May 11, 2023 – Both are popular ways to lose weight. Anti-obesity drugs like semaglutide (Wegovy) and liraglutide (Saxenda) are in such high demand that drug manufacturers sometimes report shortages. And gastric sleeve surgery, a procedure that reduces the size of the stomach by up to 80%, remains the most common weight loss procedure.
Research shows that both strategies can reduce overall body weight, but little is known about what happens when they are combined.
Is it better to take weight loss drugs first and then reduce the size of the stomach, or the other way around? If you’re going to do both, how long should you wait?
Researchers are beginning 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 from Digestive Disease Week (DDW) 2023. DDW is an international gathering of GI doctors, nurses and other providers that had 13,000 virtual and in-person attendees this year.
In the study of 224 people with obesity, 69 had the combination of medications and the gastric sleeve procedure. Having both within 6 months of each other was considered “combination therapy.” This approach was associated with the greatest weight loss: an average of 24% of total body weight in 1 year.
Gastric sleeve surgery was performed endoscopically in the study, a minimally invasive procedure known as a gastroplasty. Instead of cutting into the stomach, specialists known as bariatric endoscopists insert a flexible tube down the throat and use a special instrument at the end to make the stomach smaller.
Different anti-obesity drugs studied
The combination group took different anti-obesity drugs. About a third took a glucagon-like peptide 1, or GLP-1 for short, agonist such as semaglutide and liraglutide. Other medications included phentermine/topiramate extended-release capsules (Qsymia) or an extended-release combination of bupropion and naltrexone for weight loss (Contrave).
When combined with gastroplasty, these other medications led to an 18% total body weight loss in 1 year.
Another 77 people in the study only had sleeve gastroplasty. They lost an average of 17% of their total body weight.
A third group of 78 people received “sequential therapy,” meaning they started medication more than 6 months before or after gastroplasty. This group had the least amount of weight loss: 14% of total body weight per year if the gastroplasty was performed first and 12% if the medication was given first.
Waiting for weight loss to start to stabilize after gastroplasty might be an ideal time to add weight-loss medications, said Pichamol Jirapinyo, MD, a bariatric endoscopist at Brigham and Women’s Hospital in Boston. “Usually when I see them at 3 months, I visualize how fast their weight loss has been. If you’ve been going down [steadily]We don’t offer an anti-obesity drug until I see them again at 6 months.”
Not all patients offered weight-loss drugs are interested, said Jirapinyo, the study’s lead researcher.
The rate of serious side effects of gastroplasty was similar between groups: 2.6% for the procedure-only group, 1.4% with combination therapy, and 1.3% with sequential therapy. Obesity medication-related side effects occurred in 1.3% of the sequential therapy group, and were not reported in either of the other two groups.
Combo makes sense
“I certainly believe that combination therapy should be more effective than gastroplasty alone and probably better,” said Gregory L. Austin, MD, a gastroenterologist at the UCHealth Center for Digestive Health in Denver.
But the study did not address whether people should still have a gastroplasty after taking medications for 6 months or more. He said they probably should if they don’t see enough weight loss to translate into better health outcomes by then.
“Whether it starts right away or waits 3 months later is a question that still needs to be answered,” Austin said.
‘wave of the future’
The study is “really exciting and interesting,” said Linda S. Lee, MD, medical director of endoscopy at Brigham and Women’s Hospital.
Medication started within 6 months of the endoscopic procedure “led to superior results compared to endoscopy alone,” he said.
“I think that’s really the wave of the future in terms of treating patients with obesity issues. We clearly know that diet and exercise alone for most people are not good enough,” Lee said. “Of course we have [bariatric] surgery, but we also find that with surgery, sometimes the weight starts to creep up over time.”
“From my point of view, as long as the drug is safe and doesn’t harm them, let’s do it together,” he said.
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