What Can I Take for My Headache? I FORGET!

"What medications can I take for pain if I have had bariatric surgery? I always forget!

The short answer? TYLENOL. TYLENOL. TYLENOL.

Take Tylenol for pain. Its effects are much stronger at 165 pounds than when at 380 pounds. Try two Tylenol as it does not risk your pouch. Ulcers are a very bad problem to needlessly or accidentally create for yourself - please don't go to Walgreen's and buy the wrong kind of OTC pain capsules. You are safest with Tylenol. Tylenol. Tylenol.

It Is Good To Know the Facts

This is an informal discussion of a medical topic - questions regarding your specific situation should always be directed towards your bariatric professionals. However, it is YOUR body and it is important for YOU to know what class of meds may damage your stomach. We personally know more than a few bariatric post ops who have regained consciousness in ICU after NSAIDS had eaten a hole through a pouch or sleeve and created a near death situation - this is real.

NSAIDS are an entire class of pain medication that can erode soft tissues of the esophagus, stomach and intestines. NSAIDS stands for Non Steroidal Anti Inflammatory Drugs. They can be capsules, softgels, or even topical creams or gels, or injections. Names you would recognize in this NO NO NO category would be those containing Ibuprofen (Advil, Motrin) or Naproxen (Aleve)

It is important for you to understand this as some of your non-bariatric doctors will tell you that it is okay for you to take these meds when it is not. Your dentist is not a bariatric expert and you should not rely on his knowing about your body modifications when he tells you to 'take Advil' for pain after a dental procedure. Ditto for your foot doctor.

After having a minor in-office foot procedure, I was offered an NSAID for swelling. I told the doctor that I couldn't take NSAIDS after a gastric bypass - it initiated a discussion and now his office knows that bariatric patients should not take Ibuprofen, Naproxen or Aspirin. It was not critical to my healing and I took Tylenol instead. I am the one who brought it up when asked and said 'NO, I cannot take NSAIDS', as I am the advocate for my body.

What are NSAIDS? A Deeper Dive.

NSAIDS stands for Non Steroidal Anti Inflammatory Drugs. They can be capsules, softgels, or even topical creams or gels, or injections. Names you would recognize in this NO NO NO category would be those containing Ibuprofen (Advil, Motrin), Naproxen (Aleve), Aspirin (Excedrin) or meds containing these ingredients.

Since its a common question for people to ask about over the counter pain meds, it is helpful to know what NSAIDS are and why we should not take them. To understand that these meds can eat a hole through the stomach pouch even when taken only once, is a powerful impression.

'Marginal Ulcer' or simply 'Ulcer', is the term used when someone develops a nasty sore or hole in their pouch, normally where it was stitched or stapled. With a gastric bypass, the ulcer can even form in the remnant stomach, which is the part of the stomach that is no longer 'hooked up'.

NSAIDS cause ulcers when they travel through the blood and this is why topical gels and injections are also a problem. This is how a gastric bypass remnant pouch can have terrible ulcers necessitating surgical removal when the NSAID medications did not even directly touch this part of the stomach. Many do not know this - even doctors do not always know this. They cannot be expected to know everything about all meds and how they relate to all bariatric conditions.

Post-gastric bypass patients with ulcers typically have symptoms including abdominal pain and burning, nausea, and vomiting. Many complain of burning when they eat or even when they drink water. If you have been taking Advil, Motrin or Aleve and have these issues, please contact your physician.

Ulcers represent nearly half of all postoperative complications and occurs in as high as 5% of gastric bypass patients, with main causes cited as 1. Smoking 2. Use of Non-Steroidal Anti-Inflammatory Drugs called NSAIDS and 3. Alcohol use.

If after discussion with a non bariatric doctor, it has been determined that NSAIDS - non steroidal anti inflammatory drugs - are required for your condition, they should be accompanied by a proton pump inhibitor (PPI) medication such as Prilosec, Prevacid, Aciphex, Protonix, Nexium or Zegarid as protection. Some antacids that are not acceptable protection include Pepcid, Zantac, and Tagamet.

The Wrap Up

When you have a pounding headache, its better that you DO NOT take Aspirin, Advil, Motrin, or Aleve. We CAN use Tylenol, which is acetaminophen. When buying cold medications and pain relief brands - read the list of ingredients to make sure it does not contain ibuprofen, aspirin, or naproxen.

If you would like to know more, these are the six categories of drugs that are of issue.

1. ASPIRIN - should be avoided after gastric bypass - even use of baby aspirin to reduce risk in those with a family history of heart disease, must be weighed by your health professionals for benefit versus risk.
2. IBUPROFEN is the active ingredient in a range of name brand products including Advil and Motrin, and NAPROXEN which is in the brand name Aleve. We often hear "I can't remember which one I'm not supposed to take!" The answer is that we should not take Advil, Motrin and Aleve.
3. COX-2 Inhibitors are also prescribed for pain and should not be taken without discussion of risk versus benefit with health care professionals who are aware of your bariatric surgery. Currently Celebrex is the main brand that people know from this category.
4. STEROIDS delay healing in the stomach and impair the stomach lining's ability to form the protective layer between the muscle wall and acid. This can lead to an ulcer, bleeding or perforation. Examples of steroids are prednisone, decadron, depo-medrol, and solu-cortef. Steroids should be avoided the first 6 weeks after bariatric surgery and then if required should be accompanied by a proton pump inhibitor (PPI) medication. Steroid injections into a joint or the back usually do not affect the stomach so do not require taking PPI's. If you must take steroids, it is important to also discuss taking Prilosec, Prevacid, Aciphex, Protonix, Nexium or Zegarid as protection for as long as 30 days after your steroid treatment has ended. Some antacids that are not acceptable as protection include Pepcid, Zantac, and Tagamet.
5. OSTEOPOROSIS treatments - Studies have shown that gastric bypass patients have a higher incidence of osteoporosis that may lead to an increased risk of fracture. It is fairly common for a Primary Care physician to see lab results of a bone scan and prescribe a bone building regimen. However, an ulceration of the gastric pouch can cause serious health issues, and therefore, it is important to choose the treatment least likely to cause an ulcer. Bariatric surgeons often advise patients to use these medications as a last resort. Examples of these drugs are: Fosamax, Boniva, Reclast, Aclasta, and Actonel. Studies show that Actonel (risedronate) appears be the safer drug for bariatric patients. Actonel is available in daily, weekly, monthly or yearly dosing; this flexibility may lead to better adherence. If you need this type of treatment, discuss monthly or yearly dose versions, make sure you remain upright for a period after taking the dose and be aware of any heartburn, indigestion or abdominal pain so you can stop taking it and report to your physician. If financially feasible, intravenous Reclast (zoledronic acid), should be discussed and considered.
6. NICOTINE - smoking is one of the worst things someone can do after weight loss surgery, due to the high risk of ulceration of the stomach. Don't smoke! I know a brilliant and charming businessman who 8 months after gastric bypass nearly died when nicotine ate a hole in his pouch and his stomach contents emptied into his abdominal cavity. He woke up in ICU and learned he had been there for six weeks, three of them as a John Doe since he was exercising without an ID when his medical emergency took place. He had quit smoking for his surgery, but started back soon afterwards. It took two additional surgeries and six months for him to recover.

THE 'NO' LIST - Medications for Bariatric Post Ops

• aspirin - acetylsalicylic acid - BRAND NAMES: Aspirin, Anacin, Arthritis Foundation Safety Coated Aspirin, Asper~, Bayer Aspirin, Bayer Children's Aspirin, Ecotrin, and many others Empirin, BC Powder, Vincent's Powders
• celecoxib - BRAND NAMES: Celebrex
• diclofenac - BRAND NAMES: Voltaren (pills and topical gel), Cataflam, Voltaren-XR, Cambia
• ibuprofen - BRAND NAMES: Advil, Childrenís Advil/Motrim, Advil Migraine, Motrin, Motrin IB, Motrin Migraine Pain, Liquigels, Nuprin, PediaCare Fever, Vicoprofen (combination with hydrocodone), Combunox (combination with oxycodone)
• indomethacin - BRAND NAMES: Indocin, Indocin SR (discontinued brand in the US)
• ketoprofen - BRAND NAMES: Orudis (discontinued brand)
• ketorolac - BRAND NAME: Toradol (discontinued brand in the US)
• methyl salicylate - BRAND NAME: Salonpas NOTE: Even though this is a patch the active ingredient can create ulcers similar to topical gels such as Voltaren
• nabumetone - BRAND NAME: Relafen (discontinued brand)
• naproxen - BRAND NAMES: Aleve, Anaprox, Naprosyn, Naprelan, Naprapac (copackaged with lansoprazole)
• piroxicam - BRAND NAME: Felene
• salsalate - BRAND NAMES: Amigesic, Salflex, Argesic-SA, Marthritic, Salsitab, Artha-G
• sulindac - BRAND NAME: Clinoril (discontinued brand)
• tolmetin - BRAND NAME: Tolectin (discontinued brand)

*There are many OTC Combinations with ibuprofen: Advil Cold And Sinus, Advil Cold, Advil Allergy Sinus, Children's Advil Allergy Sinus, DIMETAPP, Sine-Aid IB, Children's Motrin Cold. READ THE LABEL - CHECK ACTIVE INGREDIENTS Other Drugs to avoid: Fosamax, Boniva, and Aclasta Source: Mayo Clinic Health list of NSAIDS