Remission of Insulin Resistance in Type 2 Diabetic Patients After Gastric Bypass Surgery or Exenatide Therapy

Bariatric surgery, novel glucose-lowering agents, and insulin for type 2 diabetes and obesity: Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

This network meta-analysis aimed to compare the effects of bariatric surgery, novel glucose-lowering agents (SGLT2i, GLP1RA, DPP4i), and insulin for patients with type 2 diabetes mellitus (T2DM) and obesity.

METHODS

Four databases were searched from inception to April 2023 to identify randomized controlled trials (RCTs) comparing bariatric surgery, SGLT2i, GLP1RA, DPP4i, insulin, and/or placebo/usual care among patients with T2DM and obesity in the achievement of HbA1c < 7.0 per cent within one year, and 12-month changes in HbA1c and body weight.

RESULTS

A total of 376 eligible RCTs (149 824 patients) were analysed. Bariatric surgery had significantly higher rates of achieving HbA1c < 7.0 per cent than SGLT2i (RR = 2.46, 95 per cent c.i. = 1.28, 4.92), DPP4i (RR = 2.59, 95 per cent c.i. = 1.36, 5.13), insulin (RR = 2.27, 95 per cent c.i. = 1.18, 4.58) and placebo/usual care (RR = 4.02, 95 per cent c.i. = 2.13, 7.93), but had no statistically significant difference from GLP1RA (RR = 1.73, 95 per cent c.i. = 0.91, 3.44), regardless of oral (RR = 1.33, 95 per cent c.i. = 0.66, 2.79) or injectable (RR = 1.75, 95 per cent c.i. = 0.92, 3.45) administration. Significantly more GLP1RA patients achieved HbA1c < 7.0 per cent than other non-surgical treatments. Bariatric surgery had the greatest reductions in HbA1c (∼1 per cent more) and body weight (∼15 kg more) at 12 months. Among novel glucose-lowering medications, GLP1RA was associated with greater reductions in HbA1c than SGLT2i (-0.39 per cent, 95 per cent c.i. = -0.55, -0.22) and DPP4i (-0.51 per cent, 95 per cent c.i. = -0.64, -0.39) at 12 months, while GLP1RA (-1.74 kg, 95 per cent c.i. = -2.48, -1.01) and SGLT2i (-2.23 kg, 95 per cent c.i. = -3.07, -1.39) showed greater reductions in body weight than DPP4i at 12 months.

CONCLUSION

Bariatric surgery showed superiority in glycaemic control and weight management compared to non-surgical approaches. GLP1RA administered by oral or injectable form demonstrated reduced HbA1c and body weight at 12 months, and was preferable over other non-surgical treatments among patients with T2DM and obesity.

PROSPERO REGISTRATION NO

CRD42020201507.

Weight loss between glucagon-like peptide-1 receptor agonists and bariatric surgery in adults with obesity: A systematic review and meta-analysis

OBJECTIVE

Glucagon-like peptide-1 (GLP-1) receptor agonists recently demonstrated 15% to 20% weight loss in adults with obesity, a range which has previously been achieved only with bariatric surgery. This systematic review and meta-analysis compares weight loss between GLP-1 receptor agonists and bariatric surgery.

METHODS

The databases MEDLINE, MEDLINE In-Process, MEDLINE Epubs Ahead of Print, Embase Classic + Embase (OvidSP), and Cochrane (Wiley) were searched from inception to April 21, 2021, for randomized controlled trials and observational studies. Two independent reviewers extracted data, reported risk of bias, and graded certainty of evidence. Random-effects models were used to pool change in weight, BMI, and glycated hemoglobin.

RESULTS

Six studies, encompassing 332 patients, were included. Among randomized controlled trials, mean difference in weight between all bariatric surgery types and GLP-1 receptor agonists was -22.68 kg (95% CI: -31.41 to -13.96), mean difference in BMI was -8.18 kg/m² (95% CI: -11.59 to -4.77), and mean difference in glycated hemoglobin was -1.28% (95% CI: -1.94% to -0.61%). Among observational studies, mean difference in weight was -25.11 kg (95% CI: -40.61 to -9.60), and mean difference in BMI was -10.60 kg/m² (95% CI: -17.22 to -3.98). Only one observational study reported glycemic outcomes.

CONCLUSION

In adults with obesity, bariatric surgery still confers the highest reductions in weight and BMI but confers similar effects in glycemic control when compared with GLP-1 receptor agonists.

Metabolic surgery in China: present and future

Obesity and its related complications comprise a serious public health problem worldwide, and obesity is increasing in China. Metabolic surgery is a new type of treatment with unique advantages in weight loss and obesity-related metabolic complications. The pathogenesis of obesity is complex and not yet fully understood. Here, we review the current efficacy and safety of metabolic surgery, as well as recent progress in mechanistic studies and surgical procedures in China. The exciting and rapid advances in this field provide new opportunities for patients with obesity and strike a balance between long-term effectiveness and safety.

Adiponectin/SIRT1 Axis Induces White Adipose Browning After Vertical Sleeve Gastrectomy of Obese Rats with Type 2 Diabetes

PURPOSE

White adipose tissue (WAT) browning plays a crucial role in energy metabolism. However, it remains unclear whether WAT browning is involved in the adipose reduction following sleeve gastrectomy (SG). Adiponectin is upregulated after Roux-en-Y gastric bypass surgery. The role of adiponectin in SG was further investigated in the current study.

MATERIALS AND METHODS

Diabetic Sprague Dawley rats were randomly divided into control, sham + libitum, sham + food restriction, and sleeve groups. Browning markers, including uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor (PPAR) γ, and PPARγ coactivator-1 alpha (PGC-1α), were examined 4 weeks after the operation.

RESULTS

UCP1, PPARγ, and PGC-1α expression were significantly higher in the sleeve group compared to the other study groups. The adipose tissue of the sleeve group exhibited tissue weight loss and additional morphological browning features. In addition, adiponectin expression in the sleeve group was significantly increased. Adiponectin upregulated the expression of the browning genes and sirtuin 1 (SIRT1) in 3T3-L1 adipocytes. SIRT1 could increase the WAT browning levels, revealing that adiponectin induced the browning process via the upregulation of SIRT1. Furthermore, SIRT1 represented a positive regulatory feedback loop for adiponectin. SIRT1 activated adenosine monophosphate-activated protein kinase (AMPK), which can mediate WAT browning. Inhibition of the AMPK signaling pathway by dorsomorphin decreased UCP1, PPARγ, and PGC-1α expression. However, additional studies are needed to understand the relationship between adiponectin and glucose homeostasis.

CONCLUSIONS

Sleeve gastrectomy increased adiponectin levels, which in turn upregulated SIRT1. Thus, SIRT1 may function as an endocrine signal to mediate WAT browning.

GLP-1 Analogues as a Complementary Therapy in Patients after Metabolic Surgery: a Systematic Review and Qualitative Synthesis

The evidence is strong that bariatric surgery is superior to medical treatment in terms of weight loss and comorbidities in patients with severe obesity. However, a considerable part of patients presents with unsatisfactory response in the long term. It remains unclear whether postoperative administration of glucagon-like peptide-1 analogues can promote additional benefits. Therefore, a systematic review of the current literature on the management of postoperative GLP-1 analogue usage after metabolic surgery was performed. From 4663 identified articles, 6 met the inclusion criteria, but only one was a randomized controlled trial. The papers reviewed revealed that GLP-1 analogues may have beneficial effects on additional weight loss and T2D remission postoperatively. Thus, the use of GLP-1 analogues in addition to surgery promises good results concerning weight loss and improvements of comorbidities and can be used in patients with unsatisfactory results after bariatric surgery.

Efficacy of laparoscopic sleeve gastrectomy and intensive medical management in obese patients with type 2 diabetes mellitus

BACKGROUND

There are a dearth of studies comparing laparoscopic sleeve gastrectomy (LSG) and intensive medical treatment (IMT) in obese type 2 diabetes mellitus (T2DM) patients. This study compares these modalities in terms of weight loss, metabolic parameters and quality of life (QOL) score.

METHODS

We evaluated the efficacy of LSG (n = 14) vs. IMT (n = 17) comprising of low calorie diet, exenatide, metformin and if required insulin detemir in 31 obese T2DM patients with BMI of 37.9 ± 5.3kg/m(2) and target HbA1c < 7 %. The mean (±SD) age of the patients was 49.6 ± 11.9 years and 74 % were women. The mean duration of diabetes was 8.5 ± 6.1 years and mean HbA1c was 8.6 ± 1.3 %. Primary end point was excess body weight loss (EBWL) at the final follow-up.

RESULTS

The mean duration of follow-up was 12.5 ± 5.0 (median 12) months. EBWL was 61.2 ± 17.6 % and 27.4 ± 23.6 % in LSG and IMT group respectively (p < 0.001). Glycemic outcomes improved in both with mean HbA1c of 6.6 ± 1.5 % in LSG and 7.1 ± 1.2 % in IMT group. In LSG group, there was resolution of diabetes and hypertension in 36 and 29 % of patients respectively while none in the IMT group. HOMA-IR, hsCRP, ghrelin and leptin decreased while adiponectin increased significantly in LSG compared to IMT group. QOL score improved in LSG as compared to IMT.

CONCLUSIONS

In obese T2DM patients, LSG is superior to IMT in terms of weight loss, resolution of comorbidities and QOL score.