May 11, 2023 — Both are great ways to lose weight. Demand for anti-obesity drugs such as semaglutide (Wegovy) and liraglutide (Saxenda) is so high that drug makers sometimes report shortages. Sleeve gastrectomy – a procedure to reduce the size of the stomach by up to 80% – remains the most popular weight loss procedure.
Research shows that both strategies can lower total body weight, but not much is known about what happens when you combine them.
Is it better to take weight-loss drugs first, then reduce stomach size – or vice versa? If you were to do both, how long should you wait?
Investigators are setting out to answer these and other questions that could help the 42% of Americans with obesity.
Adding medication appears to help people lose more total body weight than gastric sleeve alone, according to a study in Gastroenterology Week 2023. DDW is an international meeting of gastroenterologists, nurses, and other service providers that was attended by 13,000 people both virtually and in person this year.
In a study of 224 obese people, 69 had a combination of medication and a sleeve gastrectomy. Having both within 6 months of each other was considered “combined therapy”. This approach was associated with the greatest amount of weight loss: an average of 24% of total body weight by one year.
Laparoscopic sleeve gastrectomy was performed in the study – a minimally invasive procedure known as gastroplasty. Instead of cuts in the stomach, specialists known as bariatric endoscopy insert a flexible tube down the throat and use a special tool at the end to make the stomach smaller.
Various anti-obesity drugs have been studied
The combination group took different anti-obesity medications. Taking about a third of a glucagon-like peptide-1 agonist, or GLP-1 for short, like semaglutide and liraglutide. Other medications included phentermine/topiramate extended-release capsules (Qsymia) or a combination of bupropion and naltrexone extended-release for weight loss (Contrave).
When combined with gastric bypass surgery, these other medications resulted in a loss of 18% of total body weight in one year.
Another 77 people in the study had the sleeve gastrectomy alone. They lost an average of 17% of their total body weight.
A third group of 78 subjects received ‘sequential therapy’, which means they started treatment more than 6 months before or after gastroplasty. This group had the least amount of weight loss – 14% of total body weight at one year if gastric bypass surgery came first and 12% if medication came first.
Waiting for weight loss to start plateauing after gastric bypass surgery may be an ideal time to add weight-loss medications, said Pichamol Jirapinyo, MD, a bariatrician at Brigham and Women’s Hospital in Boston. “Usually when I see them at 3 months old, I draw on how fast they are losing weight. If they are backing off [steadily]We don’t introduce anti-obesity medication until I see them again at 6 months old.”
Not every patient who was offered weight-loss medication was interested, Gerapinho, the study’s principal investigator, said.
The rate of serious side effects for gastroplasty was similar between groups: 2.6% for the procedure-only group, 1.4% with combination therapy, and 1.3% with sequential treatment. Side effects associated with anti-obesity medication occurred in 1.3% of the sequential treatment group – and were not reported in either of the other two groups.
The combo makes sense
Austin, MD, a gastroenterologist at UCHealth Digestive Health Center in Denver: “I definitely think that combination therapy should be more effective than just gastroplasty alone and maybe even better.”
But the study did not address whether people should still have gastric bypass surgery after taking the drug for 6 months or longer. He said they probably should if they don’t see enough weight loss yielding improved health outcomes by then.
“Whether to start immediately or wait 3 months after that is a question that still needs to be answered,” said Austin.
Linda S. said: Lee, MD, medical director of endoscopy at Brigham and Women’s Hospital, said the study is “really exciting and interesting.”
She said treatment started within 6 months of the endoscopy procedure “led to better results compared to endoscopy alone.”
I think this is really the wave of the future in terms of treating patients with obesity problems. We clearly know that for most people diet and exercise alone are not good enough,” he told me. “Of course we have [bariatric] surgery, but we also realize that with surgery, the weight sometimes starts creeping back up over time.”
“From my point of view,” she said, “as long as the medicine is safe and doesn’t harm them, let’s do both.”