The Potential of Semaglutide Once-Weekly in Patients Without Type 2 Diabetes with Weight Regain or Insufficient Weight Loss After Bariatric Surgery-a Retrospective Analysis

Effectiveness of Adjuvant Semaglutide Following Bariatric Metabolic Surgery

BACKGROUND

Obesity is a relapsing condition and response to anti-obesity therapies appears to be normally distributed. Therefore, some patients undergoing metabolic bariatric surgery (MBS) will demonstrate a partial response to therapy. When prescribing therapies to patients living with obesity (PwO) the median total weight loss (TWL) gives a good indication of the likely utility of prescription for that individual. GLP-1 agonists (GLP1a) offer patients a reasonable prospect of clinically significant weight loss even if they have been previously treated with MBS.

METHODS

A retrospective review of prospectively collected data in a single bariatric clinic was performed. Patients with insufficient weight loss at any time point were offered semaglutide therapy with doses titrated depending on response to treatment, tolerability, availability and affordability. Duration of therapy, highest dose tolerated, anthropometric measures and reported side effects were recorded. Reasons for discontinuation were noted where possible; however, discontinuation due to medication unavailability was not reliably captured in the dataset.

RESULTS

The median dose tolerated was 1 mg s/c per week, and 78% tolerated ≤ 1 mg as the maximum achieved dose. The median TWL was 7.5% and side effects were uncommon. Most patients took therapy for > 6 months, but continued therapy > 1 year was uncommon.

CONCLUSION

Overall 'real-world' utility of semaglutide after MBS may potentially be hampered by supply and cost issues more than issues associated with effectiveness or side effect profile.

Revisional endoscopic sleeve gastroplasty versus semaglutide and tirzepatide for weight recidivism after sleeve gastrectomy

BACKGROUND AND AIMS

Weight recidivism following sleeve gastrectomy (SG) is common. Adjuvant treatments include new glucagon-like peptide 1 and glucose-dependent insulinotropic peptide receptor agonists (GLP1/GIP-RA) or revisional endoscopic sleeve gastroplasty (R-ESG). We here compare the outcomes of these treatments.

METHODS

A retrospective study of patients ≥18 years with prior SG treated with semaglutide, tirzepatide or R-ESG for weight recidivism between January 2019 and 2023 at large academic centre. Primary outcomes were total body weight loss (TBWL) and adverse events (AEs). Secondary outcomes were changes in metabolic parameters. Tertiary outcome was to compare GLP1/GIP-RA outcomes in SG patients to matched patients with intact stomach.

RESULTS

Our study included 68 (prior SG + GLP1/GIP-RA) and 22 (prior SG + R-ESG). R-ESG offered higher TBWL% than GLP1/GIP-RA at 3 (11.2% vs. 4.3%, p < .001), 6 (13.5% vs. 6.8%, p < .001) and 12 months (13.4% vs. 9.2%, p = .07) with no significant difference in AEs or change in metabolic parameters. On subgroup analysis, tirzepatide achieved similar 12-months TBWL% as R-ESG (13.2% vs. 13.4%, p = .9) and significantly more than semaglutide (13.2% vs. 8.1%, p = .04). Compared to patients with intact stomach (n = 87), GLP1/GIP-RA achieved significantly lower TBWL% in patients with prior SG at 3 (4.3% vs. 5.7%, p = .02), 6 (6.8% vs. 9.2%, p = .02) and 12 months (9.2% vs. 12.7%, p = .03). Medication refills were difficult in 41.3% of patients.

CONCLUSIONS

In a single-centre real-world experience study, R-ESG and tirzepatide appear to offer more weight loss than semaglutide in SG patients with weight recidivism although GLP1/GIP-RA were underdosed. GLP1/GIP-RA achieved higher weight loss in patients with intact stomach than those with prior SG.

The Efficacy of Glucagon-like Peptide-1 (GLP-1) Receptor Agonists for Insufficient Weight Loss or Regain After Metabolic/Bariatric Surgery: A Systematic Review and Meta-analysis

Metabolic and bariatric surgery (MBS) is a successful surgical option for obesity. However, many patients can experience insufficient weight loss and weight regain post-operatively. Glucagon-like peptide-1 (GLP-1) receptor agonists have become available for effective weight loss treatment due to their effects of suppressing appetite, slowing gastric emptying, and promoting fat loss. This systematic review aims to evaluate the efficacy of using GLP-1 agonists to treat insufficient weight loss or regain after metabolic/bariatric surgery. Pooled analysis demonstrated that GLP-1 agonists have a moderate effect on weight loss after failed weight loss or weight regain following MBS, with a Cohen's d-score of 0.470 (p ≤ 0.001). GLP-1 agonists show promise and deserve additional research as part of the standard of care following MBS with insufficient weight loss.

A Randomized, Double-Blind, Two-Way Cross-over Study to Evaluate the Efficacy of Liraglutide Treatment in Patients Undergoing Transoral Outlet Reduction Endoscopy for Weight Regain Post Roux-en-Y Gastric Bypass

BACKGROUND

Transoral outlet reduction endoscopy (TORe) and glucagon-like peptide-1 agonist, liraglutide, have individually shown promise in managing weight regain after Roux-en-Y gastric bypass. However, combined effects of adjunctive liraglutide to TORe remain unexplored. A cross-over design was utilized to evaluate the efficacy of liraglutide treatment when initiated immediately post-TORe or 1 year post-TORe.

METHODS

Data was analyzed from a double-blinded randomized controlled trial conducted at three outpatient clinics in São Paulo, Brazil, from January 2019 to December 2021. Two cohorts were established: group placebo then liraglutide (group PL) received subcutaneous saline dosed daily for 12 months after TORe then liraglutide for the subsequent 12 months, while group liraglutide then placebo (group LP) started subcutaneous liraglutide followed by subcutaneous saline in a similar fashion. Each participant received placebo and liraglutide for equal duration over the 24-month treatment phase. The primary outcomes were percent total body weight loss (%TBWL) at 12 and 24 months.

RESULTS

The study comprised 58 participants in group PL and 51 participants in group LP, with no significant difference in mean baseline BMI between groups. Group LP showed significantly higher %TBWL than group PL at 6, 9, and 12 months. Surprisingly, at 21 and 24 months, group LP continued to exhibit greater %TBWL than group PL, even after discontinuing liraglutide.

CONCLUSION

Immediate post-procedure administration of liraglutide appears to be more effective than placebo in reversing weight regain in patients undergoing TORe. Results indicate that the timing of post-TORe liraglutide initiation may enhance the therapeutic benefits of the procedure.

Tackling suboptimal clinical response after metabolic bariatric surgery: Impact of tirzepatide on weight loss and body composition

INTRODUCTION

Insufficient weight loss (IWL) or weight regain (WR) after metabolic bariatric surgery remains a challenge in obesity management. Therefore, this study aimed to retrospectively evaluate the impact of adjunctive tirzepatide therapy over 6 months following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).

METHODS

Post-bariatric patients without type 2 diabetes with IWL or WR (n = 21) were analyzed. Key outcomes included changes in weight, BMI, waist circumference, body composition, basal metabolism, metabolic markers, and inflammatory markers. Subgroup analyses assessed differences based on sex, surgery type, and classification as IWL or WR. Linear regression was performed to identify predictors of weight loss outcomes.

RESULTS

At 6 months, mean total weight loss was 12.0 % ± 3.4 % (p < 0.001), with significant reductions in BMI, waist circumference, body fat percentage, and HbA1c. Basal metabolism declined proportionally with weight loss. Weight loss ≥ 5 % occurred in 100.0 % of patients, ≥ 10 % in 76.5 %, and ≥ 15 % in 23.5 %. Basal metabolism differences between RYGB and SG patients converged by 6 months. Male and female patients showed comparable weight loss and metabolic adaptation. IWL patients experienced less fat-free mass loss at 3 months compared to WR (p < 0.05). Baseline BMI nadir, prior weight regain, body composition, and chronic inflammation were significant predictors of weight loss outcomes.

DISCUSSION

Tirzepatide treatment significantly enhances weight loss and metabolic health in post-bariatric patients, regardless of surgery type or sex. Differences in fat-free mass loss highlight the need for tailored interventions in IWL and WR groups. Baseline factors, including inflammation and body composition, may help predict treatment success.

Resolution of Metabolic Dysfunction-associated Steatohepatitis With No Worsening of Fibrosis After Bariatric Surgery Improves 15-year Survival: A Prospective Cohort Study

BACKGROUND & AIMS

The aim of this study was to investigate the consequences of the histological progression of metabolic dysfunction-associated steatohepatitis (MASH) and fibrosis on long-term survival after bariatric surgery.

METHODS

From 1994 to 2021, 3028 patients at the University Hospital of Lille were prospectively included. Baseline liver biopsies were systematically performed with proposed follow-up biopsies 1 year after surgery, mainly in patients with MASH. We evaluated the association of the baseline and 1-year histologic progression of MASH and fibrosis status and long-term survival using Cox regression models.

RESULTS

At baseline, 2641 patients (89%) had a biopsy, including 232 with MASH (8.7%) and 266 (10.8%) with significant fibrosis (grade F2-F4). The median follow-up was 10.1 years. At 1 year, 594 patients had qualitative paired biopsies. Survival was shorter at the 15-year follow-up in patients with baseline MASH, than in those without (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.38-3.53) and in F2 to F4 than in F0 to F1 (HR, 3.38; 95% CI, 2.24-5.10). At the 1-year landmark analysis, compared with patients without baseline MASH, mortality increased in those with persistent MASH and/or if fibrosis worsened (adjusted HR, 2.54; 95% CI, 1.06-6.10), but not if MASH resolved without the worsening of fibrosis (adjusted HR, 0.73; 95% CI, 0.28-1.87). Similarly, compared with patients without significant fibrosis at baseline, patients with persistent significant fibrosis had increased mortality (adjusted HR, 4.03; 95% CI, 1.86-8.72) but not if fibrosis improved from F2 to F4 to F0 to F1 (adjusted HR; 1.49; 95% CI, 0.52-4.24).

CONCLUSION

Histologic remission of MASH or significant fibrosis improves survival after bariatric surgery.

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Weight Loss Pharmacotherapy: Current and Future Therapies

The rising prevalence of obesity is of major concern. There are currently 5 Food and Drug Administration-approved medications for the treatment of obesity: orlistat, phentermine/topiramate, naltrexone/bupropion, liraglutide 3.0 mg, and semaglutide 2.4 mg. Surgical options such as bariatric surgery and endoscopic surgery induce more durable weight loss than pharmacotherapy or lifestyle interventions alone. However, patients often experience weight regain and weight loss plateau after surgery. The addition of multimodal or multihormonal pharmacotherapy is a promising tool to address these challenges. The optimal timing of obesity pharmacotherapy with surgical and endoscopic interventions requires further investigation.

Combination Therapies: Anti-Obesity Medications and Endoscopic Bariatric Procedures

The obesity epidemic continues to worsen in the United States with currently 40% of adults with obesity. While lifestyle changes, pharmacologic and surgical treatments are the mainstay of therapy, they often are either inadequate to meet desired weight loss or underutilized due to patient preference. Endoscopic bariatric treatment can fill these gaps. Combination of endoscopic therapy with pharmacologic therapy can help narrow the gap between endoscopic and surgical bariatric treatment, as well as treat weight recidivism, inadequate weight loss, or further improve associated medical comorbidities in patients who have undergone or are undergoing endoscopic bariatric treatment.

Pharmacotherapy as an Augmentation to Bariatric Surgery for Obesity

A global obesity pandemic is one of the most significant health threats worldwide owing to its close association with numerous comorbidities such as type 2 diabetes mellitus, arterial hypertension, dyslipidemia, heart failure, cancer and many others. Obesity and its comorbidities lead to a higher rate of cardiovascular complications, heart failure and increased cardiovascular and overall mortality. Bariatric surgery is at present the most potent therapy for obesity, inducing a significant weight loss in the majority of patients. In the long-term, a substantial proportion of patients after bariatric surgery experience a gradual weight regain that may, in some, reach up to a presurgical body weight. As a result, anti-obesity pharmacotherapy may be needed in some patients after bariatric surgery to prevent the weight regain or to further potentiate weight loss. This article provides an overview of the use of anti-obesity medications as an augmentation to bariatric surgery for obesity. Despite relatively limited published data, it can be concluded that anti-obesity medication can serve as an effective adjunct therapy to bariatric surgery to help boost post-bariatric weight loss or prevent weight regain.

Effect of Glucagon-like Peptide-1 Receptor Agonists (GLP-1RA) on Weight Loss Following Bariatric Treatment

CONTEXT

There has been growing recognition of the need for considering weight-loss strategies following metabolic bariatric surgery (MBS) to limit the magnitude of potential weight regain. The use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in this setting remains uncertain.

OBJECTIVE

We conducted a systematic review and meta-analysis to evaluate the effect of GLP-1RAs on weight changes in patients who previously underwent MBS.

METHODS

We examined the effect of GLP-1RAs on weight changes by calculating pooled estimates (random-effects model) of the absolute differences in body weight (kg) compared to baseline for observational studies and compared to a control group for randomized controlled trials (RCTs). A total of 17 studies (1164 participants) met our inclusion criteria. Pooling the data from the 14 observational studies evaluating the effect of GLP-1RAs post bariatric treatment demonstrated a reduction of 7.83 kg compared to pre treatment (before the use of GLP-1RA) (weight-7.83 kg [95% CI, -9.27 to -6.38]). With respect to tolerability, 23% (95% CI, 10%-36%) of participants reported any adverse event but only 7% discontinued treatment. Data from RCTs showed that the use of GLP-1RAs induced weight reduction of 4.36 kg (95% CI, -0.42 to -8.30) compared to placebo with a similar safety profile.

CONCLUSION

Our findings suggest that the use of liraglutide and semaglutide in patients who previously underwent MBS can promote significant weight reduction with an acceptable safety profile.

Maternal Cardiac Function in Pregnancies with Metabolic Disorders

The obesity epidemic is growing and poses significant risks to pregnancy. Metabolic impairment can be associated with short- and long-term maternal and perinatal morbidity and mortality. The cardiovascular implications are known in those with metabolic disorder outside of pregnancy; however, little is known of the cardiac function in pregnancies complicated by obesity. Maternal cardiac adaptation plays a vital role in normal pregnancy and is known to be involved in the pathophysiology of adverse pregnancy outcomes. Bariatric surgery is the most successful treatment for sustainable weight loss and pre-pregnancy bariatric surgery can drastically change the maternal metabolic profile and pregnancy outcomes. In this review, we discuss the available evidence on maternal cardiac function in pregnancies affected by obesity and its associated consequences of gestational diabetes and hypertension (chronic and hypertensive disorders in pregnancy), as well as pregnancies following bariatric surgery.

Adjuvant and Neo-Adjuvant Anti-Obesity Medications and Bariatric Surgery: A Scoping Review

PURPOSE OF REVIEW

To comprehensively summarize the current body of literature on the topic of adjuvant and neoadjuvant pharmacotherapy used in combination with bariatric surgery.

RECENT FINDINGS

Anti-obesity medications (AOMs) have been used since the mid-1900s; however, their use in combination with bariatric surgery is a newer area of research that is rapidly growing. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery. Recent literature suggests that adjuvant AOMs may address weight regain and inadequate weight loss following bariatric surgery. Research on neoadjuvant AOM used to optimize weight loss before bariatric surgery is more limited. A literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-four studies were included after screening and exclusion of irrelevant records. Included studies were as follows: seven prospective studies on adjuvant AOM use, 23 retrospective studies on adjuvant AOM use, one prospective study on adjuvant and neoadjuvant AOM use, one retrospective study on adjuvant or neoadjuvant AOM use, one prospective study on neoadjuvant AOM use, and one case series on neoadjuvant AOM use. In the following scoping review, each of these studies is discussed with the goal of presenting a complete synthesis of the current body of literature on AOM use in combination with bariatric surgery.

Evaluating the use of adjuvant and neoadjuvant terminology in bariatric surgery: a scoping review

BACKGROUND

Weight regain and inadequate weight loss are common after bariatric surgery. Literature is emerging regarding the use of pharmacotherapy with bariatric surgery as a potential solution to these adverse effects. Pharmacotherapy may be used before (neoadjuvant) or after (adjuvant) bariatric surgery, although this terminology has not been standardized. As a rapidly growing area of research, there is opportunity to standardize terminology for future ease of research, data synthesis, and communication. This review aimed to comprehensively evaluate the use of the terms "adjuvant" and "neoadjuvant" to describe pharmacotherapy used in combination with bariatric surgery and propose standardized terminology for future research.

METHODS

Literature search was conducted systematically and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were published after 1999; were randomized controlled trials, prospective/retrospective cohort studies, or case series; and used human subjects that were adults at least 18 years of age. The use of the terms "neoadjuvant" and "adjuvant" was analyzed over time.

RESULTS

Thirty-four publications were included. Thirty-two (94.1%) studied the use of adjuvant pharmacotherapy after bariatric surgery. Four (11.8%) studied the use of pharmacotherapy before bariatric surgery, and 1 used the term "neoadjuvant" to describe medications used before bariatric surgery. Eight publications used the term "adjuvant" to describe medications used after bariatric surgery.

CONCLUSION

Standardized terminology is needed to ease future understanding, evidence synthesis, and dissemination of work. We propose that the terms "neoadjuvant" and "adjuvant" become the standard terminology to describe pharmacotherapy use before and after bariatric surgery, respectively.

Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article

As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.

Adjuvant Glucose-Like Peptide 1 Receptor Agonist Therapy for Suboptimal Weight Loss After Bariatric Surgery: a Systematic Review

Addressing suboptimal weight loss post-bariatric surgery poses a challenge. While glucagon-like peptide 1 receptor agonists (GLP1-RA) show promise in managing obesity, their role as an adjuvant treatment after bariatric surgery remains uncertain. We conducted a systematic literature review focused on the efficacy and safety of GLP1-RA in bariatric surgery patients with insufficient weight loss or distant weight regain. Our literature search identified 1167 articles, with 10 (involving 594 patients) meeting inclusion/exclusion criteria for detailed review. GLP1-RA therapy resulted in 5 to 17% weight loss over 6 to 12 months, with 10-50% experiencing non-severe side effects like nausea. Overall, GLP1-RA emerges as an effective adjuvant therapy for patients experiencing inadequate weight loss or regain after bariatric surgery, offering a viable alternative to revision surgery.

Glucagon-Like Peptide-1 Receptor Agonists in Post-bariatric Surgery Patients: A Systematic Review and Meta-analysis

BACKGROUND

A significant number of patients face the issue of weight gain (WG) or inadequate weight loss (IWL) post-bariatric surgery for obesity. Several studies have been published evaluating the role of glucagon-like peptide-1 receptor agonists (GLP1RA) for weight loss post-bariatric surgery. However, no systematic review and meta-analysis (SRM) till date has evaluated the efficacy, safety and tolerability of GLP1RA in this clinical scenario. Hence, this SRM aimed to address this knowledge gap.

METHODS

Databases were searched for randomized controlled trials (RCTs), case-control, cohort and observational studies involving use of GLP1RA in the intervention arm post-bariatric surgery. Primary outcome was weight loss post at least 3 months of therapy. Secondary outcomes were evaluation of body composition parameters, total adverse events (TAEs) and severe adverse events (SAEs).

RESULTS

From initially screened 1759 articles, 8 studies (557 individuals) were analysed. Compared to placebo, patients receiving liraglutide had significantly greater weight loss after 6-month therapy [MD - 6.0 kg (95% CI, - 8.66 to - 3.33); P < 0.001; I2 = 79%]. Compared to liraglutide, semaglutide had significantly greater percent reduction in body weight after 6-month [MD - 2.57% (95% CI, - 3.91 to - 1.23); P < 0.001; I2 = 0%] and 12-month [MD - 4.15% (95% CI, - 6.96 to - 1.34); P = 0.004] therapy. In study by Murvelashvili et al. (2023), after 12-month therapy, semaglutide had significantly higher rates of achieving > 15% [OR 2.15 (95% CI, 1.07-4.33); P = 0.03; n = 207] and > 10% [OR 2.10 (95% CI, 1.19-3.71); P = 0.01; n = 207] weight loss. A significant decrease in fat mass [MD - 4.78 kg (95% CI, - 7.11 to - 2.45); P < 0.001], lean mass [MD - 3.01 kg (95% CI, - 4.80 to - 1.22); P = 0.001] and whole-body bone mineral density [MD - 0.02 kg/m2 (95% CI, - 0.04 to - 0.00); P = 0.03] was noted with liraglutide.

CONCLUSION

Current data is encouraging regarding use of GLP1RAs for managing WG or IWL post-bariatric surgery. Deterioration of bone health and muscle mass remains a concern needing further evaluation.

TRIAL REGISTRATION

The predefined protocol has been registered in PROSPERO having registration number of CRD42023473991.

Semaglutide and Tirzepatide for the Management of Weight Recurrence After Sleeve Gastrectomy: A Retrospective Cohort Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the most effective treatment for obesity and improvement of obesity-associated comorbidities. However, a proportion of these patients may suffer from weight recurrence and recurrence of obesity-associated comorbidities.

METHOD

A retrospective cohort study of patients who underwent SG between January 2008 and August 2022 and sought treatment for weight recurrence with semaglutide or tirzepetide from January 2022 onwards.

RESULT

A total of 115 patients were included, of which 70 had SG and treated for weight recurrence with semaglutide and 45 had SG and treated with tirzepatide. The mean age of patients was 38.8 (10.4) and 80.9% of patients were female. The mean pre-treatment weight and BMI was 94.0 (23.8) kg and 35.1 (6.0) kg/m2. Following treatment with semaglutide and tirzepatide, the mean post-treatment weight at 6 months was 81.0 (19.0) kg from 90.1 (19.6) kg and 87.6 (28.3) kg from 100.2 (28.5) kg respectively, corresponding to a clinically significant mean weight loss from baseline to 6 months of 10.3 (5.9)% (p < 0.05) and 15.5 (6.3)% (p < 0.05). Weight loss in tirzepatide patients was significantly greater than the semaglutide patients at 6 months (p < 0.02). There were no reported severe adverse events to the treatment.

CONCLUSION

Short-term outcomes show that semaglutide and tirzepatide can be an effective treatment for managing weight recurrence after SG. Studies with longer follow-up are needed to determine the durability, as weight regain after discontinuation of the medication is highly likely, and the high cost of these medications can limit their use.

Practical guide: Glucagon-like peptide-1 and dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonists in diabetes mellitus

In 2005, exenatide became the first approved glucagon-like peptide-1 receptor agonist (GLP-1 RA) for type 2 diabetes mellitus (T2DM). Since then, numerous GLP-1 RAs have been approved, including tirzepatide, a novel dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA, which was approved in 2022. This class of drugs is considered safe with no hypoglycemia risk, making it a common second-line choice after metformin for treating T2DM. Various considerations can make selecting and switching between different GLP-1 RAs challenging. Our study aims to provide a comprehensive guide for the usage of GLP-1 RAs and dual GIP and GLP-1 RAs for the management of T2DM.

Special considerations for the adolescent with obesity: An obesity medicine association (OMA) clinical practice statement (CPS) 2024

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details special considerations for the management of the adolescent with obesity. The information in this CPS is based on scientific evidence, supported by medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement addresses special considerations in the management and treatment of adolescents with overweight and obesity.

Conclusions

This OMA Clinical Practice Statement on the adolescent with obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations and is designed to help the provider with clinical decision making.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years

BACKGROUND

Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality.

OBJECTIVES

The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission.

METHODS

We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle.

RESULTS

A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%).

CONCLUSIONS

Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Advances in obesity pharmacotherapy; learning from metabolic surgery and beyond

Currently, metabolic surgery (MS) constitutes the most effective means for durable weight loss of clinically meaningful magnitude, type 2 diabetes remission and resolution of non-alcoholic steatohepatitis, as well as other obesity-related comorbidities. Accumulating evidence on the mechanisms through which MS exerts its actions has highlighted the altered secretion of hormonally active peptides of intestinal origin with biological actions crucial to energy metabolism as key drivers of MS clinical effects. The initial success of glucagon-like peptide-1 (GLP-1) receptor agonists regarding weight loss and metabolic amelioration have been followed by the development of unimolecular dual and triple polyagonists, additionally exploiting the effects of glucagon and/or glucose-dependent insulinotropic polypeptide (GIP) which achieves a magnitude of weight loss approximating that of common MS operations. Through the implementation of such therapies, the feasibility of a "medical bypass", namely the replication of the clinical effects of MS through non-surgical interventions may be foreseeable in the near future. Apart from weight loss, this approach ought to be put to the test also regarding other clinical outcomes, such as liver steatosis and steatohepatitis, cardiovascular disease, and overall prognosis, on which MS has a robustly demonstrated impact. Besides, a medical bypass as an alternative, salvage, or combination strategy to MS may promote precision medicine in obesity therapeutics.

Suboptimal Weight Loss 13 Years After Roux-en-Y Gastric Bypass Is Associated with Blunted Appetite Response

PURPOSE

Bariatric surgery remains the most efficient treatment to achieve a sustained weight loss. However, a large proportion of patients experience suboptimal weight loss (SWL). The exact mechanisms involved remain to be fully elucidated, but the homeostatic appetite control system seems to be involved. The aim of this study was, therefore, to compare the plasma concentration of gastrointestinal hormones, and appetite ratings, between those experiencing SWL and optimal weight loss (OWL) after Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Fifty participants from the Bariatric Surgery Observation Study (BAROBS) experiencing either SWL or OWL (< or ≥ 50% of excess weight loss (EWL), respectively) > 13 years post-RYGB were compared to 25 non-surgical controls. Plasma concentrations of acylated ghrelin (AG), total glucagon-like peptide-1 (GLP-1), total peptide YY (PYY), cholecystokinin (CCK), and subjective ratings of hunger, fullness, desire to eat (DTE), and prospective food consumption (PFC) were assessed in the fasting and postprandial (area under the curve (AUC)) states.

RESULTS

Those experiencing OWL presented with higher basal AG and GLP-1 iAUC, and lower AG iAUC compared with SWL and controls. Additionally, both bariatric groups presented with higher PYY and CCK iAUC compared to controls. PFC tAUC was also lower in OWL compared to the SWL group. Total weight loss was positively correlated with GLP-1 tAUC and negatively correlated with fasting and tAUC DTE and PFC tAUC.

CONCLUSIONS

SWL > 13 years post-RYGB is associated with lower basal ghrelin, as well as a weaker satiety response to a meal. Future studies should investigate the causality of these associations.

Post metabolic bariatric surgery weight regain: the importance of GLP-1 levels

Weight regain and insufficient weight loss are essential problems after metabolic bariatric surgery (MBS) in people living with obesity. Changes in the level of glucagon-like peptide-1 (GLP-1) secreted from the gut after bariatric surgery are one of the underlying mechanisms for successful initial weight loss. Studies and meta-analyses have revealed that postprandial GLP-1 levels increase after the Roux-en-Y gastric bypass and sleeve gastrectomy, but fasting GLP-1 levels do not increase significantly. Some observational studies have shown the relationship between higher postprandial GLP-1 levels and successful weight loss after bariatric surgery. There is growing evidence that GLP-1-receptor agonist (GLP-1-RA) use in patients who regained weight after bariatric surgery has resulted in significant weight loss. In this review, we aimed to summarize the changes in endogenous GLP-1 levels and their association with weight loss after MBS, describe the effects of GLP-1-RA use on weight loss after MBS, and emphasize metabolic adaptations in light of the recent literature. We hypothesized that maintaining higher basal-bolus GLP-1-RA levels may be a promising treatment choice in people with obesity who failed to lose weight after bariatric surgery.

Semaglutide 2.4 mg/wk for weight loss in patients with severe obesity and with or without a history of bariatric surgery

OBJECTIVE

This retrospective cohort study aimed to assess the effectiveness of semaglutide 2.4 mg in patients with severe obesity (BMI ≥ 40 kg/m2 ) who had previously undergone bariatric surgery (BS) but failed to achieve satisfactory weight loss or experienced weight regain compared with patients without a history of BS with similar BMI.

METHODS

The authors analyzed data from 129 patients with a BMI ≥ 40 kg/m2 , including 39 with (BS+) and 90 without (BS-) a history of BS. The patients received semaglutide treatment for 24 weeks starting at 0.25 mg/wk and gradually increasing to reach a final dose of 2.4 mg/wk. The treatment outcomes were assessed based on the percentage of weight loss, changes in BMI, and waist circumference.

RESULTS

Semaglutide treatment resulted in significant 9.1% weight loss in the BS+ group, with no significant difference in weight loss between the BS+ and BS- groups.

CONCLUSIONS

This study is the first, to the authors' knowledge, to compare the effectiveness of semaglutide treatment in patients with versus those without a history of BS, providing valuable evidence of its efficacy. By focusing on individuals with severe obesity (BMI > 40 kg/m2 and associated comorbidities), it fills a gap in the current literature and highlights the potential of semaglutide 2.4 mg as a treatment option for this specific population.

How to address weight regain after bariatric surgery in an individualized way

Bariatric surgery is the most effective obesity treatment. As a chronic and progressive disease, weight loss response to surgery will vary individually. Thus, insufficient weight loss or regain can happen after surgery, but they lack a standard definition. There are different mechanisms underlying weight regain and/or insufficient weight loss, such as genetics, maladaptive eating behaviors, and the inadequate choice of index operations, among others. Patients with weight regain or insufficient weight loss should be submitted to an individualized and comprehensive evaluation by a multidisciplinary team. This may help identify the causes and direct the appropriate treatment individually. Options for patients with insufficient weight loss and/or weight regain following bariatric surgery include repair of postoperative complications, conversion into another operation, endoscopic therapies with inconsistent outcomes, and dietary/behavioral counseling. Revision and conversion surgeries have higher complication rates than primary operations. Although there is no standard pharmacological regimen for that indication, the new agents seem efficient and safe to promote the loss of the regained weight and even be adjunctive to selected patients before they reach the plateau. This review aims to summarize the knowledge of the best approach for patients with weight regain/insufficient weight loss and suggests an algorithm to customize the approach and therapeutic options after bariatric surgery.

Preoperative and early adjuvant weight loss medications in bariatric surgery patients with body mass index over 60 or suboptimal initial response to surgery

BACKGROUND

Few studies have examined the adjuvant use of antiobesity medications with surgery, especially in the pre- and early postoperative periods.

OBJECTIVE

Evaluate the impact of adjuvant pharmacotherapy on bariatric surgery outcomes.

SETTING

University hospital, United States.

METHODS

A retrospective chart review of patients receiving adjuvant pharmacotherapy for obesity treatment and bariatric surgery. Patients received pharmacotherapy either preoperatively if their body mass index was >60, or in the first or second postoperative years for suboptimal weight loss. Outcome measures included percentage of total body weight loss as well as comparison with the expected weight loss curve as determined by the Metabolic and Bariatric Surgery Risk/Benefit Calculator.

RESULTS

A total of 98 patients were included in the study, with 93 (94.9%) undergoing sleeve gastrectomy and 5 (5.1%) undergoing Roux-en-Y gastric bypass surgery. During the study period, patients were prescribed phentermine and/or topiramate. At postoperative year 1, patients who received pharmacotherapy preoperatively lost 31.3% of their total body weight (TBW) compared with 25.3% TBW for patients with suboptimal weight loss who received medication in the first postoperative year, and 20.8% TBW for patients who did not receive any antiobesity medication in the first postoperative year. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) curve for comparison, patients receiving medication preoperatively weighed 2.4% less than expected, whereas patients receiving medication during the first postoperative year weighed 4.8% higher than expected.

CONCLUSION

For patients having bariatric surgery who fall below the expected MBSAQIP weight loss curve, early initiation of antiobesity medications can improve the weight loss, with preoperative pharmacotherapy having the greatest effect.

Pediatric Obesity: Complications and Current Day Management

Obesity affects approximately 1 in 5 youth globally and increases the risk of complications during adolescence and young adulthood, including type 2 diabetes, dyslipidemia, hypertension, non-alcoholic fatty liver disease, obstructive sleep apnea, and polycystic ovary syndrome. Children and adolescents with obesity frequently experience weight stigma and have an impaired quality of life, which may exacerbate weight gain. Pediatric obesity is typically defined using sex-, age-, and population-specific body mass index percentiles. Once identified, pediatric obesity should always be managed with lifestyle modification. However, adolescents with obesity may also benefit from anti-obesity medications (AOM), several of which have been approved for use in adolescents by the US Food and Drug Administration, including liraglutide, phentermine/topiramate, and semaglutide. For children with specific, rare monogenic obesity disorders, setmelanotide is available and may lead to significant weight loss. Metabolic and bariatric surgery may be used for the management of severe obesity in youth; though highly effective, it is limited to specialized centers and has had relatively low pediatric uptake. In this narrative review using pediatric-focused data from original research, reviews, clinical practice guidelines, governmental agencies, and pharmaceutical companies, we review obesity-related metabolic complications in youth and management strategies, including AOM and bariatric surgery.