What vitamin deficiencies should be monitored in post-bypass Biliopancreatic Diversion with Duodenal Switch (BPD/DS) patients?

Vitamin Deficiencies to Monitor in Post-BPD/DS Patients

Patients who have undergone Biliopancreatic Diversion with Duodenal Switch (BPD/DS) require comprehensive monitoring for multiple vitamin deficiencies, with particular attention to fat-soluble vitamins (A, D, E, K), B vitamins, and minerals including iron, zinc, copper, and selenium. 1

Fat-Soluble Vitamins

Vitamin A

• Check serum vitamin A levels every 3 months initially, then annually once levels stabilize 1
• Clinical signs of deficiency include night blindness, dry eyes, and protein malnutrition 1, 2
• Supplementation should start at 10,000 IU (3000 μg) daily and be adjusted based on blood levels 1
• Water-miscible forms may improve absorption in these patients 1, 2

Vitamin D

• Monitor serum 25-hydroxyvitamin D levels at 3,6, and 12 months in the first year, then annually 1
• Target serum levels of 75 nmol/L or greater are considered sufficient 1
• Supplementation should begin at 3000 IU daily and be titrated to reach therapeutic levels 1
• Deficiency rates as high as 76.7% have been reported at 5-year follow-up despite supplementation 3

Vitamin E

• Check serum vitamin E levels at least annually 1
• Additional testing if unexplained anemia or neuropathy develops 1
• Supplementation should start at 100 IU daily 1
• When adjusted for cholesterol levels, deficiency rates may be higher than initially detected (21.4% in BPD/DS) 4

Vitamin K

• Monitor vitamin K1 and PIVKA-II levels at least annually 1
• Supplementation should start at 300 μg daily 1
• Deficiency rates of 11.6-60% have been reported in long-term follow-up 3, 5

B Vitamins

Vitamin B12

• Check levels at 3,6, and 12 months in the first year, then annually 1
• Supplementation of 1000-2000 μg/day sublingual or 3000 μg every 6 months IM is recommended 1
• Untreated deficiency may result in irreversible neuropathy 1

Thiamine (B1)

• Include in routine multivitamin supplement at government-recommended levels 1
• Consider additional supplementation (thiamine 200-300 mg daily) for the first 3-4 months post-surgery 1
• Immediate treatment is required if symptoms of deficiency appear (vomiting, poor intake, rapid weight loss) 1

Folate

• Monitor serum folate levels at 3,6, and 12 months in the first year, then annually 1
• Women planning pregnancy require 800-1000 μg daily 1

Minerals

Iron

• Monitor full blood count and ferritin at 3,6, and 12 months in the first year, then annually 1
• Supplementation of 100-200 mg elemental iron daily is often needed 6
• Women of reproductive age require 50-100 mg elemental iron daily 1
• Anemia rates of 44.1% and iron deficiency rates of 39.5% have been reported in long-term follow-up 3

Zinc and Copper

• Check serum/plasma zinc and copper levels at least annually 1
• Additional testing if unexplained anemia, hair loss, taste changes, or poor wound healing occurs 1
• Zinc supplementation should start at 30 mg daily 1
• Copper supplementation of 2 mg daily is recommended 1
• Maintain a ratio of 8-15 mg zinc to 1 mg copper 1

Calcium

• Monitor serum calcium levels at 3,6, and 12 months in the first year, then annually 1
• Daily intake from food and supplements should reach 1800-2400 mg after BPD/DS 1
• Calcium citrate is preferred over calcium carbonate due to better absorption 2

Selenium

• Check serum selenium levels at least annually 1
• Additional testing if chronic diarrhea, metabolic bone disease, unexplained anemia, or cardiomyopathy develops 1
• Additional routine supplementation may be needed to prevent deficiency 1

Clinical Considerations

• Despite supplementation, 81.4-93% of BPD/DS patients develop at least one vitamin or mineral deficiency in long-term follow-up 3, 5
• Water-miscible forms of fat-soluble vitamins show improved absorption and should be considered 1, 2
• Carrier molecules (like retinol binding protein for vitamin A and cholesterol for vitamin E) should be measured to accurately assess fat-soluble vitamin status 4
• Life-long monitoring at a specialized bariatric center is crucial to prevent deficiencies 3
• Initial supplementation prescriptions and early adjustments are often insufficient to prevent long-term deficiencies 3