What is your approach to treating osteoporosis in patients post bariatric surgery?

While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bisphosphonates and see no reason to risk a GI problem with an oral agent. Osteoporosis is quite common in patients with historical gastric bypass (especially Roux N Y surgery) so this is a common issue.

We also cannot forget the possibility of osteomalacia in these patients. We must watch the vitamin D levels like a hawk and insist on lifelong supplementation with calcium and vitamin D.

When you see a roux-en-Y patient with diffuse body pain, joint pains, or muscle weakness, always check their vitamin D level and PTH (along with vit B12 levels, etc). It is amazing how the symptoms resolve once you correct those with supplementation.

I share Dr. @Dr. First Last’s concern and also wonder about the actual absorption of medications in this situation. To that end, I tend to favor parenteral therapy for osteoporosis and use markers of bone metabolism in those patients who would rather take oral therapy than parenteral therapy to assist in the early affirmation of absorption and potential efficacy.