Advertisement

Effect of long-term proton pump inhibitor therapy on hemoglobin and serum iron levels after sleeve gastrectomy

      Highlights

      • 1.
        Iron deficiency anemia (IDA) and iron deficiency (ID) has been studied at depth for Roux En Y gastric bypass, and to some extent in sleeve gastrectomy patients.
      • 2.
        Gastro-esophageal reflux disease (GERD) is commonly associated with sleeve resections and warrants post-operative acid reducing therapy.
      • 3.
        This is a single institution case control study. Comparing preoperative and post-operative hemoglobin and serum iron levels in those patients still taking PPIs to those not taking PPIs at 12 months.
      • 4.
        We have not found any other study focusing this issue in bariatric population.
      • 5.
        Our study indicates that PPIs can increase the severity of post-operative iron deficiency and iron deficiency anemia in patients who underwent LSG.
      • 6.
        Aggressive surveillance is needed in those taking long-term PPIs after LSG and we encourage to discontinue PPIs as clinically appropriate.
      • 7.
        It is encouraged to further analyze these findings in a larger randomized study model.

      Abstract

      Background

      Iron deficiency anemia and iron deficiency are commonly seen after bariatric surgery. Gastroesophageal reflux disease is commonly associated with sleeve resections and warrants postoperative acid reducing therapy.

      Objective

      To analyze the impact of long-term proton pump inhibitors on iron deficiency or iron deficiency anemia in laparoscopic sleeve gastrectomy (LSG) patients.

      Setting

      University hospital, USA.

      Methods

      A single-institution case control study included 2 groups of bariatric patients who underwent LSG. Patient characteristics such as age, sex, American Society of Anesthesiologists risk, body mass index, nutritional status, and co-morbidities were comparable. Postoperative follow-up was scheduled at 1-week, and 1-, 3-, 6-, and 12-month durations. All received standard postoperative iron, multivitamin therapy, and nutritional screening and evaluation. All patients were placed on postoperative proton pump inhibitors (PPI) therapy for at least 3 months. At third postoperative visit, anemia indicators were assessed by serum iron concentration, total iron binding capacity, transferrin saturation, red blood cell count, hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin concentration. Postoperative hemoglobin and serum iron levels were compared between those patients still taking PPIs to those not taking PPIs at 12 months.

      Results

      A total of 287 patients underwent LSG from January 2016 to December 2017, 203 were included and 84 patients were excluded. Patients taking long-term PPIs (>12 mo, n = 85) were compared with those not taking PPIs (n = 118) and outcomes were respectively as follows: mean pre- and postoperative hemoglobin levels (in g/DL) were 13.2 and 10.7, and 13.3 and 13.7; mean postoperative serum iron levels (in μg/DL) were 41.7 and 88.7. Results were computed using paired t test and odds ratio that showed iron deficiency anemia in 12.9% (11/85) in PPI group compared with 4.23% (5/118) in the non-PPI group (odds ratio of 3.3, 95% confidence interval [1.21–10], and P = .03). Iron deficiency was seen in 22.3% (19/85) in the PPI group and 11% (13/118) in the non-PPI group (odds ratio of 2.3, 95% confidence interval [1.07–5.02] and P = .031).

      Conclusions

      Our study indicates that PPIs can increase the severity of iron deficiency and iron deficiency anemia in patients who underwent LSG. Aggressive surveillance is needed in those taking long-term PPIs after LSG. It is encouraged to further analyze these findings in a larger randomized study model design.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Amaya García M.J.
        • Vilchez López F.J.
        • Campos Martín C.
        • Sánchez Vera P.
        • Pereira Cunill J.L.
        Micronutrients in bariatric surgery [article in Spanish].
        Nutr Hosp. 2012; 27: 349-361
        • Ammor N.
        • Berthoud L.
        • Gerber A.
        • Giusti V.
        Nutritional deficiencies in candidates for bariatric surgery [article in French].
        Rev Med Suisse. 2009; 5: 676-679
        • Von Drygalski A.
        • Andris D.A.
        Anemia after bariatric surgery: more than just iron deficiency.
        Nutr Clin Pract. 2009; 24: 217-226
        • Anty R.
        • Dahman M.
        • Iannelli A.
        • et al.
        Bariatric surgery can correct iron depletion in morbidly obese women: a link with chronic inflammation.
        Obes Surg. 2008; 18: 709-714
        • Cheng H.L.
        • Bryant C.
        • Cook R.
        • O’Connor H.
        • Rooney K.
        • Steinbeck K.
        The relationship between obesity and hypoferraemia in adults: a systematic review.
        Obes Rev. 2012; 13: 150-161
        • Muñoz M.
        • Botella-Romero F.
        • Gomez-Ramirez S.
        • Campos A.
        • Garcia-Erce J.A.
        Iron deficiency and anaemia in bariatric surgical patients: causes, diagnosis and proper management.
        Nutr Hosp. 2009; 24: 640-654
        • von Drygalski A.
        • Andris D.A.
        • Nuttleman P.R.
        • Jackson S.
        • Klein J.
        • Wallace J.R.
        Anemia after bariatric surgery cannot be explained by iron deficiency alone: results of a large cohort study.
        Surg Obes Relat Dis. 2011; 7: 151-156
        • Damms-Machado A.
        • Friedrich A.
        • Kramer K.M.
        • et al.
        Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy.
        Obes Surg. 2012; 22: 881-889
        • Hartin Jr., C.W.
        • ReMine D.S.
        • Lucktong T.A.
        Preoperative bariatric screening and treatment of Helicobacter pylori.
        Surg Endosc. 2009; 23: 2531-2534
        • Ciacci C.
        • Sabbatini F.
        • Cavallaro R.
        • et al.
        Helicobacter pylori impairs iron absorption in infected individuals.
        Dig Liver Dis. 2004; 36: 455-460
        • McKie A.T.
        • Raja K.B.
        • Peters T.J.
        • Farzaneh F.
        • Simpson R.J.
        Expression of genes involved in iron metabolism in mouse intestine.
        Am J PhysiolGastrointest Liv Physiol. 1996; 271: G772-G779
        • Csendes A.
        • Braghetto I.
        Changes in anatomy and physiology of distal esophagus and stomach after sleeve gastrectomy.
        J Obes Weight Loss Ther. 2016; 6: 297
        • Alexandrou A.
        • Armeni E.
        • Kouskouni E.
        • Tsoka E.
        • Diamantis T.
        • Lambrinoudaki I.
        Cross-sectional long-term micronutrient deficiencies after sleeve gastrectomy versus Roux-en-Y gastric bypass: a pilot study.
        Surg Obes Relat Dis. 2014; 10: 262-268
        • Moize V.
        • Andreu A.
        • Flores L.
        • et al.
        Long-term dietary intake and nutritional deficiencies following sleeve gastrectomy or Roux-en-Y gastric bypass in a Mediterranean population.
        J Acad Nutr Diet. 2013; 113: 400-410
        • Schade S.G.
        • Cohen R.J.
        • Conrad M.E.
        Effect of hydrochloric acid on iron absorption.
        N Engl J Med. 1968; 279: 672-674
        • Hakeam H.A.
        • O’Regan P.J.
        • Salem A.M.
        • Bamehriz F.Y.
        • Eldali A.M.
        Impact of laparoscopic sleeve gastrectomy on iron indices: 1-year follow-up.
        Obes Surg. 2009; 19: 1491-1496
        • Saif T.
        • Strain G.W.
        • Dakin G.
        • Gagner M.
        • Costa R.
        • Pomp A.
        Evaluation of nutrient status after laparoscopic sleeve gastrectomy 1, 3, and 5 years after surgery.
        Surg Obes Relat Dis. 2012; 8: 542-547
        • McCarthy D.M.
        Adverse effects of proton pump inhibitor drugs: clues and conclusions.
        Curr Opin Gastroenterol. 2010; 26: 624-631
        • Ito T.
        • Jensen R.T.
        Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, and magnesium.
        Curr Gastroenterol Rep. 2010; 12: 448-457
        • Tran-Duy A.
        • Connell N.J.
        • Vannmolkot F.H.
        • Souverein P.C.
        • et al.
        Use of proton pump inhibitors and risk of iron deficiency: a population-based case-control study.
        J Intern Med. 2019; 285: 205-214
        • Lam J.R.
        • Schneider J.L.
        • Quesenberry C.P.
        • Corley D.A.
        Proton pump inhibitor or H-2 receptor antagonist use and iron deficiency.
        Gastroenterology. 2017; 152: 821-829
        • Kreig L.
        • Milstein O.
        • Krebs P.
        • Xia Y.
        • et al.
        Mutation of the gastric hydrogen-potassium ATPase alpha subunit causes iron-deficiency in mice.
        Blood. 2011; 118: 6418-6425
        • McColl K.E.
        Effect of proton pump inhibitors on vitamin C and iron.
        Am J Gastroenterol. 2009; 104: S5-S9
        • De Domenico I.
        • McVey Ward D.
        • Kaplan J.
        Regulation of iron acquisition and storage: consequences for iron-linked disorders.
        Nat Rev Mol Cell Biol. 2008; 9: 72-81
        • Andrews N.C.
        Iron metabolism: iron deficiency and iron overload.
        Annu Rev Genomics Hum Genet. 2000; 1: 75-98
        • Muñoz M.
        • Garcia-Erce J.A.
        • Remacha A.F.
        Disorders of iron metabolism. Part 1: molecular basis of iron homoeostasis.
        J Clin Pathol. 2011; 64: 281-286
        • Zhang A.S.
        • Enns C.A.
        Molecular mechanisms of normal iron homeostasis.
        Hematol Am Soc Hematol Educ Program. 2009; 1: 207-214
        • Hentze M.W.
        • Muckenthaler M.U.
        • Galy B.
        • Camaschella C.
        Two to tango: regulation of mammalian iron metabolism.
        Cell. 2010; 142: 24-38
        • Anderson G.J.
        • Frazer D.M.
        • McLaren G.D.
        Iron absorption and metabolism.
        Curr Opin Gastroenterol. 2009; 25: 129-135
        • Anderson G.J.
        • Vulpe C.D.
        Mammalian iron transport.
        Cell Mol Life Sci. 2009; 66: 3241-3261
        • Doulami G.
        • Triantafyllou S.
        • Natoudi M.
        • et al.
        GERD-related questionnaires and obese population: can they really reflect the severity of the disease and the impact of gerd on quality of patients’ life?.
        Obes Surg. 2015; 25: 1882-1885
        • Thereaux J.
        • Lesuffleur T.
        • Czernichow S.
        • et al.
        Do sleeve gastrectomy and gastric bypass influence treatment with proton pump inhibitors 4 years after surgery? A nationwide cohort.
        Surg Obes Relat Dis. 2017; 13: 951-959
        • Mandeville Y.
        • Van Looveren R.
        • Vancoillie P.J.
        • et al.
        Moderating the enthusiasm of sleeve gastrectomy: up to fifty percent of reflux symptoms after ten years in a consecutive series of one hundred laparoscopic sleeve gastrectomies.
        Obes Surg. 2017; 27: 1797-1803
        • Kwon Y.
        • Kim H.J.
        • Lo Menzo E.
        • Park S.
        • Szomstein S.
        • Rosenthal R.J.
        Anemia, iron and vitamin B12 deficiencies after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a meta-analysis.
        Surg Obes Relat Dis. 2014; 10: 589-597