Weight loss drugs and surgery

[Planktonmd]

30 Y/O Female, obese, otherwise healthy, on Sibutramine (Meridia) for 12 months, coming for Rhinoplasty under GA, any concerns?

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[sdn1977]

OK - I'll bite, although I really don't have much familiarity with Meridia, although I can't speak to technique if that was your question.

From its drug class alone, I'm going to guess you might see some changes in the cardiovascular system - increases in bp, changes in hr, some arrhythmias due to its effects on norepi.

From its effects on serotonin, you might see some platelet derangement, so more bleeding than you might otherwise expect????

Perhaps more nasal congestion than the same pt without Meridia post-op.

Depending on when the last dose was, you might see some changes due to the pt being off the drug for a bit, so some compensatory changes secondary, which might make it hard post-operatively to maintain bp control.

I've never seen a pt in an OR setting with Meridia, but I've also never seen weight reduction surgery of any kind in my location either. However, I have seen an ICU pt who was admitted post-trauma (not requiring surgery) who had been on Meridia & who had unstable bp & some arrhythmias for a few days, but it was hard to know if that was due to the stopping of the drug or the trauma & subsequent medical situation.

What did you find - anything you didn't expect to find???

 

[Noyac]

Before the FDA ban on ephedra type drugs we had an otherwise healthy young male who was having a very routine GA but ended up in the ICU on a pressor (epi) b/c of very low BP after induction. It was later revealed that he was taking large amounts of ephedra (Hydroxycut) in the days prior to surgery. He recovered fine but caused my group to send out a letter to all surgeons that we will cancel all elective cases in which the pt was taking these types of "herbals". We required them to be off the herbal for 2 weeks or greater. It wasn't a big issue after everyone got accustomed to asking about the meds in the preadmit. It was a burden early on however.

I vaguely recall a pt being on meridia that I treated a few years back. I believe we continued the med and I don't recall any consequences. Is that vague enough?

 

[urgewrx]

Probably the most important thing to do is give them a hamburger through an OG after induction.

 

[Planktonmd]

So, would you guys proceed with the case or postpone it?
And if you postpone, for how long?
These drugs in general inhibit the re-uptake of Norepinephrine and Dopamine, The half life of Meridia is around 16 hours.
It appears that there is very little data concerning these drugs and elective anesthesia, although you would think they are comparable to chronic Cocaine use when it comes to sympathetic reserve.
Knowing that a Rhinoplasty might involve injecting significant amounts of Local + Epinephrine, would that make you more or less concerned?

 

[urgewrx]

Never seen a pt on that drug.

Most places seem to ask pts to stop taking them. How long? I don't know. The company says in 15 days 86% of the drug is excreted. Does this translate to clinical effects under anesthesia? No, but 2 weeks seems like a good number.

Local w epi= probably ok since its a direct sympathomimetic.

Probably best to cancel the case. Or, you might want to do it under local + sedation.


Would you give Zofran, reglan or droperidol to this pt? There seem to be interactions but I could find what specifically.

 

[Noyac]

Another question to ask yourself is, " Is there any risk if they stop the medication?"

What do you think?

 

[sdn1977]

Another question to ask yourself is, " Is there any risk if they stop the medication?"

What do you think?

For a short period of time, I think the greatest risk of stopping the drug is the effect on bp & rhythm & this is most likely due to the combined effects of the drugs you might give in addition to the effect of the Meridia itself, but these changes will be very slow because of the active metabolites.

Meridia has two active metabolites, the longest has a half life of about 18-23 hours. Using the rule of thumb of 5 half lives to get rid of the drug & about as long to rebalance the neurotransmitters....you get about 10 days - close to what the previous poster mentioned.

To give you an idea....when a pt like this is started on an MAOI, there is a wash-out period of 14 days before the MAOI is started. That should be sufficient for any other drug exposure as well.

For the longer term (>5 days) you might see psychological effects after stopping suddenly due to its effects on serotonin.

You might also have the same drug interactions as anything that is metabolized by the CP450 system - erythromycins, ketoconazole, cimetidine, etc...

Likewise, anything that might interfere with platelets or clotting factors as well - ASA, Vit E, plavix, pletal, warfarin.....

 

[urgewrx]

Plankton, did you do the case? If so, how did it go?

 

[core0]

Another question to ask yourself is, " Is there any risk if they stop the medication?"

What do you think?

If you look at the effects it is similar to Wellbutrin + Lexapro (NRSI, SSRI, and Dopamine). This is a fairly common combination. I guess the other way to look at it would be would you cancel on those two drugs.

David Carpenter, PA-C

 

[rmh149]

If you look at the effects it is similar to Wellbutrin + Lexapro (NRSI, SSRI, and Dopamine). This is a fairly common combination. I guess the other way to look at it would be would you cancel on those two drugs.

David Carpenter, PA-C

Not on wellbutrin and lexapro. Your right, that is a common combination. But I have and would never cancel a case on those two drugs.

 

[Planktonmd]

Plankton, did you do the case? If so, how did it go?

Actually this was not my case, one of my partners asked me to help him make a decision.
I see this case as comparable to a chronic Cocaine user, and I wouldn't cancel such a case but there is no evidence either way and there are people who would wait 2 weeks.
He ultimately decided to wait 2 weeks.

 

[Noyac]

Actually this was not my case, one of my partners asked me to help him make a decision.
I see this case as comparable to a chronic Cocaine user, and I wouldn't cancel such a case but there is no evidence either way and there are people who would wait 2 weeks.
He ultimately decided to wait 2 weeks.

As I mentioned earlier, I have had one pt that I can remember that was taking this diet med and I didn't cancel her. The case went well.

 

[Intubate]

You guys don't cancel cases for MAOI's do you? I certainly wouldn't cancel for one of these diet drugs or a reuptake inhibitor of any kind. I agree with the comment likening the situation to a chronic cocaine user. You wouldn't cancel him unless he was acutely intoxicated (at least I wouldn't).