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Preventing weight regain

Weight regain: Post-op adjuvant weight loss medication is effective

The outcomes were better in gastric bypass and gastric banding patients, compared with sleeve gastrectomy patients

Adjuvant weight loss medications after bariatric surgery can stop weight regain and maintain weight loss, according to a study by researchers from the Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH. The study found that more than one third of patients who received adjuvant weight loss medications achieved>5% weight loss and the response was ‘significantly better’ in gastric bypass and gastric banding patients, compared with sleeve gastrectomy patients.

“Our study showed that adjuvant weight loss medications halted weight regain in patients who underwent bariatric surgery,” the authors write. “More than one third achieved meaningful weight loss with the addition of weight loss medication. The observed response was significantly better in Roux-en-Y gastric bypass and adjustable gastric banding patients compared with sleeve gastrectomy cases. Our data also indicated that adjuvant pharmacotherapy would be more effective in patients with higher BMI at the time of initiation of pharmacotherapy.”

The paper, ‘Efficacy of adjuvant weight loss medication after bariatric surgery’, published in SOARD, sought to determine the effectiveness of adjuvant weight loss medications after surgery for patients undergoing one of these three bariatric procedures.

The researchers retrospectively reviewed all patients who received weight loss medications after bariatric surgery from 2012 to 2015 at their single academic centre. Although 443 patients were prescribed weight loss medications, only 209 patients continued the medication use for at least three months. Weight regain was defined as <50% excess weight loss or regain of at least 5% of their lowest weight despite dietary counselling and behavioural and lifestyle changes.

The weight loss medications included phentermine, phentermine/topiramate extended-release, lorcaserin, and naltrexone slow-release/bupropion slow-release and the weight loss medications were prescribed individually to each patient depending on their co-morbidities and their relative contraindications.

Outcomes

In total, 209 patients received weight loss medications from 2012 until 2015 and were included in the study. One hundred and twenty-six patients received a RYGB, 52 a sleeve gastrectomy and 21 laparoscopic adjustable gastric banding, 4 a gastric plication and 6 underwent revisional bariatric surgery. The mean time between the procedure and the prescription of pharmacotherapy was 38 months. Phentermine was prescribed in the vast majority of cases (n=156, 74.6%), as well as phentermine/topiramate extended release (n=25, 12%), lorcaserin (n=18, 8.6%) and naltrexone slow-release/bupropion slow-release (n=10, 4.8%). Twelve patients were prescribed low-dosage liraglutide by an endocrinologist for diabetes control (1.2–1.8mg daily). Follow up at three months was 95% (n=199) and 76% at 12 months (n=159).

Total weight loss (TWL) at three and 12 months were 3.2% and 2.2%, respectively, with TWL>5% after adjuvant pharmacotherapy at 12 months in 37% of patients. In addition, 19% of patients reported TWL>10% at 12 months.

At 12 months, there was a significant difference in in laparoscopic adjustable gastric banding patients vs sleeve gastrectomy (4.6% vs 0.3%, p=0.02) and RYGB vs sleeve gastrectomy (2.8% versus 0.3%, p=0.01). Furthermore, significantly more patients in the laparoscopic adjustable gastric banding patients and RYGB groups achieved TWL>5% and>10% at 12 months after pharmacotherapy, compared with sleeve gastrectomy patients.

The researcher also reported a significant positive correlation between BMI at the start of adjuvant pharmacotherapy and %TWL at 12 months (p=0.025). The %TWL for patients with BMI ≥36 versus those with BMI<36 were 3.5±7.9% and 0.9±7.0%, respectively (p=0.027). There was no significant correlation between pre-surgery weight and pre-surgery BMI with %TWL 12 months after initiation of pharmacotherapy.

“Given the low risk of medications compared with revisional surgery, adjuvant pharmacotherapy would be a reasonable first option in appropriate patients,” the authors conclude. “However, further study is needed to standardise a protocol for chronic weight loss medications, to define the ideal time to initiate weight loss medication, and to determine the optimal drug choice and dosages in this challenging patient population.”

To access the paper, please click here

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