Multicentre cohort study of antihypertensive and lipid-lowering therapy cessation after bariatric surgery

Medication and supplement pharmacokinetic changes following bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

To evaluate the impact of bariatric surgery on the pharmacokinetic (PK) parameters of orally administered medications and supplements.

METHODS

Systematic searches of bibliographic databases were conducted to identify studies. Pooled effect estimates from different surgical procedures were calculated using a random-effects model.

RESULTS

Quantitative data were synthesized from 58 studies including a total of 1985 participants. Whilst 40 medications and 6 supplements were evaluated across these studies, heterogeneity and missing information reduced the scope of the meta-analysis to the following medications and supplements: atorvastatin, paracetamol, omeprazole, midazolam, vitamin D, calcium, zinc, and iron supplements. There were no significant differences in PK parameters post-surgery for the drugs atorvastatin and omeprazole, and supplements calcium, ferritin, and zinc supplements. Paracetamol showed reduced clearance (mean difference [MD] = -15.56 L/hr, p = 0.0002, I2 = 67%), increased maximal concentration (MD = 6.90 μg/ml, p = 0.006, I2 = 92%) and increased terminal elimination half-life (MD = 0.49 hr, p < 0.0001, I2 = 3%) post-surgery. The remaining 36 medications and 2 supplements were included in a systematic review. Overall, 18 of the 53 drugs and supplements showed post-operative changes in PK parameters.

CONCLUSION

This study demonstrates heterogeneity in practice and could not reach conclusive findings for most PK parameters. Prospective studies are needed to inform best practice and enhance patient healthcare and safety following bariatric surgery.

Osteoarthritis in patients with obesity: The bariatric surgery impacts on its evolution

Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results.

French National Authority for Health assessment of metabolic surgery for type 2 diabetes remission-A meta-analysis in patients with class I to III obesity

OBJECTIVE

Randomized controlled trials (RCTs) have demonstrated the superiority of metabolic surgery (MS) over medical therapy (MT) in patients with obesity and type 2 diabetes, leading, to a joint statement in 2016 proposing MS to patients with class I obesity and uncontrolled glycemia. Yet, these RCTs included few patients with class I obesity (body mass index 30-35 kg/m2) and even fewer patients with overweight. Our aim was to provide an updated systematic review (SR) with meta-analysis (MA) of RCTs reporting diabetes remission (DR) after MS in these patients.

RESEARCH DESIGN AND METHODS

We included in the SR with MA only RCTs with at least 24-month follow-up found in Medline, Cochrane Library, Embase, and LiSSA between January 2008 and September 2022 comparing DR post-MT versus post-MS. We calculated relative risk (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel random-effects approach to examine differences in DR between patients allocated to MS versus MT.

RESULTS

DR was significantly higher in MS versus MT after 36 months' follow-up in patients with obesity (RR = 6.65 [95 %CI 2.24;19.79]; I² = 27 %; 5 trials, 404 patients), but also specifically in patients with class I obesity (RR = 5.27 [1.31;21.23]; I² = 0 %; 4 trials, 80 patients). Furthermore, and in line with previous results, all additional MAs performed in patients with obesity in this work favor MS (specifically Roux-en-Y gastric bypass) over MT at 24, 36 (only) and 60 months of follow-up.

CONCLUSIONS

Although the data available in patients with class I obesity and type 2 diabetes remains limited, MA shows higher rates of DR after MS compared with MT after 36 months' follow-up in these patients. Consequently, the French National Authority for Health French (HAS) recommends MS for these patients.

Temporal Changes in Obesity-Related Medication After Bariatric Surgery vs No Surgery for Obesity

IMPORTANCE

Bariatric surgery can resolve hyperlipidemia, cardiovascular disease, and diabetes, but the long-term postoperative trajectories of medications for these conditions are unknown.

OBJECTIVE

To clarify the long-term use of lipid-lowering, cardiovascular, and antidiabetic medication after bariatric surgery compared with no surgery for morbid obesity.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study took place in Sweden (2005-2020) and Finland (1995-2018) and included individuals diagnosed with obesity. Analysis took place between July 2021 and January 2022.

EXPOSURES

Bariatric surgery (gastric bypass or sleeve gastrectomy) patients using lipid-lowering, cardiovascular, or antidiabetic medication were compared with 5 times as many control patients with an obesity diagnosis treated with no surgery, matched for country, age, sex, calendar year, and medication use.

MAIN OUTCOMES AND MEASURES

Proportions with 95% CIs of lipid-lowering, cardiovascular, or antidiabetic medication.

RESULTS

A total of 26 396 patients underwent bariatric surgery (with gastric bypass or sleeve gastrectomy) (17 521 [66.4%] women; median [IQR] age, 50 [43-56] years) and 131 980 matched control patients (87 605 [66.4%%] women; median [IQR] age, 50 [43-56] years) were included. The proportion of lipid-lowering medication after bariatric surgery decreased from 20.3% (95% CI, 20.2%-20.5%) at baseline to 12.9% (95% CI, 12.7%-13.0%) after 2 years and 17.6% (95% CI, 13.3%-21.8%) after 15 years, while it increased in the no surgery group from 21.0% (95% CI, 20.9%-21.1%) at baseline to 44.6% (95% CI, 41.7%-47.5%) after 15 years. Cardiovascular medications were used by 60.2% (95% CI, 60.0%-60.5%) of bariatric surgery patients at baseline, decreased to 43.2% (95% CI, 42.9%-43.4%) after 2 years, and increased to 74.6% (95% CI, 65.8%-83.4%) after 15 years, while it increased in the no surgery group from 54.4% (95% CI, 54.3%-54.5%) at baseline to 83.3% (95% CI, 79.3%-87.3%) after 15 years. Antidiabetic medications were used by 27.7% (95% CI, 27.6%-27.9%) in the bariatric surgery group at baseline, decreased to 10.0% (95% CI, 9.9%-10.2%) after 2 years, and increased to 23.5% (95% CI, 18.5%-28.5%) after 15 years, while it increased in the no surgery group from 27.7% (95% CI, 27.6%-27.7%) at baseline to 54.2% (95% CI, 51.0%-57.5%) after 15 years.

CONCLUSIONS AND RELEVANCE

In this study, undergoing bariatric surgery was associated with a substantial and long-lasting reduction in the use of lipid-lowering and antidiabetic medications compared with no surgery for obesity, while for cardiovascular medications this reduction was only transient.

The effect of bariatric surgery in comparison with the control group on the prevention of comorbidities in people with severe obesity: a prospective cohort study

Background

Obesity is a global health priority, particularly in developing countries. The preventive effect of bariatric surgery against obesity-related diseases in the developing countries of the Middle East and North Africa region, where type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia prevail, has not been examined.

Method

Severely obese participants who underwent bariatric surgery were compared with their counterparts who underwent no intervention. These patients had been followed up in two prospective cohort studies for three years. We here determined the incidence of new-onset T2DM, HTN, and dyslipidemia and reported absolute and relative risks for the incidence of these comorbidities in the two groups.

Results

In this study, 612 participants in the bariatric surgery group were compared with 593 participants in the control group. During the follow-up period, T2DM developed in eight (2.9%) people in the surgery group and 66 (15.0%) people in the control group (P < 0.001). New-onset HTN and dyslipidemia showed significantly lower frequencies in the surgery group compared to the control group (4 (1.8%) vs. 70 (20.4%) and 33 (14.3%) vs. 93 (31.5%), respectively). Regarding a less favorable metabolic profile in the surgery group at the baseline, the relative risk reductions associated with bariatric surgery were 94, 93, and 55% for the development of T2DM, HTN, and dyslipidemia, respectively.

Conclusion

The risk reduction of obesity-related comorbidities after bariatric surgery should be considered in the decision-making process for public health in the region, which bariatric surgery could result in the prevention of comorbidities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01740-7.

Changes in Antihypertensive Medication Following Bariatric Surgery

Obesity is a leading cause of hypertension (i.e., high blood pressure [BP]). While hypertension can be managed with antihypertensive medication, substantial weight loss can also lower BP, reducing the need for antihypertensive medication. Articles in this review (n = 60) presented data on antihypertensive medication use among adults pre- and postoperatively. Roux-en-Y gastric bypass was the most studied surgical approach followed by Laparoscopic Sleeve Gastrectomy. Antihypertensive medication was discontinued in a large proportion of patients after surgery, and the mean number of antihypertensive medications decreased by approximately one. In almost a third of the studies, over 75% of participants experienced hypertension remission. All articles aside from two reported a decrease in systolic BP, with about 40% reporting a decrease of ≥ 10 mm Hg.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Anatomical Quality Criteria for Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. However, without a standardised surgical technique, heterogeneous outcomes and complications such as gastro-oesophageal reflux disease (GERD) have been reported. The aim of this study was to identify reproducible anatomical criteria for SG to obtain safe and effective results.

METHODS

A prospective photographic study that captured every phase of each procedure was completed. The photographic documentation was carefully examined in order to identify anatomical criteria that would help make our technique reproducible. Postsurgical results were reported in terms of complications and mortality, while functional and morphological results were evaluated using 3-month upper gastrointestinal (UGI) series and 12-month computed tomography (CT) scan, respectively. BMI, percentage excess weight loss (%EWL), comorbidities, and GERD symptoms at 12 months were analysed.

RESULTS

One hundred thirty-four consecutive laparoscopic SG were photographed, and four reproducible anatomical criteria were identified: (1) to preserve the gastric antral posterior ligament (GAPL); (2) to dissect the gastro-pancreatic ligament (GPL); (3) to expose the right edge of the left diaphragmatic crus; and (4) to ensure staple-line linearity. No leaks occurred, and only one patient needed relaparoscopy for staple-line hematoma. Mortality and 30-day readmission rates were null. Gastric tube morphologies on the 12-month CT scans were homogeneous. At 12 months, median BMI was 30.8 kg/m² [IQR 20-47.2] and mean %EWL was 69.0 ± 24.5%; comorbidities resolved in 65.8-88.1% of patients, and GERD symptoms resolved in 44.4%.

CONCLUSION

The four anatomical criteria for SG that we propose are safe, effective, and reproducible and have acceptable postsurgical outcomes.

Impact of bariatric surgery on oral anticoagulants pharmacology, and consequences for clinical practice: a narrative review

The prevalence of obesity has been steadily increasing in recent years worldwide. At the same time bariatric surgery, the best therapeutic strategy to date in terms of sustainable weight loss and improvement of associated comorbidities has been also increasing. However, these surgeries, whether primarily restrictive or malabsorptive, raise questions about the pharmacology of oral drugs. Among widely used drugs, anticoagulants are the referent therapy to treat some cardiovascular diseases such as atrial fibrillation and venous thromboembolism. How bariatric surgery may impact pharmacological properties of oral anticoagulants, and more specifically, direct oral anticoagulants (DOACs) are difficult to anticipate. In this review, we describe available data concerning the potential impact of bariatric surgery on the pharmacology of oral anticoagulants. The vitamin K antagonists (VKAs) requirements for the same international normalized ratio target are reduced after bariatric surgery. Limited data available for dabigatran 150 mg twice daily indicate a risk of insufficient efficacy in atrial fibrillation after gastric bypass due to probable impaired absorption. Data for rivaroxaban at the prophylactic dose of 10 mg per day suggest no impact of bariatric surgery from 3 days to 8 months post-surgery. However, no conclusive data are available for other anticoagulants or the use of DOACs at therapeutic doses. To date, DOACs are not recommended in patients who have undergone bariatric surgery, because of limited available data. Pending new studies to confirm the predictable pharmacokinetics and safety of DOACs in this population, especially at therapeutic doses, VKAs remain the first option for chronic anticoagulation.

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis

BACKGROUND

Previous clinical trials and institutional studies have demonstrated that surgery for the treatment of obesity (termed bariatric or metabolic surgery) reduces all-cause mortality and the development of obesity-related diseases such as type 2 diabetes mellitus (T2DM), hypertension, and dyslipidaemia. The current study analysed large-scale population studies to assess the association of bariatric surgery with long-term mortality and incidence of new-onset obesity-related disease at a national level.

METHODS AND FINDINGS

A systematic literature search of Medline (via PubMed), Embase, and Web of Science was performed. Articles were included if they were national or regional administrative database cohort studies reporting comparative risk of long-term mortality or incident obesity-related diseases for patients who have undergone any form of bariatric surgery compared with an appropriate control group with a minimum follow-up period of 18 months. Meta-analysis of hazard ratios (HRs) was performed for mortality risk, and pooled odds ratios (PORs) were calculated for discrete variables relating to incident disease. Eighteen studies were identified as suitable for inclusion. There were 1,539,904 patients included in the analysis, with 269,818 receiving bariatric surgery and 1,270,086 control patients. Bariatric surgery was associated with a reduced rate of all-cause mortality (POR 0.62, 95% CI 0.55 to 0.69, p < 0.001) and cardiovascular mortality (POR 0.50, 95% CI 0.35 to 0.71, p < 0.001). Bariatric surgery was strongly associated with reduced incidence of T2DM (POR 0.39, 95% CI 0.18 to 0.83, p = 0.010), hypertension (POR 0.36, 95% CI 0.32 to 0.40, p < 0.001), dyslipidaemia (POR 0.33, 95% CI 0.14 to 0.80, p = 0.010), and ischemic heart disease (POR 0.46, 95% CI 0.29 to 0.73, p = 0.001). Limitations of the study include that it was not possible to account for unmeasured variables, which may not have been equally distributed between patient groups given the non-randomised design of the studies included. There was also heterogeneity between studies in the nature of the control group utilised, and potential adverse outcomes related to bariatric surgery were not specifically examined due to a lack of available data.

CONCLUSIONS

This pooled analysis suggests that bariatric surgery is associated with reduced long-term all-cause mortality and incidence of obesity-related disease in patients with obesity for the whole operated population. The results suggest that broader access to bariatric surgery for people with obesity may reduce the long-term sequelae of this disease and provide population-level benefits.