Is there still a place for bariatric surgery in the era of GLP-1 receptor agonist drugs?

Alongside the rise in popularity of GLP-1 receptor agonist drugs has been a significant drop in bariatric surgery and even the closing of bariatric surgery programs.According to a study in JAMA Network Open, there was a 132.6% increase in patients prescribed GLP-1 medications along with a 25.6% decrease in patients undergoing metabolic bariatric surgery across the U.S. from 2022 through 2023.The cross-sectional study used Medicare Advantage insurance data from 2022 to 2023, which included claims from nearly 17 million adult patients. From that, only non-diabetic patients with obesity were included for analyses, along with GLP-1 prescriptions specifically for treating obesity.The Boston-based researchers identified all patients with any claim for any formulation of semaglutide or liraglutide, and for metabolic bariatric surgery for each quarter. The researchers did not respond to interview requests.A total of 5,173 patients were found to have undergone bariatric surgery. Of these 4,096 (79.2%) were women and 1,073 (20.7%) men; 81,092 were prescribed GLP-1 prescriptions of which 59,724 (73.6%) were women and 21.314 (26.3%) were men. All were between 18 to 35 years old.The remaining 1.5-million patients had obesity but didn’t undergo either treatment and consisted of 926,540 (59.9%) women and 619,740 (40.1%) men. The researchers did not speculate on why less than 6% of the study population received neither GLP-1 nor surgery for obesity.Looking at trends during the period studied, it was found there was a 132.6% increase in patients who were prescribed GLP-1 drugs between the last six months of 2022 compared to the last six months of 2023.On the other hand, there was a 25.6% decrease in the number of patients undergoing metabolic bariatric surgery comparing the same periods.The study noted that those undergoing bariatric surgery were more likely to have multiple comorbidities. For example, 46.9% of the surgery patients had two to three comorbidities, and another 18.8% had more than four. This is in contrast with 29.5% of GLP-1 patients who had two to three comorbidities and only 8.2% with four or more.While GLP-1s are increasingly used, they aren’t perfect. “Although GLP-1 receptor agonists are effective for the treatment of obesity and related comorbid conditions, such as diabetes, the high cost and high rates of gastrointestinal adverse effects can lead to treatment cessation and subsequent weight regain,” the researchers said.They added that, “Policymakers and clinicians should continue to closely monitor trade-offs between pharmacologic and surgical management of obesity to ensure optimal access to effective obesity treatment.”“Although GLP-1 receptor agonists are effective for the treatment of obesity and related comorbid conditions, such as diabetes, the high cost and high rates of gastrointestinal adverse effects can lead to treatment cessation and subsequent weight regain,” the researchers said.They added that, “Policymakers and clinicians should continue to closely monitor trade-offs between pharmacologic and surgical management of obesity to ensure optimal access to effective obesity treatment.”Another study by Canadian researchers from 2022 in the journal Obesity, which compared weight loss via the two approaches, found that bariatric surgery led to higher reductions in weight and body mass index (BMI), but lead to similar effects in glycemic control as GLP-1 drugs. The Toronto researchers did not respond to interview requests.Six studiesThe study was a systematic review and meta-analysis that compared weight loss between the two approaches. It included six studies that were either randomized controlled trials or observational studies and comprised a combined total of 332 patients. Studies that reported on adjunctive GLP-1 use after bariatric surgery were excluded.The study directly compared the weight-lowering and glycemic effect of GLP-1 drugs and bariatric surgery in adults aged 18 years and older with obesity, defined as BMI of at least 25 kg/m2. Studies that reported change in weight from baseline up to 10 years were included. “This meta-analysis demonstrated that bariatric surgery still conferred the highest degree of long-term and sustained weight loss compared with novel pharmacotherapy with a GLP-1 receptor agonist.”On the other hand, “Bariatric surgery resulted in no significant change in glycemic control compared with GLP-1 receptor agonists, with a similar mean difference in HbA1C across both treatment categories,” the study said.With bariatric surgery there are risks of possible adverse effects of malabsorption and micronutrient deficiency. It also comes with postoperative surgical risks of bleeding, anastomotic leak and infection.The study is available in JAMA Network Open.

Is there still a place for bariatric surgery in the era of GLP-1 receptor agonist drugs?

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