@Briswife15 Hopefully, the psychologist you visit will have some background in evaluating potential bariatric patients. We're actually a scary population for most health professionals because it exposes their lack of knowledge about what bariatric surgery involves.

My psych evaluation was a 20-minute appointment that assessed my readiness to commit to the lifestyle changes ahead. When we were finished talking, she took a blank page of letterhead and wrote, by hand, a short letter "psychologically" clearing me for surgery.

Psychologists know zilcho about meds, by the way, because they aren't medical doctors; they're either licensed social workers or PhDs... and neither can prescribe medication. Not that you wouldn't know this. Sometimes I can't stop my fingers from talking my hand off!

[CyclicalLoser 155]

Briswife15, you're welcome. My surgeon really wanted me to go with the Sleeve because of the lamotrigine, but I had my psychiatrist call him and give the okay. At the end of the day, we know our moods better than anyone, and we know if we can tolerate some trial and error. I called and I have an appointment on Monday, I'll keep y'all posted!

[Missouri-Lee's Summit 1,256]

Yes, @CyclicalLoser. Keep us posted. I very much want to know how things progress for you, too.

[CyclicalLoser 155]

I agree, Psychologists are not doctors in a medical sense - my sister is actually a psychologist and she has a PsyD which is a Doctorate's in Psychology. Generally, I would say that some psychologists by nature of their instruction tend to be skeptical about medications (Beliveing in the "environmental" cause). Others are more willing to work with a psychiatrist (Who can prescribe as noted, and due to their instruction tend to believe in the "physiological" cause) and those are, in my opinion, the ones that are worth seeing. I would have another heart to heart with your psychiatrist and express your desire to have the RNY, and your wilingness to work through the adjustment period.

re Benzos: I get it and I actually do have both lorapezam and alprazolam for break through anxiety. I just need a lot of anxiety before I take them - I have used about ten over the last 20 years, but I did take an alprazolam before surgery so I wouldn't pass out from a panic attack like I almost did when I got the lap band 7 years ago. In general, benzos do have a huge addictive potential, but it sounds like you have that under control

[KimTriesRNY 1,853]

6 hours ago, Missouri-Lee's Summit said:

@KimTriesRNY When I say generic drug name, I don't mean generic in the sense of "lesser" or "off-brand". This is more like it's pharmaceutical name. It's real name. Think about the common acetaminophen. Many people refer to it as Tylenol, which is well-known but it's really just a brand name for acetaminophen. Many drug stores (CVS, Walgreen's, Wal-Mart) carry there own brands of acetaminophen with more obscure brand names like CVSHealth or Equate. What if someone went to the hospital and when asked what they take for pain relief they answered. "I take Equate." Giving the brand name, in this case, tells the hospital staff nothing. If you're able to remember acetaminophen, however, there is absolutely no mistake. The generic drug name is not always easy to "remember" or even spell or say, so it's a good idea to write down your meds with their generic drug names, if possible. I often have to admit to nurses and other health professionals that I don't speak brand names. For that reason, I get confused when asked, "Do you still take Xanax?" Yes, Xanax is a common brand name, but I only know it as alprazolam.

Likewise, some bariatric patients are given Dilaudid (the brand name) but its generic drug name is hydromorphone. It's not wrong to use a brand name, but there can be confusion. I'm just following the advice of my daughter, and my two sons (who are medical doctors). This is not something I do to appear snooty-toot-toot. I do it because I now understand the difference between a drug's generic drug name and its brand name. If you're not sure what the generic drug name is, describe the pill (color, letters, numbers) and enter into a pill-identifier site this one: https://www.drugs.com/pill_identification.html

Brand names for lisinopril include Prinivil and Zestril. Sites like this one identify over-the-counter medication as well as by-prescription medication.

When I said I didn't want to bore anybody, I didn't intend to appear facetious; I was really just too lazy to continue with my way-after-midnight post and, truthfully, I wasn't sure if anyone gave a flying fig newton.

Yes.

As a Registered Nurse I am aware of this. I thought there was some chemical reason for it you were referring to. Not something regarding medication names.

I mistook what you were referring to when you said your daughter was a pharmD and thought you had some information that was more lucrative and not readily available. My bad.