September 25, 2023

As much as one in 4 sufferers who endure metabolic/bariatric surgery have lower than 20% weight reduction and sufferers want extra methods to assist them attain their targets.

In the brand new BARI-OPTIMISE trial, sufferers with poor weight reduction after such surgical procedure have been randomized to the GLP-1 agonist liraglutide 3.0 mg/day or placebo. Liraglutide was protected and well-tolerated and led to a clinically significant 8% additional discount in body weight in contrast twith placebo, report Jessica Mok, BMBS, MPhil, College Faculty London, UK, and colleagues, of their research published online July 26 in JAMA Surgical procedure.

Weight reduction in BARI-OPTIMISE (–9.2 kg or –20 lb) was larger than the burden loss within the earlier GRAVITAS trial of 80 sufferers with persistent or recurrent type 2 diabetes randomized to liraglutide 1.8 mg/day or placebo, Mok and colleagues observe. And extra sufferers in BARI-OPTIMISE than in GRAVITAS misplaced 5% or extra of their baseline weight (72% vs 46%).

“Our findings due to this fact counsel that liraglutide, 3.0 mg, might have a job within the therapy of individuals with poor weight reduction following metabolic surgical procedure,” they write.  

Nonetheless, newer intestine hormone–based mostly therapies with larger efficacy than liraglutide 3.0 mg (eg, semaglutide and tirzepatide) are rising, they add.

Subsequently, “randomized medical trials investigating the efficacy of novel pharmaceutical brokers can be wanted to generate the proof required to ship individualized precision-medicine approaches to sufferers with obesity and suboptimal weight reduction following metabolic surgical procedure,” the researchers urge.

Extraordinarily Welcome Instruments for Extreme Weight problems

“The extra weight reduction with related favorable metabolic adjustments achieved with liraglutide reported in [the BARI-OPTIMISE and GRAVITAS trials] is extraordinarily welcomed with the brand new antiobesity medicines…including one other efficient device within the toolbox for the therapy of extreme weight problems,” Paulina Salminen, MD, PhD, Turku College Hospital, Finland, and Ali Aminian, MD, Cleveland Clinic, Ohio, write in an accompanying editorial.

Nonetheless, additionally they level to limitations of the present trial.

Nearly all sufferers (65 of 70 [93%]) underwent laparoscopic sleeve gastrectomy in BARI-OPTIMISE. Nonetheless, “there are protected and more practical surgical choices that may be thought of in sufferers with suboptimal preliminary medical response or recurrent weight achieve” after laparoscopic sleeve gastrectomy, equivalent to “conversion to Roux-en-Y gastric bypass (RYGB), duodenal swap, or single-anastomosis duodeno-ileal bypass,” they observe.

The small variety of sufferers and low follow-up price of 81% (57 of 70 sufferers) for the brief intervention are different limitations.

“In treating a affected person with ischemic heart disease, a mixture of way of life intervention, threat issue modification, pharmacotherapy, coronary stenting, and open-heart surgical procedure could also be wanted,” observe the editorialists. “A really comparable idea could be relevant within the administration of extreme weight problems.”

Prior to now, they add, there was not a lot progress with mixture therapies for weight problems due to an absence of efficient antiobesity medicines.

Nonetheless, “with the higher availability of potent [antiobesity medications] now and within the close to future, the follow of mixture remedy will develop as [metabolic and bariatric surgery] and [antiobesity medications] work in synergy in each treating extreme weight problems and hopefully additionally in enabling elevated entry to efficient weight problems therapy,” Salminen and Aminian speculate.

“Hopefully, based mostly on findings of future research and the usage of international uniform standards for evaluating therapy outcomes,” the editorialists conclude, “we will develop follow tips to help and optimize phenotype-tailored multimodal therapy of this heterogeneous persistent illness of extreme weight problems.”

Most Sufferers Had Extreme Weight problems, Sleeve Gastrectomy

People with poor weight reduction after surgical procedure have elevated urge for food coupled with an unfavorable intestine hormone profile, together with decrease circulating GLP-1 ranges, Mok and colleagues observe.

In 2018 and 2019, they recruited and randomized 70 adults who had had metabolic surgical procedure at two hospitals in London, UK, at the very least a yr earlier and had 20% or much less weight reduction, in contrast with the day of surgical procedure, in addition to a suboptimal nutrient-stimulated GLP-1 response.

Sufferers have been excluded if they’d type 1 diabetes or have been taking a GLP-1 agonist, insulin, or different medicines that may have an effect on weight, amongst different standards.

The imply age of sufferers was 48 years and 74% have been girls; 13% had kind 2 diabetes.

Members had a imply weight of 120 kg, and a imply physique mass index (BMI) of 43 kg/m2 (57% had a BMI ≥ 40 kg/m2). Nearly all sufferers (93%) had had sleeve gastrectomy and seven% had RYGB.

On common, they’d surgical procedure 4.3 years earlier and had misplaced 7% of their preliminary weight.

Sufferers have been randomized 1:1 to obtain liraglutide 3.0 mg or placebo every day for twenty-four weeks. All sufferers acquired dietary counseling and aimed for a 500 kcal/day power deficit. They have been inspired to do a minimal of 150 minutes of reasonable to vigorous train every week.

The first endpoint, proportion change in physique weight from baseline to week 24, was –8.8% with liraglutide versus –0.53% with placebo.

Adversarial results have been predominantly gastrointestinal in nature and have been extra frequent with liraglutide (80%) than placebo (57%). There have been no severe hostile occasions.

This research was funded by the Sir Jules Thorn Charitable Belief and the Nationwide Institute for Well being and Care Analysis. Novo Nordisk offered the liraglutide and placebo pens. Writer disclosures are listed with the article. Salminen has reported receiving private charges from Novo Nordisk. Aminian has reported receiving acquired grants and private charges from Medtronic and Ethicon.

JAMA Surg. Printed on-line July 26, 2023. Article, Editorial

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