Effects of Bariatric Surgery on the Pharmacokinetics of Cardiovascular Drugs: A Systematic Review and Meta-Analysis

Obesity is a global health issue associated with increased cardiovascular risk. Bariatric surgery is the most effective long-term treatment for severe obesity, but it may alter drug pharmacokinetics, impacting the management of cardiovascular medications.

A systematic review and meta-analysis were conducted according to PRISMA 2020 guidelines. Four databases (PubMed, Embase, Web of Science, Scopus) were searched for studies examining the pharmacokinetics of cardiovascular drugs before and after bariatric surgery. After duplicate removal, titles and abstracts were screened, followed by a full-text review with inclusion criteria of adult patients undergoing bariatric surgery who reported pharmacokinetic or pharmacodynamic outcomes for cardiovascular drugs. Meta-analysis was performed using a random-effects model in R (meta and metafor packages), with effect sizes and heterogeneity (I²) reported.

From 817 identified records, 24 studies met the inclusion criteria, revealing that bariatric surgery has varied and drug-specific effects on the pharmacokinetics of cardiovascular medications. Among anticoagulants, systemic exposure of all of them did not significantly change. Rivaroxaban and apixaban pharmacokinetics remained largely unchanged, and warfarin dosing requirements slightly decreased. The impact of beta-blockers was highly dependent on the specific drug and formulation; peak concentrations (Cmax) of atenolol increased slightly, whereas those of immediate-release metoprolol tended to increase, but both types of carvedilols (S- and R-carvedilol) and controlled-release metoprolol and propranolol showed a decrease. Regarding statins, atorvastatin absorption was significantly delayed, as shown by a prolonged time to peak concentration Tmax​ (pooled SMD = 0.99, p < 0.05), without a significant change in Cmax​ (slightly decreased). Both rosuvastatin and simvastatin showed transient changes in exposure, which normalized over time.

Bariatric surgery can significantly impact the pharmacokinetics of cardiovascular drugs, especially atorvastatin and beta-blockers, highlighting the need for individualized dose adjustments and therapeutic monitoring. These findings provide essential evidence for optimizing cardiovascular pharmacotherapy in post-bariatric surgery patients, supporting the development of tailored dosing guidelines.