1. Slide set for Workshop 3 Bariatric follow up in Primary Care Acknowledgments H Parretti and C Nwosu

2. WORKBOOK PAGES 21 - 25 Workshop 3 Bariatric follow up in Primary Care

3. Aims To review types and frequency of bariatric procedures To understand essential aspects of long term follow up after bariatric surgery To explore the role of audit in improving the quality of routine care in primary care

4. NICE Guidance CG 189 NICE guidance updated 2014 Expedited assessment for bariatric surgery if BMI greater than or equal to 35 and recent onset type 2 DM Consider bariatric surgery if BMI between 30 and 35 and recent onset diabetes First line option for those with a BMI more than 50kg/m 2 in whom surgical intervention is considered appropriate Lower BMI threshold if of Asian origin

5. Bariatric surgery types Types of surgery Restrictive Gastric banding Sleeve gastrectomy Malabsorptive and restrictive Gastric bypass Malabsorptive Duodenal switch

6. Bariatric surgery procedures Data: Health and Social Care Information Centre 2012 and Health Survey England 2012-13

7. Bariatric surgery procedures NBSR data 2011-2013 53.9% procedures were gastric bypass 21.4% procedures were gastric band 21.4% procedures were sleeve gastrectomy 0.06% procedures were duodenal switch

8. Bariatric surgery patient characteristics Average BMI pre-surgery 48.8kg/m 2 26% patients are male (increase from 16% in 2006) 26% women and 45% men have type 2 diabetes pre- surgery 71.5% women and 73.2% men have some functional impairment Average number of co-morbidities 3.4 for women and 3.7 for men (2.3 and 2.6 in 2006) 54% of men and 41% women have 4 or more co- morbidities Average number of co-morbidities increases with age and pre-surgery BMI

9. Funding and follow up Patients who have had their procedure carried out under the NHS have follow up within specialist services for the first 1-2 years post surgery Patients who have moved area or who undergo a private procedure are at risk of being lost to specialist follow up 76% procedures NHS funded and 22.6% privately funded Publicly fundedPrivately funded Gastric band18791686 Gastric bypass77501350 Gastrectomy2795819 Duodenal switch65

10. RCGP Top Tips These guidelines are aimed at all non-specialist clinicians, dietitians and nurses to aid management within primary care or where follow up guidance by the surgical team was not issued. National guidance not currently available for primary care Patchy commissioning of local Tier 3 weight management services means many post-bariatric surgery patients may be lost to follow-up, risking nutritional deficiencies and metabolic complications New concerns should always trigger referral to a Tier 3 weight management service (if available) or the local bariatric surgical team for further advice

11. Top Tip One Keep a register of bariatric surgery patients and record the type of procedure in the register Note that follow up varies according to the type of surgery

12. Top Tip Two Encourage patients to check their own weight regularly and to attend an annual BMI and diet review with a health professional

13. Top Tip Three Arrange emergency admission under the local surgical team if symptoms of continuous vomiting dysphagia intestinal obstruction (gastric bypass) severe abdominal pain

15. Top Tip Four Continue to review co-morbidities post surgery such as diabetes mellitus hypertension hypercholesterolaemia sleep apnoea mental health

16. Top Tip Four - A Medication needs are likely to fall with post-operative weight loss, but may increase later if weight loss is not maintained Keep on QOF diabetes register. Continue routine diabetes follow-up even if diabetes is in remission Cardiovascular and metabolic risk factors – continue to monitor and adjust treatments as required Patients on CPAP should continue to use their machines until repeat sleep studies are performed post surgery Mental health should be reviewed regularly. There is a higher rate of mental health problems in patients with severe and complex obesity surgery compared to the general population

17. Top Tip Five Review the patient’s regular medications. The formulations may need adjusting post-surgery to allow for changes in bio- availability and swallowing post surgery.

18. Top Tip Five - A Review co-morbidity medications post surgery, such as anti-hypertensives, diabetes medications, analgesics Use diuretics with caution due to the increased risk of hypokalaemia Replace extended release formulations with immediate release formulations Consider pill size – patients may need liquid formulations or syrups in the immediate post- operative period. Usual medication formulations should be tolerated by around 6 week post-op

19. Top Tip Five - B Avoid bisphosphonates Avoid NSAIDS: if no alternative use with PPI Monitor anticoagulants carefully Psychiatric medications may need increased or divided doses Avoid effervescent medications for patients with gastric bands

20. Top Tip Six Bariatric surgery patients require lifelong annual monitoring blood tests, including micronutrients. Encourage patients to attend for their annual blood tests. Gastric band patients only require FBC, U&Es and LFTs annually, or sooner if there are concerns about the band.

21. Blood testSurgical procedure Gastric bypassSleeve gastrectomyDuodenal switch LFTsYes FBCYes FerritinYes FolateYes Vitamin B12Yes* CalciumYes Vitamin DYes PTHYes Vitamin APossibly**NoYes Zinc, copperYesPossibly***Yes SeleniumNo*** * If patient is having three monthly intramuscular injections of vitamin B12, there may be no need for annual checks. **If the patient has a long limbed bypass, symptoms of steatorrhoea or night blindness. ***Measure when concerns

22. Top Tip Seven Be aware of potential nutritional deficiencies that may occur and their signs and symptoms. If a patient is deficient in one nutrient, then screen for other deficiencies too. In particular, consider risk of anaemia vitamin D deficiency protein malnutrition other vitamin and micronutrient deficiencies.

23. Top Tip Seven - A Protein malnutrition Oedema - need urgent referral back to the bariatric team Anaemia iron, folate and vitamin B12 deficiencies all possible. unexplained anaemia may result from less common causes such as zinc, copper and selenium deficiencies some patients may need parenteral iron or blood transfusions if oral iron does not correct the deficiency Calcium and vitamin D deficiency may result in secondary hyperparathyroidism Vitamin A deficiency suspect in patients with changes in night vision patients with steatorrhoea or those who have had a duodenal switch are at high risk

24. Top Tip Seven - B Zinc, copper and selenium unexplained anaemia, poor wound healing, hair loss, neutropenia, peripheral neuropathy and cardiomyopathy ask about OTC supplements and liaise with bariatric unit as zinc supplements can induce copper deficiency and vice versa Thiamine deficiency suspect in patients with poor intake, persistent regurgitation or vomiting may be caused by anastomotic stricture in the early postoperative phase, food intolerances or an overtight band start thiamine supplementation immediately and refer urgently to the local bariatric unit - risk of Wernicke’s encephalopathy (ophthalmoplegia, ataxia and confusion) do not give sugary drinks as this may precipitate Wernicke’s encephalopathy

25. Top Tip Eight Ensure the patient is taking the appropriate lifelong nutritional supplements, as recommended by the bariatric centre. Ensure guidance regarding vitamin supplementation has been issued by the bariatric surgery team. Request a copy for the patient’s GP records if this has not been included in the discharge information. More details: “GP Guidance for the Management of Nutrition following Bariatric Surgery” http://www.bomss.org.uk/nutritional-guidelines/ http://www.bomss.org.uk/nutritional-guidelines/

26. Top Tip Eight - A Gastric band No supplements should be needed, but a comprehensive multivitamin and mineral supplement od, (Sanatogen A to Z or Forceval) is recommended Gastric bypass multivitamin and mineral (OTC comprehensive multivitamin preparation bd or Forceval od) 3 monthly vitamin B12 injections calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or Calcichew D3 Forte) plus additional vitamin D as required iron (start at 200mg od and monitor as may need to increase dose), especially for women of menstruating age

27. Top Tip Eight - B Sleeve gastrectomy multivitamin and mineral (OTC comprehensive multivitamin preparation bd or Forceval od) 3 monthly vitamin B12 injections, if low B12 levels at 12 months calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or Calcichew D3 Forte) plus additional vitamin D as required possibly iron especially for women of menstruating age (dose as above) Duodenal switch As for gastric bypass, but additional fat soluble vitamins (A, D, E and K) also needed as well as possibly zinc and copper supplementation. Liaise with specialist local services for advice regarding these supplements

28. Top Tip Nine Discuss contraception – ideally pregnancy should be avoided for at least 12-18 months post surgery LARC of the patient’s choice would be appropriate. Avoid OCP due to issues with absorption Avoid Depo-Provera due to risk of weight gain

29. Top Tip Ten If a patient plans to become pregnant after bariatric surgery alter their nutritional supplements to one suitable during pregnancy Inform the local bariatric unit of patient’s pregnancy the obstetric team of the patient’s history of bariatric surgery

30. Top Tip Ten - A Gastric band patients may need their band adjusting Recommended changes before and during pregnancy are : Change forceval to a supplement appropriate in pregnancy such as Pregnacare or Boots Pregnancy Support If a PPI is needed, omeprazole recommended Continue vitamin D supplementation according to vitamin D levels and National Osteoporosis Society guidance Continue vitamin B12 injections or monitor vitamin B12 levels for those not receiving vitamin B12 injections (for sleeve gastrectomy patients) Iron 200mg od Folic acid 5mg od

31. Thanks Co-Authors Dr CA Hughes Ms M O’Kane Mr S Woodcock Dr R Pryke Full guidance available on RCGP Nutrition Web Pages

32. References Duke E and Finer N (2012) Bariatric Surgery: Pre-Operative and Post-Operative Care. Information for General Practitioners. UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, UK. Francis R et al, (2013) Vitamin D and Bone Health: A practical clinical guideline for patient management. National Osteoporosis Society. [Online] Available from: http://www.nos.org.uk/document.doc?id=1352 http://www.nos.org.uk/document.doc?id=1352 Heber D et al, (2010) Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism, 95 (11): 4823-4843. Mechanick JI et al, (2013) Clinical Practice Guidelines for the Perioperative Nutritional Metabolic and Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery. Obesity 21: S1-S27. National Institute for Health and Clinical Excellence (NICE) (2006) Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence. [Online] Available from: http://www.nice.org.uk/guidance/CG43. O’Kane M, Pinkney J, Aasheim ET, Barth JH, Batterham RL and Welbourn R (2014) Management of nutrition following bariatric surgery: GP guidance. [Online] Available from: http://www.bomss.org.uk/nutritional-guidelines/. http://www.bomss.org.uk/nutritional-guidelines/ Thomas CM et al. (2011) Monitoring for and Preventing the Long-term Sequelae of Bariatric Surgery. Journal of the American Academy of Nurse Practitioners 23: 449-458. Woodcock S (2014) Primary care management of post operative bariatric patients. British Obesity and Metabolic Surgery Society. [Online] Available from: insert RCGP nutrition pages URL here

33. Acknowledgments H Parretti and C Nwosu

34. WORKBOOK PAGES 26 - 32 Audit Tool for Managing Patients Post Bariatric Surgery in Primary Care

35. The Audit Tool Kit Running the audit of patients 2 years post bariatric surgery highlights:- Importance of coding Medication and co-morbidity review Annual blood monitoring Nutritional Supplements Annual health check Concerning symptoms Pregnancy

36. In the Real World! Results of a practice audit in the north of England showed Initial audit cycle - no patients had all their correct bloods done 55% of patients required an intervention based on blood results How does your surgery compare?