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Adderall XR Post-Bariatric Surgery: What Clinicians and Patients Need to Know

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At a glance

  • Direct Adderall XR evidence / Absorption and symptom effects after bariatric surgery remain unknown
  • Bariatric absorption / Drug-specific, not a uniform reduction [2]
  • RYGB dissolution model / 10 of 22 psychiatric preparations dissolved significantly less, 2 significantly more [4]
  • Measured example / In 8 of 12 patients on serotonin reuptake inhibitors, drug exposure over time at 1 month after gastric bypass averaged 54% of the pre-surgery value [5]
  • Tablet label monitoring / Blood pressure up about 2 to 4 mm Hg, heart rate about 3 to 6 bpm [3]
  • Controlled status / Amphetamine, Schedule II, with an abuse, misuse and addiction boxed warning [3]

What has been measured after bariatric surgery

A 2010 systematic review of drug absorption after bariatric surgery found 26 studies and concluded the effect is drug-specific. Evidence of reduced absorption appeared in 15 of 22 studies involving jejunoileal bypass but in only 1 of 3 studies of gastric bypass or gastroplasty; the most consistent reductions were for cyclosporine, thyroxine, phenytoin and rifampin [2]. The review does not establish how mixed amphetamine salts are absorbed after surgery.

A 2005 laboratory study built an in vitro model of the post-RYGB gut: 10 of 22 psychiatric medication preparations dissolved significantly less than in the control model and 2 dissolved significantly more [4]. It measured dissolution in a dish, not blood levels or symptoms.

A 2012 prospective study followed 12 patients taking serotonin reuptake inhibitors. In 8 of the 12, area under the concentration-time curve one month after RYGB averaged 54% of the pre-operative value (range 36% to 80%); in 6 of those 8 it had returned to baseline or higher by 6 months [5]. It is a small study in a different drug class.

What the Adderall XR prescribing information covers

Adderall XR is the extended-release capsule form of mixed amphetamine salts, taken once daily in the morning and approved for ADHD in adults and children 6 and older [1]. The label says the capsule may be swallowed whole or the entire contents sprinkled on applesauce and swallowed without chewing. It gives 15 mg for adults with severe renal impairment and says Adderall XR is not recommended in end-stage renal disease [1]. No bariatric-surgery regimen appears in it.

What the amphetamine label says to watch

The Adderall tablet label records mean rises in blood pressure of about 2 to 4 mm Hg and heart rate of about 3 to 6 bpm [3]. New psychotic or manic symptoms at recommended doses occurred in about 0.1% of stimulant-treated patients versus 0% on placebo in pooled short-term trials, and anorexia and weight loss are listed as undesirable effects [3]. The label calls for assessment of misuse risk before treatment, education about storage and disposal, and continued reassessment during treatment. Amphetamine is a Schedule II controlled substance [3].

In a prospective bariatric-surgery cohort, alcohol use disorder symptoms were reported in 9.6% in the second postoperative year, compared with 7.6% in the year before surgery, with higher odds after Roux-en-Y gastric bypass than banding (adjusted odds ratio 2.07, 95% CI 1.40 to 3.08) [6]. That study measured alcohol, not stimulant misuse.

Frequently asked questions

Does Adderall XR work the same after gastric bypass?
That has not been measured. Absorption changes after bariatric surgery vary by drug rather than following one pattern [2], and the Adderall XR prescribing information gives no post-bariatric guidance [1].
Does the Adderall XR label give a dose for after bariatric surgery?
No. The prescribing information gives 15 mg for adults with severe renal impairment and says Adderall XR is not recommended in end-stage renal disease, but it contains no bariatric-surgery regimen [1].
Does vitamin C or an antacid change amphetamine levels?
The Adderall label states that acidifying agents such as ascorbic acid lower amphetamine blood levels and efficacy, while alkalinizing agents such as antacids and sodium bicarbonate raise levels and should be avoided with Adderall [3].
What does the label say about misuse risk?
Amphetamine has a high potential for abuse and misuse, which can lead to a substance use disorder including addiction, and misuse can result in overdose and death, with greater risk at higher doses or with snorting or injection [3].

References

  1. Takeda. Adderall XR (mixed amphetamine salts extended-release capsules) prescribing information, NDA 021303, via Drugs@FDA. Drugs@FDA: FDA-Approved Drugs
  2. Padwal R, Brocks D, Sharma AM. A systematic review of drug absorption following bariatric surgery and its theoretical implications. Obes Rev. 2010;11(1):41-50. A systematic review of drug absorption following bariatric surgery and its theoretical implications
  3. U.S. National Library of Medicine, DailyMed. Adderall (mixed amphetamine salts) tablets, Teva (dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate) prescribing information. Adderall (mixed amphetamine salts) tablets, Teva (dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate) label
  4. Seaman JS, Bowers SP, Dixon P, Schindler L. Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model. Psychosomatics. 2005;46(3):250-3. Dissolution of common psychiatric medications in a Roux-en-Y gastric bypass model
  5. Hamad GG, Helsel JC, Perel JM, Kozak GM, McShea MC, Hughes C, et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors. Am J Psychiatry. 2012;169(3):256-63. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors
  6. King WC, Chen JY, Mitchell JE, Kalarchian MA, Steffen KJ, Engel SG, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307(23):2516-25. Prevalence of alcohol use disorders before and after bariatric surgery
Evidence overview for Adderall XR Post-Bariatric Surgery: What Clinicians and Patients Need to Know