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Original article
Efficacy of adjuvant weight loss medication after bariatric surgery
Zubaidah Nor Hanipah, M.D.a,b, Elie C. Nasr, B.A.a, Emre Bucak, M.D.a,
Philip R. Schauer, M.D.a, Ali Aminian, M.D.a, Stacy A. Brethauer, M.D.a, Derrick Cetin, D.O.a,*
a
Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
b
Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
Received March 27, 2017; accepted October 3, 2017
Abstract Background: Some patients do not achieve optimal weight loss or regain weight after bariatric
surgery. In this study, we aimed to determine the effectiveness of adjuvant weight loss medications
after surgery for this group of patients.
Setting: An academic medical center.
Methods: Weight changes of patients who received weight loss medications after bariatric surgery
from 2012 to 2015 at a single center were studied.
Results: Weight loss medications prescribed for 209 patients were phentermine (n ¼ 156, 74.6%),
phentermine/topiramate extended release (n ¼ 25, 12%), lorcaserin (n ¼ 18, 8.6%), and naltrexone
slow-release/bupropion slow-release (n ¼ 10, 4.8%). Of patients, 37% lost 45% of their total
weight 1 year after pharmacotherapy was prescribed. There were significant differences in weight
loss at 1 year in gastric banding versus sleeve gastrectomy patients (4.6% versus .3%, P ¼ .02) and
Roux-en-Y gastric bypass versus sleeve gastrectomy patients (2.8% versus .3%, P ¼ .01).There was
a significant positive correlation between body mass index at the start of adjuvant pharmacotherapy
and total weight loss at 1 year (P ¼ .025).
Conclusion: Adjuvant weight loss medications halted weight regain in patients who underwent
bariatric surgery. More than one third achieved 45% weight loss with the addition of weight loss
medication. The observed response was significantly better in gastric bypass and gastric banding
patients compared with sleeve gastrectomy patients. Furthermore, adjuvant pharmacotherapy was
more effective in patients with higher body mass index. Given the low risk of medications compared
with revisional surgery, it can be a reasonable option in the appropriate patients. Further studies are
necessary to determine the optimal medication and timing of adjuvant pharmacotherapy after
bariatric surgery. (Surg Obes Relat Dis 2018;14:93–98.) r 2018 American Society for Metabolic
and Bariatric Surgery. All rights reserved.
Keywords: Bariatric surgery; Weight loss; Medications; Adjuvant; Obesity; Weight; Phentermine
Obesity is a global health problem and has a strong cardiovascular diseases. In the United States, more than
association with metabolic disorders such as type 2 one third of the population has a body mass index (BMI)
diabetes, hypertension, hyperlipidemia, and other 430 kg/m2, and these numbers are increasing every year. If
these obesity trends continue, the total healthcare costs
This study was presented at the 33nd Annual Meeting of the American could reach $957 billion by 2030 [1].
Society for Metabolic and Bariatric Surgery at Obesity Week, New Bariatric surgery has evolved since the 1950s and is
Orleans, LA; October 31 to November 4, 2016.
*
Correspondence: Derrick Cetin, D.O., Bariatric and Metabolic Insti-
proven to be the most effective and have the best long-term
tute, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195. success in the management of obesity. Furthermore, it also
E-mail: CETIND@ccf.org has been shown to improve most of the metabolic disorders
http://dx.doi.org/10.1016/j.soard.2017.10.002
1550-7289/r 2018 American Society for Metabolic and Bariatric Surgery. All rights reserved.
94 Z. N. Hanipah et al. / Surgery for Obesity and Related Diseases 14 (2018) 93–98
Table 3
Summary of weight and BMI changes after adjuvant pharmacotherapy
Mean weight changes, kg Mean BMI changes, kg/m2 Percent total weight loss (TWL%)
3 mo 12 mo 3 mo 12 mo 3 mo 12 mo
Laparoscopic adjustable gastric band −4.5 −4.6 −1.7 −1.7 4.6 4.6*
Roux-en-Y gastric bypass −3.2 −3.2 −1.2 −1.2 3.2 2.8†
Sleeve gastrectomy −2.4 −.3 −.9 .1 2.5 .3
Total cohort −3.2 −2.4 −1.2 −.9 3.2 2.2
year to the 10th year after RYGB, AGB, and vertical band good safety profile [21,22]. Short-term use of phentermine
gastroplasty. and the combination of phentermine-topiramate until 1 year
Weight recidivism after bariatric surgery can be multi- have been shown to result in 5% to 10% excess weight loss
factorial and results from noncompliance to dietary guide-
lines and calorie intake, poor eating behaviors, physical
inactivity, and metabolic and anatomic complications.
Studies have shown that eating disorders, such as binge
eating or grazing, result in weight regain after bariatric
surgery [17,18]. Kofman et al. [18] conducted a survey on
maladaptive eating patterns and weight outcome after
gastric bypass. It was reported that 87% of patients regained
weight after gastric bypass at a mean follow-up of 4 years.
Binge eating, grazing, and a loss of control when eating
showed significant correlation with greater weight regain
after surgery. Magro et al. [19] showed that 78% had weight
regain at 18 months post-RYGB. Of patients, 60% avoided
nutritional follow-up and 80% never underwent psycholog-
ical follow-up. Yimcharoen et al. [20] studied the possible
anatomic causes of weight recidivism after gastric bypass.
Dilation of stoma, enlarged pouch, or both were seen in
59%, 29%, and 12% of patients, respectively.
Weight recidivism post–bariatric surgery can be an
important issue, both for patients and bariatric surgery
teams. Permanent lifestyle modification including changes
in eating habits and calorie intake, increasing physical
activity, and overcoming stressful events leading to binge
eating can be difficult. Failure to lose weight or early weight
loss plateau can cause additional frustration and anxiety for
patients, resulting in an increase in appetite and binge eating
behavior. Therefore, multidisciplinary team approaches and
proper strategies to manage weight regain or failure to lose
adequate weight in these patients are recommended.
The use of weight loss medication as an adjunct to
treatment of weight regain or inability to lose adequate
weight after bariatric surgery would be considered, espe-
cially in patients who are at high risk for revisional surgery.
Weight loss medications have been available since 1959
and were used in patients who were not suitable candidates
for bariatric surgery. Phentermine has been the most
commonly prescribed weight loss medication in the United
States, despite other newer weight loss medications that are Fig. 1. (A) Mean weight. (B) Mean body mass index (BMI). LAGB ¼
available [12–15]. Even though some of the old weight loss laparoscopic adjustable gastric band; RYGB ¼ Roux-en-Y gastric bypass;
medications had cardiac side effects, phentermine has a SG ¼ sleeve gastrectomy.
Effectiveness of Adjuvant Weight Loss Medications After Surgery / Surgery for Obesity and Related Diseases 14 (2018) 93–98 97
Fig. 2. (A) Total weight loss (TWL) 45% at 3 months after adjuvant pharmacotherapy. (B) TWL 45% at 12 months after adjuvant pharmacotherapy.
(C) TWL 410% at 3 months after adjuvant pharmacotherapy. (D) TWL 410% at 12 months after adjuvant pharmacotherapy. LAGB ¼ laparoscopic
adjustable gastric band; RYGB ¼ Roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy.
[23–25]. Schwartz et al. [12] reported 12.8% excess weight data showed a positive correlation between TWL and
loss after phentermine use (n ¼ 24) and 12.9% excess BMI at time of pharmacotherapy, BMI before surgery
weight loss after phentermine-topiramate use (n ¼ 6) at 90 did not correlate with weight loss outcomes of adjuvant
days in patients after RYGB or AGB. In our cohort, pharmacotherapy.
phentermine and phentermine-topiramate extended-release As a retrospective observational study, compliance with
were the 2 most commonly used weight loss medications, weight loss medications, dietary regimen, and exercise were
comprising a combined total of 86.8% of prescriptions. difficult to assess in our cohort. Furthermore, we were not
In our series, 37% of patients achieved additional able to differentiate the effects of lifestyle modification from
TWL 45%, and 19% of patients achieved an additional pharmacotherapy. Lack of a control group and missing data
TWL 410% at 1 year. Patients with history of AGB and limited our study. Despite the 3-month follow-up being
RYGB showed a higher percentage of TWL 45% at 1 year 95%, the 1-year follow-up was only 76%. This is due to
compared with SG. Patients with AGB and RYGB showed various factors, including financial constraints, intolerance
significantly higher TWL at 1 year compared with SG. In of adjuvant pharmacotherapy, and patients lost to follow-
our cohort, the BMI at the start of adjuvant pharmacother- up. Furthermore, we were not able to analyze the efficacy of
apy and TWL at 1 year showed a significant positive any specific drugs or the different combinations of the
correlation. Patients with BMI ≥36 kg/m2 had greater TWL weight loss medications on weight loss outcome. The
after taking adjuvant pharmacotherapy. strength of our study is that this is one of the largest series
In a recently published multicenter study, Stanford et al. from an academic center comparing the outcome of
[26] showed that 56% of patients had TWL 45% at 1 year adjuvant weight loss medications in patients who underwent
of using weight loss medications after bariatric surgery. The 1 of the 3 common bariatric procedures.
mean added weight loss was −7.6% (17.8 lbs) of total
postsurgical weight. Similar to our observation, RYGB
Conclusion
patients had better weight loss outcomes with weight loss
medications compared with SG patients. Patients with Obesity is a chronic disease, and weight recidivism is an
higher BMI before bariatric surgery showed better weight issue to be addressed after bariatric surgery, with a multi-
loss after use of weight loss medications. While our disciplinary team approach. Our experience using adjuvant
98 Z. N. Hanipah et al. / Surgery for Obesity and Related Diseases 14 (2018) 93–98
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