GLP-1 Receptor Agonists After Bariatric Surgery How and When

In this video, obesity experts Holly Lofton, MD, and Marina Kurian, MD, discuss how clinicians can use the new weight loss medications to improve their patients' outcomes after bariatric surgery.
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Holly Lofton, MD: Hello. I'm Dr Holly Lofton. I'm an obesity medicine specialist at NYU Langone Health in Manhattan. Today I have a special guest, Dr Marina Kurian, who is a clinical professor of surgery at NYU Langone Health and the president of the American Society for Metabolic and Bariatric Surgery. Welcome, Dr Kurian.
Marina Kurian, MD: Thank you so much for having me. Holly. Thank you.
Lofton: Today, I want to discuss a very hot topic, which is the combined use of bariatric surgery and antiobesity medications, because we know there are so many different modalities that are being used to treat overweight and obesity right now. Those include lifestyle interventions, antiobesity medications, and bariatric metabolic surgery. However, some patients need multiple modalities to achieve success. I want to ask you first: What are some of the more common metabolic bariatric surgeries that are performed today?
Kurian: I'd say the two most common currently in the United States are the sleeve gastrectomy and the Roux-en-Y gastric bypass. In the sleeve gastrectomy, we remove a portion of the stomach, whereas in the gastric bypass, we make the stomach small and then reroute the intestines - so we don't remove any stomach in that procedure. With the sleeve gastrectomy, we expect patients to lose about 30%-35% of total body weight. And with the bypass, it can be slightly more - maybe 35%-40% of total body weight.
Lofton: Have you seen patients who don't achieve this expected weight loss?
Kurian: Absolutely. And when that occurs, something that we both do in our practices is to add antiobesity medication to that regimen. But first, of course, I look to see what type of diet they're on, what their caloric intake is, and what is their level of activity before I just say, "Hey, take this medication."
Lofton: What would you say are other potential benefits of using antiobesity medications after bariatric surgery vs a revisional surgery or a second metabolic or bariatric surgery?
Kurian: It's a complex answer. Some of the benefits obviously are if the medication can get the patient to their goal, then we're saving them an operation. I frequently do this with my patients first to see if they really would benefit from a revision. I'll start them on medication after their initial bariatric surgery to see how well they do with dietary modification and behavioral modification. And then I add the medication as well. If they lose enough weight, they don't need a bariatric revision. But if they don't lose or there's some other reason - like sometimes it's about access to the medications - then I will consider them for a revisional procedure, depending on what their initial operation was, of course.
Lofton: Is there scientific evidence that antiobesity medications are better for patients after bariatric surgery than, say, just seeing a dietitian to get more results?
Kurian: Absolutely. As you know, and I believe you've written some of that literature, there are plenty of articles out there that look at the use of antiobesity medications vs lifestyle change and dietary changes. Antiobesity medication along with that will really have the maximum results for patients. This is if they have weight recurrence after the initial procedure, or if they have inadequate weight loss and they're not following the trajectory that I usually feel that they should be on - based on my experience with so many patients.
Lofton: That's a really good point, and I want to talk more about that for the audience. If you're a primary care physician and you're seeing someone with a previous bariatric surgery, even if it was 5 or 10 years ago, a very common practice was to refer them to a dietitian and have them log and track calories and things like that. But if the evidence is stating that they may be better managed by either seeing their bariatric surgeon for medication or revisional options, or seeing an obesity medicine specialist or even the primary care doctor prescribing medications, if the evidence is there, then that may change some of the current practices and help our patients get more success.
Kurian: I think that's absolutely true. If you look at the landscape of obesity treatments that are out there, because we've had so many medications added to our arsenal, I know that many of our colleagues around the country are getting more familiar with using them in patients. I think the key to it is to try to identify who would benefit, and it is completely appropriate for the patient to be evaluated for the use of antiobesity medication, even if they've had surgery.
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