Obesity med cessation more likely after RYGB than sleeve gastrectomy

Patients who are on obesity-related medications before undergoing bariatric surgery may be more likely to discontinue their medications and less likely to restart them after undergoing Roux-en-Y gastric bypass (RYGB) than laparoscopic sleeve gastrectomy (LSG), a recent study has shown.

“[B]oth gastric bypass and sleeve gastrectomy were associated with a high incidence of medication discontinuation up to 5 years after surgery,” said the researchers. “[However,] gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart compared with sleeve gastrectomy,” they noted.

For this study, the researchers looked at fee-for-service Medicare claims data for 95,405 adults (mean age 56.6 years, 74.8 percent female) with morbid obesity who were on medication for diabetes, hypertension, or hyperlipidaemia 6 months prior to undergoing LSG or RYGB in 2012–2018. At time of surgery, 30,588 patients were on diabetes medication for diabetes, 52,081 were on antihypertensive medication for hypertension, and 35,055 were on lipid-lowering medications for hyperlipidaemia.

The likelihood of 5-year cumulative incidence of medication discontinuation for any reason was greater among patients who underwent RYGB than LSG be it discontinuation of diabetes medication (74.7 percent vs 72.0 percent; adjusted hazard ratio [adjHR], 1.30, 95 percent confidence interval [CI], 1.12–1.51), antihypertensive medication (53.3 percent vs 49.4 percent; adjHR, 1.31, 95 percent CI, 1.18–1.45), or lipid-lowering medication (64.6 percent vs 61.2 percent; adjHR, 1.28, 95 percent CI, 1.16–1.40*). [JAMA Surg 2022;157:248-256]

A total of 19,599 patients who discontinued their diabetes medications post-surgery later restarted them, as did 21,611 and 18,546 patients who discontinued their antihypertensive and lipid-lowering medications, respectively.

Among patients who needed to restart their medication, the 5-year cumulative incidence of medication restart was lower among those who underwent RYGB than LSG for restart of diabetes medications (30.4 percent vs 35.6 percent; adjHR, 0.78, 95 percent CI, 0.63–0.96), antihypertensive medications (67.2 percent vs 70.6 percent; adjHR, 0.81, 95 percent CI, 0.73–0.89*), and lipid-lowering medications (46.2 percent vs 52.5 percent; adjHR, 0.44, 95 percent CI, 0.38–0.50).

The median duration of medication discontinuation in patients who underwent RYGB vs LSG was 866 vs 578 days for diabetes medication, 410 vs 388 days for antihypertensive medication, and 647 vs 345 days for lipid-lowering medication (p<0.001 for all).

“Overall, we believe these results suggest that both procedures are associated with long-term improved outcomes enabling obesity-related medication discontinuation and suggest that patients who underwent gastric bypass may be slightly more likely to remain off of medications for diabetes, hypertension, and hyperlipidaemia after surgery compared with patients who underwent sleeve gastrectomy,” the researchers concluded, noting the difference in durability of medication discontinuation and restart across comorbidities.

The researchers cautioned that medication discontinuation does not necessarily equate to comorbidity resolution and more studies are warranted to determine long-term effects of bariatric surgery on comorbidities. Furthermore, the efficacy benefits of RYGB over LSG in this study should be weighed against the improved safety with LSG over RYGB seen in prior research, they added. [JAMA Surg 2021;156:1160-1169]

As to the takeaway from these findings, in an accompanying editorial, Professor Anita Courcoulas and Associate Professor Beston Ahmed from the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, US, highlighted that the focus of this study on medication use may be important to patients “who seek bariatric and metabolic surgery not only to achieve durable weight loss but also to relieve the burden of using multiple medications.” [JAMA Surg 2022;157:257]