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New 2023 Ohio Rules for Weight Loss Medications

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On February 8th, 2023, the State Medical Board of Ohio adopted new rules regarding weight loss medications.  These new rules will significantly increase access to these critical medications for many Ohioans.  As the old rules have been in place for a long time, it may take a little while for pharmacists to become accustomed to these new rules.  It may be necessary for a patient to print out the new regulations and present them to the pharmacist if they are still wanting to follow the old rules.

A copy of the new regulations can be downloaded at the link below, if the need arises in such a situation.

Most significantly, a patient can now be treated for more than 3 months with Adipex (phentermine) providing that they lose at least 5% of their total body weight (e.g. 10 lbs in a patient that starts out at 200 lbs) by the end of 90 days.  Also, some visits can be done via telemedicine whereas previously every visit was supposed to be live.

These new rules will greatly increase access to care for overweight patients in Ohio!

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Ohio 2023 revised rules for weight loss medications

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SIPS/SADI/LDS Versus Sleeve–What’s the Difference

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Gastric Sleeve

vertical sleeve gastrectomy

SIPS/SADI/LDS

loop duodenal switch

The field of bariatric surgery, or weight loss surgery, is always changing.  New options seem to come around frequently (and sometimes go away just as quickly).  One of the most recent options that has come to the forefront, however, is based on a time-tested procedure that has been around for decades and is likely to stick around.  The reason it is likely to stay is simple:  it offers great weight loss, similar to the older procedure on which it is based, but it has fewer complications overall.

Gastric sleeve has been around for a while now, so if you need to review the simple anatomy of this procedure just click here.  This article will focus on a newer procedure that can be thought of in some ways as a gastric sleeve/gastric bypass mash-up.

This new procedure, unfortunately, does not have a standard name.  In fact, at least three different labels have been assigned to it: SIPS, SADI-S, and LDS.

  • SIPS: Stomach-Intestinal Pylorus Sparing procedure
  • SADI-Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy
  • LDS: Loop Duodenal Switch

All of these acronyms refer to the same operation.  For the purposes of this article, we will use the name SADI-S.  In order to understand the SADI-S, first you need to understand the original procedure on which it’s based:  the duodenal switch, or DS. 

Duodenal Switch

SIPS procedure is based on duodenal switch

Five things are done in a traditional DS:

  1. A loose gastric sleeve is done
  2. The duodenum (first part of the small intestine) is divided just past the stomach
  3. The small intestine is divided way downstream
  4. The distal (far end) of this intestine is pulled up and re-connected to the duodenum up by the stomach
  5. The proximal (closer end) of this divided intestine is re-connected far downstream, resulting in a very short common channel

The “common channel” is the point where the food you eat gets mixed in with the digestive enzymes coming down from your liver and pancreas.  So the DS is very effective for weight loss because of this very short common channel–much shorter than in a gastric bypass, and of course much shorter than a regular gastric sleeve.  Of course, in a regular sleeve the common channel is the entire length of the intestine, because none gets bypassed at all.  Because of this short common channel, most studies show the DS to have better long-term weight loss results and diabetes remission than any other weight loss surgery around.

SADI-S/SIPS/LDS

Anatomy of a SADI-S procedure, also known as SIPS or LDS.

So what’s different about a SADI-S?  The SADI-S takes the original DS and simplifies it a bit.  In a SADI-S, the intestine is only divided one time, just past the stomach in the duodenum.  The short stump of duodenum is then re-connected to the side of the small intestine, far downstream.  So in a SADI-S pretty much the same thing is accomplished–separating the food from the digestive enzymes.  Because the procedure is simpler, though, there are less things that can go wrong with it.  Whenever a connection is made between intestine and intestine, or intestine and stomach, there is a risk that the connection could leak.  This can be a serious problem, and bariatric surgeons do everything they can to avoid this complication.  Since the SADI-S has only one connection that has to be made instead of two, this risk could be cut in half.  If we list the steps as before, only three things have to be done:

  1. A tighter gastric sleeve is done
  2. The duodenum is divided just past the stomach
  3. The duodenal stump is connected to the small intestine far downstream

Are there any disadvantages then to the SADI-S versus the old DS?  Except for a lower risk of leak in a SADI-S, most studies show pretty much the same results for the two procedures.  Some people worry about a problem called bile reflux after a SADI-S, but it doesn’t seem to be a huge problem.  Bile reflux could occur in SADI where the duodenum is plugged into the small intestine.  Bile from the liver is flowing past this connection, but in the original DS bile is kept completely away from that area.

 

Most bariatric surgeons are getting away from the DS and moving towards SADI-S.  So then, let’s look at the pro’s and con’s of SADI-S as compared to just a gastric sleeve.

SADI-S/SIPS/LDS

Pro’s

  • Better weight loss
  • Better diabetes remission
  • Less GERD issues

Con’s

  • More complex procedure
  • Longer operative time
  • Longer recovery time
  • Much higher chance of serious vitamin/nutrient deficiencies
  • No good options for revision down the road
  • Yearly lab work needed for life
  • If you don’t take your vitamins you will get a serious vitamin deficiency!

Gastric Sleeve/VSG

Pro’s

  • Simpler procedure
  • Can be done as outpatient
  • Shorter operative time
  • Can be converted to SADI-S or RNY

Con’s

  • Post-op GERD rate higher
  • Less weight loss
  • Lower diabetes remission rate
  • Vitamin/nutrient deficiencies rare

From a surgeon’s point of view, I think it makes sense for patients with higher BMI’s to go for the SADI-S.  For a patient with a BMI over 60 most surgeons would recommend SADI-S over gastric sleeve.  For a patient with a BMI under 50 many would recommend sleeve over SADI-S.  50-60 BMI is a gray zone as there are some patients who can be successful with a sleeve, and avoid all those long-term SADI-S risks.  In my opinion, sleeve would be my first choice but I would discuss with the patient that conversion to SADI-S down the road could be necessary.

Another issue to consider is insurance coverage.  Many policies will cover the older DS, but not the new SADI-S.  This will change with time, though, and more weight loss surgeons will become adept at performing this procedure.  So we can expect the SADI-S to not only stick around, but also to become more and more popular with time, given its excellent weight loss results and lower complication rates.

Trace Curry M.D.

Dr. Trace Curry is the medical director of JourneyLite Physicians and JourneyLite Surgery Center in Cincinnati, Ohio.  JourneyLite is a multi-specialty center that focuses on advanced outpatient laparoscopic weight loss surgery and incisionless weight loss procedures.  He has done over 7000 weight loss procedures in his career and is a key opinion leader in the field of surgical and incisionless weight loss.

JourneyLite For Life logo

Pre-op EKG Requirements for JourneyLite Surgery Center

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Prior to any surgery, all patients need some sort of pre-admission testing, or PAT’s.  All patients having surgery at JourneyLite will require at the very least a recent set of basic labs.

Patients who meet certain criteria will also need an EKG.  If we also request for you to see your primary care physician or cardiologist for clearance, it is best to have them do your EKG so that they can compare it to previous tracings.  If we do not request clearance from any of your doctors, we will do your EKG at your pre-op/consent appointment according to the criteria below.

  • The guidelines for EKG are:
    • Age >50
    • Chronic kidney disease
    • Obstructive sleep apnea (with an AHI of 15 or above and requiring a C-pap machine)
    • Hypertension
    • Hyperlipidemia (high cholesterol)
    • Heart disease
    • Diabetes
    • Current smoker or past heavy smoker

Any EKG done within the last 6 months is acceptable unless there are new symptoms, or there has been a change in the cardiac history. Then a new one would need be obtained.

For Endoscopy and Balloon patients:

If the patient is at age >50 and has a cardiologist for cardiac issues, they will need an EKG (done within previous 6 months) prior to the procedure.

If the patient is at age >50 and has no cardiologist and very few co-morbidities, they will be assessed by anesthesia on the day of the procedure. If there is a need for an EKG, it will be performed bedside at the surgery center.

New Study Finds Weight Loss Surgery Extends Lives

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anatomy of gastric sleeve procedure

by Dr. Trace Curry, Cincinnati, Ohio

I remember when I did my first laparoscopic gastric bypass in 2003 at Wayne Hospital in Greenville, Ohio.  I was a general surgeon then, and I wanted to branch out and challenge myself with more advanced procedures.  Those were the very early days of laparoscopic weight loss surgery, and we were still fighting the bad rap of years of high complication rates from the same exact procedure being done with a huge 12 inch incision.  Originally, I had planned on weight loss surgery being just a small part of my general surgery practice, but when I saw how these procedures totally transformed my patients’ health with just a few tiny incisions, I quickly decided to dedicate my entire practice to this exciting field.  I could see a patient’s life expectancy improve right before my very eyes – in fact I once had a patient who was so obese and had such severe sleep apnea that he had to have a tracheostomy done (this was long before Thousand Pound Sisters).  When he came in for his 1 year post op check after his gastric bypass procedure, he proudly rode his bike right into my office, his trach tube long removed!

As a weight loss surgeon, the fact that weight loss surgery increases life expectancy is something that has been plainly obvious to me for the last 20 years.  Now, however, we have new data from a study spanning 40 years and including nearly 22,000 people that confirms this as fact!

These results were just published last Wednesday in the journal Obesity. It was a retrospective study out of Utah, meaning the researchers looked back at data from patients over past years. They looked at patients with and without weight loss surgery and matched patients for things such as age, sex, and BMI so they were comparing apples to apples. There were 21,837 matched surgery and non-surgery pairs and the follow up was up to a very impressive 40 years.  This study is important not only because of the large number of patients including such a large time span, but also because it involves data on American patients which may be more applicable to patients in my practice than if the data were taken from, say patients in Sweden or Africa.

Four procedures were examined (listed from most common to least common):

  • gastric bypass
  • gastric sleeve
  • gastric band
  • duodenal switch

The researchers found that patients who underwent one of these procedures were 16% less likely to die from any cause, 29% less likely to die from cardiovascular disease, 43% less likely to die from various cancers, and incredibly–72% less likely to die from diabetes!

There have been other large studies that support the data seen here, so I feel like it’s about time to shout it from the rooftops!  In the U.S., it’s estimated that only 2% of patients who qualify actually end up having weight loss surgery.  Some of this is related to lack of insurance coverage, and some to patients’ reluctance to seek out weight loss surgery.  Many patients are not even aware that, when they choose an insurance plan, it may exclude access to a surgical weight loss procedure which they qualify for medically.  Not because they don’t need it, but because language is written into their policy that says it’s not going to be covered, no matter how badly they need it.

Regardless of the reason, considering modern techniques, the complication rate for bariatric surgery procedures such as gastric bypass, gastric sleeve, Lap Band, and duodenal switch are miniscule compared to what they used to be 30 years ago.  This, given with the data we see from this study and others, should compel more insurance companies to provide coverage for these life-saving procedures and more patients to consider taking this step to be rid of the disease of obesity.

Trace Curry M.D.

 

Dr. Trace Curry is the medical director of JourneyLite Physicians and JourneyLite Surgery Center in Cincinnati, Ohio.  JourneyLite is a multi-specialty center that focuses on advanced outpatient laparoscopic weight loss surgery and incisionless weight loss procedures.  He has done over 7000 weight loss procedures in his career and is a key opinion leader in the field of surgical and incisionless weight loss.

Gastric Sleeve

vertical sleeve gastrectomy

Gastric Bypass

gastric bypass anatomy

SIPS

loop duodenal switch

Lap Band

lap band photo

Pre-op Weight Loss

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scale

Pre-op weight loss can be essential to reducing the risk of bariatric surgery.  Therefore we set some goals for most patients at your initial consultation.  These goals are higher in patients with a higher body mass index.

Below you can see our typical pre-op weight loss goals to see where you will likely fall.  However in some cases there will be custom goals that are set that can differ from these guidelines.

BMI

30-45

Primary Weight Loss Goal

  • Maintain initial consult weight until pre-op/consent visit.

Secondary/Pre-op Diet Weight Loss Goal

  • Lose some weight.
45.1-50
  • Lose 5 pounds from initial consult weight to pre-op/consent visit.
  • Appetite suppressant optional.
  • Lose 5% of TBW from initial consult weight to surgery.
  • Appetite suppressant optional.
50.1-55
  • Lose 10 pounds from initial consult weight to pre-op/consent visit.
  • Appetite suppressant recommended.
  • Lose 8% of TBW from initial consult weight to surgery.
  • Appetite suppressant recommended.
55.1-60
  • Lose 5% of TBW from initial consult weight prior to scheduling a surgery date.
  • Appetite suppressant recommended.
  • Male: Lose 10% of TBW from initial consult weight to surgery or achieve a BMI of 55, whichever is the lower weight.
  • Female: Lose 10% of TBW from initial consult weight to surgery.
  • Appetite suppressant recommended.
60.1-65
  • Lose 5% of TBW from initial consult weight prior to scheduling a surgery date.
  • Appetite suppressant recommended.
  • Male: Lose 10% of TBW from initial consult weight to surgery, or achieve a BMI of 55 to qualify for surgery at JourneyLite.
  • Female: Lose 10% of TBW from initial consult weight to surgery or achieve a BMI of 55, whichever is lower weight.
  • Appetite suppressant recommended.
65.1+
  • Lose 10% of TBW from initial consult weight prior to scheduling a surgery date.
  • Appetite suppressant recommended.
  • Custom goal will be set.
  • Appetite suppressant recommended.

TBW = total body weight

5% of TBW: For example, in a 200 lb patient, 5% of 200 lb = 10 lbs

10% of TBW: For example, in a 300 lb patient, 10% of 300 = 30 lbs

Crushing Medications After Weight Loss Surgery-Should I or Shouldn’t I?

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As a rule we recommend against crushing medications after weight loss surgery.  There are some larger pills, however, that can be difficult to get down in the early days when there is still some swelling present.  There are many medications, however, that should NOT be crushed under any circumstances.  Generally speaking, these are extended release medications that have a special coating to cause the drug to be released slowly over a period of time.  Probably the most common medication like this is Prilosec.  If you crush it, the coating is destroyed and the medication will be absorbed all at once.  In the case of Prilosec, this would likely cause little harm, however this is not the case with all medications and in some instances life-threatening side effects could occur.

We always recommend checking with your pharmacist, however you can also refer to this fairly comprehensive list of medications that should not be crushed under any circumstance!

Do Not Crush These Meds!

weight loss medications

Incisional Pain After Gastric Bypass Surgery

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pain

Pain after surgery is expected, particularly with the gastric bypass. This is a bigger, more involved surgery than the sleeve! Setting realistic expectations after surgery is important–you should expect to have some pain after surgery. 

 

We always inject local anesthetic in each incision, however the effect of this is only temporary. This can make it seem like your pain is getting worse, but it’s actually just the numbing medicine wearing off.  

 

Most of the discomfort in the gastric bypass there is one incision on the far left side of your abdomen.  This will commonly cause complaints such as: sharp or intense pain, dull cramping pain, burning, tugging, and pulling sensations. These are sometimes worsened by movements, or certain positions and the pain is not always felt directly underneath this incision.   These types of symptoms are normal and expected after bypass surgery. 

 

This incision is necessary in order to safely complete the surgery. Because of the size and depth of this incision, a suture is placed through the deep muscle layers to help prevent a hernia. This suture is almost always the cause of the symptoms described above. This pain will commonly last for 3-6 weeks and perhaps longer in some situations. 

 

We always do our best to minimize the discomfort associated with this incision, but we cannot completely eliminate this pain all together. Patients will be prescribed a narcotic pain medication, a muscle relaxer, and a pill which helps with neuropathic (nerve) pain. In addition to the medications, we recommend using ice packs over the incisions, 20 minutes on and 20 minutes off several times per day. This will help with the inflammation. After 2-3 days you may get better relief with a heating pad as the pain becomes more muscular in nature. 

 

This same far left incision can also be prone to infection, as at the end of the procedure we pull a little piece of small intestine out through it.  This can sometimes contain bacteria which can lead to infection, despite the fact that we place it in a sterile pouch before pulling it out.  Some of the first signs of infection are: fever, swelling at the incision site, redness around the incision, or drainage at the incision )particularly yellow thick foul smelling drainage).  Occasionally a clear or pale-red drainage will be present–this does not necessarily mean there is an infection. If you have concerns with your incisions, please contact us to have your incisions evaluated by our staff! 

Go back to the post-op navigator

How To Achieve Success After Weight Loss Surgery-The Three “M’s”

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By Dr. Trace Curry

Patients always want to know what they need to do to be successful after weight loss surgery, it’s one of the most common questions I’m asked.  In my experience treating thousands of patients over the past 20 years, it all boils down to the three M’s:

  • Motivation
  • Menu
  • Movement

Motivation

I listed motivation first as it is the key.  If you are not motivated to lose weight and improve your health, even the most powerful weight loss procedure will not work in the long run.  Weight loss surgery can be life saving, by reducing or eliminating current or future medical issues such as diabetes, heart disease, high blood pressure, and high cholesterol.  You must have the motivation to make permanent lifestyle changes that include the changes listed below.  It’s worth the effort!

If you feel like you motivation is fading, even if you are 10 years out from surgery, reach out to us so that we can bring you in to meet with the team and formulate a plan to get you back on track.

Menu

Menu is the second item in the list because if you are not eating the right types of foods, you simply cannot move enough to burn off the excess calories.   First off, you need to “get the white out” of your diet!  White food refers to foods that are white in color, meaning that they have been processed and refined.  Things includes things like table sugar, flour, pasta, rice, bread, crackers, and cereal.  Secondly, eliminate liquid calories from your diet.  Everything you drink after surgery, with rare exception, should be zero (or very low) calorie.

Keep in touch with our expert registered dietitians for suggestions on healthy substitutions for these items in your diet.

Movement

It’s very difficult to be sedentary and maintain your weight loss in the long run.  These operations frequently have enough power to provide significant short-term weight loss without exercising at all.  However, once you reach your nadir (your lowest weight achieved after surgery) if you are not active AND exercising you will regain weight.  In some cases you could regain all your weight, especially if your motivation and menus are lacking.  No matter what your physical condition is, you must start somewhere!  Everyone’s definition of exercise is a little different, so just pick something you can do and build on it from there.  I highly recommend getting a good fitness tracker so that you can make sure you are reaching your move goals and modifying them as your health improves.  I’m partial to the Apple Watch as it does a good job not only to encourage you to exercise, but also not to be sitting for the rest of the day!

If your mobility is significantly limited, check out these low-impact exercise options for overweight patients.

overweight person exercising

If you keep the 3 M’s in mind, you will be successful in your weight loss journey.  The sky is the limit!

Other Posts From Dr. Curry

  • anatomy of gastric sleeve procedure

    Blue Cross/Blue Shield (BCBS) Weight Loss Surgery Coverage Updates!

    Gastric Sleeve Gastric Bypass Lap Band BMI Calculator Weight loss surgery, such as gastric sleeve and gastric bypass can be life-saving for some patients. Unfortunately, in the U.S., insurance coverage for bariatric surgery is far from uniform and most patients who do qualify don't have coverage due to an exclusion.  This is especially true for [...]
  • adipex

    New 2023 Ohio Rules for Weight Loss Medications

    On February 8th, 2023, the State Medical Board of Ohio adopted new rules regarding weight loss medications.  These new rules will significantly increase access to these critical medications for many Ohioans.  As the old rules have been in place for a long time, it may take a little while for pharmacists to become accustomed to [...]
  • loop duodenal switch

    SIPS/SADI/LDS Versus Sleeve–What’s the Difference

    Gastric Sleeve SIPS/SADI/LDS The field of bariatric surgery, or weight loss surgery, is always changing.  New options seem to come around frequently (and sometimes go away just as quickly).  One of the most recent options that has come to the forefront, however, is based on a time-tested procedure that has been around for decades and [...]
  • 12 lead ekg

    Pre-op EKG Requirements for JourneyLite Surgery Center

    Prior to any surgery, all patients need some sort of pre-admission testing, or PAT’s.  All patients having surgery at JourneyLite will require at the very least a recent set of basic labs. Patients who meet certain criteria will also need an EKG.  If we also request for you to see your primary care physician or cardiologist […]

  • anatomy of gastric sleeve procedure

    New Study Finds Weight Loss Surgery Extends Lives

    by Dr. Trace Curry, Cincinnati, Ohio I remember when I did my first laparoscopic gastric bypass in 2003 at Wayne Hospital in Greenville, Ohio.  I was a general surgeon then, and I wanted to branch out and challenge myself with more advanced procedures.  Those were the very early days of laparoscopic weight loss surgery, and [...]

Gastric Sleeve

vertical sleeve gastrectomy

Gastric Bypass

gastric bypass anatomy

Low-Impact Exercise For Overweight Patients

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Movement is one of the critical keys to success after weight loss surgery. For some of our patients though, exercise (or even walking) can be a challenge.  Once the weight starts coming off however, patients will see a dramatic improvement in weight-bearing joint pain.  Even so, it’s important to start some form of exercise as soon as possible after surgery.  The definition of exercise can vary from patient to patient.  For some just walking out to get the mail and back can be very challenging.  Below are some very low-impact exercise routines that nearly any patient can do.  Just start off slow and start building your tolerance, even before surgery!

All of these workout routines require no special equipment and can be done at home!

Low Impact Exercise Routines For Overweight Patients

Also check out Joyn – it’s a free site with all sorts of options for patients with any kind of mobility issue. There is even have a section for chair exercises!

joyn icon

Breaking A Plateau After Weight Loss Surgery

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scaleBreaking a Weight Loss Plateau

Weight loss is a journey, and with that journey will come many struggles! A common discussion we have with patients is overcoming a stall or “plateau” in weight loss. Below are some tips to help break out of a weight loss plateau.

  • First of all, consider how far you have come!
    • Before you hit your plateau, you were most likely experiencing successful weight loss for quite some time.
    • Remember your non-scale victories! This can include feeling better, having more energy, clothes fitting better, being able to do things you haven’t been able to in a while, and feeling more confident! Success is not always measured by the amount of weight that you lose!
  • Work with a dietitian to reassess caloric needs.
    • Based on the amount of weight you have lost so far, your calorie needs may have changed and will need to be adjusted. This can include changing the amounts of protein, carbohydrates, and fat in the diet as well, which all contribute to calories in the diet.
    • Sometimes the timing of your meals will need to be adjusted rather than the amount of calories.
    • Adding variety into your diet can help add different nutrients into your diet and ramp up weight loss.
    • If you aren’t tracking food already, get back into it to see if any extra calories are sneaking into your diet somewhere.  Ideally, use our Healthtrac app so that our team has access to your data!
  • Ramp up your workout routine.
    • Increasing the amount or intensity of your workouts could help you break out of a weight loss plateau because it can:
      • Help you burn more calories.
      • Make you feel better mentally and physically.
      • Bring more structure into your day.
  • Weight loss isn’t only related to what you eat. Consider if there are other factors in your life affecting your ability to lose weight.
    • Lack of sleep, excessive stress, and mental health issues can cause the body to produce more cortisol, which can tell the body to store more fat.
    • Seek medical advice if these things are affecting your life.

We hope these tips help you to explore the cause of a weight loss plateau and find ways to remedy it. Remember: You are NOT a failure for falling into a stall with weight loss, you are doing the best you can!

“When you feel like quitting, think about why you started” ~ Anonymous