Bariatric surgery superior to other interventions in type 2 diabetes

Randomized clinical trials of bariatric surgery have been limited in size, type of surgical procedure and follow-up duration, so little is known about its long-term effects on glycemic control and safety compared with medical/lifestyle management in type 2 diabetes.1A new study has pooled the results of four U.S. randomized clinical trials designed to evaluate the effectiveness of bariatric surgery, compared with combined medical therapy and lifestyle management, in improving glycemic control in participants with type 2 diabetes and a body mass index (BMI) of 27–45.2. Called ARMMS-T2D (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes), study participants were originally randomized to undergo either medical/lifestyle management or one of the following three bariatric surgical procedures: Roux-en-Y gastric bypass, sleeve gastrectomy or adjustable gastric banding. The primary outcome was change in glycated hemoglobin (A1C) from baseline to seven years for all participants, with data reported for up to 12 years.1Results showed the following:A total of 262 of 305 eligible participants (86%) were enrolled in long-term follow-up for this pooled analysis. The mean age of participants was 49.9 years, mean BMI was 36.4, 68.3% were women, 31% were black and 67.2% were white.During follow-up, 25% of participants randomized to undergo medical/lifestyle management underwent bariatric surgery. The median follow-up was 11 years. At seven years, A1C decreased by 0.2% (95% CI, −0.5% to 0.2%), from a baseline of 8.2%, in the medical/lifestyle group and by 1.6% (95% CI, −1.8% to −1.3%), from a baseline of 8.7%, in the bariatric surgery group.The between-group difference was −1.4% (95%CI, −1.8% to −1.0%; p < 0.001) at seven years and −1.1% (95%CI, −1.7% to −0.5%; p = 0.002) at 12 years. Fewer antidiabetes medications, including insulin and incretin therapies, were used in the bariatric surgery group. Diabetes remission was greater after bariatric surgery (6.2% in the medical/lifestyle group vs 18.2% in the bariatric surgery group; p = 0.02) at seven years and (0.0% in the medical/lifestyle group vs 12.7% in the bariatric surgery group; p < 0.001) at 12 years.Four deaths (2.2%) were reported, two in each group. No differences were seen in major cardiovascular adverse events. Anemia, fractures and gastrointestinal adverse events were more common after bariatric surgery.1The researchers conclude that after seven to 12 years of follow-up, individuals originally randomized to undergo bariatric surgery compared with medical/lifestyle intervention had superior glycemic control with less diabetes medication use and higher rates of diabetes remission. These advantages should be balanced against the increased risk ofnutritional deficiencies (anemia), gastrointestinal adverse events and bone fractures in long-term follow-up after bariatric surgery.1An accompanying editorial points out that this study provides the most robust evidence to date of the long-term efficacy of bariatric surgery for improving control of type 2 diabetes. Bariatric surgery was also more successful than medical/lifestyle management in achieving diabetes remission. The editorial authors believe that these data strongly support recommendations of expert panels, professional associations, and the study researchers to extend the use and coverage of bariatric surgery to individuals with a BMI ≤ 35 who cannot achieve adequate glycemic control with medical/lifestyle intervention.2The editorial authors also draw attention to the fact that the four randomized clinical trials that comprised ARMMS-T2D were launched well before semaglutide and tirzepatide were approved for type 2 diabetes and, more recently, for obesity. These medications have the potential to transform the management of both these diseases. However, further evaluation is needed to determine whether these medications will produce longer-term improvements in obesity, type 2 diabetes and related diseases comparable to that provided by bariatric surgery.2Long-term studies are needed to compare bariatric surgery with newer antiobesity medications in terms of safety, clinical efficacy, cost-effectiveness, patient acceptability and patient quality of life. In the interim, the editorial authors encourage healthcare providers to consider the long-term benefits of bariatric surgery for individuals with type 2 diabetes who are not adequately controlled by medical and lifestyle therapies. Bariatric surgery is a vastly underutilized intervention.2References:1. Courcoulas AP, Patti ME, Hu B, et al. Long-term outcomes of medical management vs. bariatric surgery in type 2 diabetes. JAMA 2024;331(8):654-64. (accessed February 27, 2024).2. Wadden TA, Kushner RF, Chao AM. Bariatric surgery produces long-term benefits in patients with type 2 diabetes. Evidence supporting its expanded use and coverage. JAMA 2024;331:643-5. JAMA 2024;331(8):643-5. (accessed February 27, 2024).

Bariatric surgery superior to other interventions in type 2 diabetes

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