Impacts of glucagon-like peptide-1 receptor agonists on the risk of adverse liver outcomes in patients with metabolic dysfunction-associated steatotic liver disease cirrhosis and type 2 diabetes

BACKGROUND/AIMS

We examined the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) initiation on long-term Adverse Liver Outcomes (ALO) in patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) cirrhosis and type 2 diabetes using real-world data from the MarketScan database.

METHODS

We conducted a retrospective cohort study of patients with MASLD cirrhosis and type 2 diabetes between 2012 and 2020. Cox proportional hazard models examine the association between GLP-1RAs initiation, modelled as time-dependent, and the risk of ALO, a composite endpoint defined by the first occurrence of hepatic decompensation(s), portal hypertension, hepatocellular carcinoma (HCC) or liver transplantation (LT). We used Overlap Propensity Score Weighting (OPSW) to account for confounding. The study included 459 GLP-1RAs and 4837 non-GLP-1RAs patients.

RESULTS

The non-GLP-1RAs patients presented with 1411 (29%) ALO over 7431.7 person years, while GLP-1RAs patients had 32 (7%) ALO over 586.6 person years - risk rate difference 13.5 (95% CI: 11.4-15.7) per 100 person-years. The OPSW-adjusted risk of ALO was reduced by 36% (hazard ratio [HR]: 0.64; 95% CI: 0.54-0.76) in patients with vs. without GLP-1RAs initiation. GLP-1RAs initiation was associated with significant reductions in the adjusted risk of hepatic decompensation (HR: 0.74; 95% CI: 0.61-0.88), portal hypertension (HR: 0.73; 95% CI: 0.60-0.88), HCC (HR: 0.37; 95% CI: 0.20-0.63) and LT (HR: 0.24; 95% CI: 0.12-0.43).

CONCLUSION

The use of GLP-1RAs was associated with significant risk reductions in long-term adverse liver outcomes, including hepatic decompensation, portal hypertension, HCC and LT, in MASLD cirrhosis patients with type 2 diabetes.

Utilization of Anti-obesity Medications After Bariatric Surgery: Analysis of a Large National Database

PURPOSE

A significant proportion of patients experience insufficient weight loss or weight regain after bariatric surgery. There is a paucity of literature describing anti-obesity medication (AOM) use following bariatric surgery. We sought to identify prevalence and trends of AOM use following bariatric surgery.

MATERIALS AND METHODS

We utilized the IBM Explorys® database to identify all adults with prior bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy). Those prescribed AOMs (semaglutide, liraglutide, topiramate, phentermine/topiramate, naltrexone/bupropion, orlistat) within 5 years of surgery were further identified. Data was analyzed to characterize AOM utilization among different age, demographic, and comorbid populations.

RESULTS

A total of 59,160 adults with prior bariatric surgery were included. Among AOMs studies, prevalence of use was highest for topiramate (8%), followed by liraglutide (2.9%), phentermine/topiramate (1.03%), naltrexone/bupropion (0.95%) semaglutide (0.52%), and orlistat (0.17%). Age distribution varied, with the highest utilization among those age 35-39 years for topiramate, 40-44 years for phentermine/topiramate and naltrexone/bupropion, 45-49 years for semaglutide, and 65-69 years for liraglutide and orlistat. African American race was associated with higher utilization across all AOMs. Among comorbidities, hypertension, hyperlipidemia, and diabetes mellitus were most associated with AOM use.

CONCLUSION

Despite a relatively high incidence of weight regain, AOMs are underutilized following bariatric surgery. It is imperative that barriers to their use be addressed and that AOMs be considered earlier and more frequently in patients with insufficient weight loss or weight regain after bariatric surgery.

Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists

Glucose-like peptide-1-receptor agonists (GLP-1RAs) have become integral to the management of type 2 diabetes and obesity. GLP-1RAs work in part through delaying gastric emptying, raising concerns about retained gastric contents (RGC) during esophagogastroduodenoscopy (EGD).1 The American Society of Anesthesiologists currently recommends holding GLP-1RAs for 1 dosing cycle before elective procedures, however, the American Gastroenterological Association (AGA) advocates proceeding with endoscopy in asymptomatic patients adhering to standard perioperative protocols without medication withholding and suggests implementing a liquid diet the day before endoscopy in lieu of stopping the medication.2,3 This variability in recommendations stems largely from a lack of GLP-1RA outcomes data from which to draw evidence-based conclusions.

Is open-capsule proton pump inhibitor associated with faster healing time for marginal ulceration after Roux-en-Y gastric bypass?

BACKGROUND

Marginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB). Proton pump inhibitors (PPIs) are the primary treatment. Prior limited data suggest that open-capsule PPIs (OC-PPIs) improve MU healing compared with intact-capsule PPIs (IC-PPIs), necessitating further validation.

OBJECTIVES

We aimed to compare healing times of MU after RYGB when treated with OC-PPIs versus IC-PPIs.

SETTING

Tertiary academic center, United States.

METHODS

We retrospectively analyzed patients with prior RYGB diagnosed with MU from 2012 to 2022. Patients requiring mechanical closure without documented healing and without clear PPI prescriptions were excluded. The primary outcome was time to ulcer healing. Log-rank testing and Kaplan-Meier survival curve analyses were performed to compare MU healing times when treated with OC-PPIs versus IC-PPIs. Subgroup analyses further characterized ulcer healing times based on type and dosage of PPI used.

RESULTS

A total of 108 patients were included for final analysis (38 received OC-PPIs and 70 received IC-PPIs). Treatment with OC-PPIs significantly decreased MU healing time compared with IC-PPIs (146.18 versus 226.14 d; p = .018). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance.

CONCLUSION

In this study, OC-PPIs significantly improved MU healing times compared with IC-PPIs in RYGB patients, consistent with prior data. However, on subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method. These results highlight the need for a prospective randomized trial to compare the true effect of administration method.

Association of Bariatric Surgery with Risk of Incident Obesity-Associated Malignancies: a Multi-center Population-Based Study

INTRODUCTION

Obesity has a known association with certain types of malignancy, and we aimed to determine whether bariatric surgery has a protective effect against de novo obesity-associated cancer development in adult patients.

METHODS

We performed a multi-center retrospective cohort studying utilizing TriNetX national database. Patients were identified utilizing ICD-10-CM coding, and propensity score matching was performed. We compared patients with obesity who underwent bariatric surgery to patients with obesity who did not undergo bariatric surgery.

RESULTS

We initially identified 60,285 patients in the bariatric surgery group and 1,570,440 patients in nonsurgical control group. After propensity score matching, we included 55,789 patients in each patient cohort. The cumulative incidence of de novo obesity-associated cancers at 10 years was 4.0% (2206 patients) in the bariatric surgery group and 8.9% (4,960 patients) in the nonsurgical control group (HR 0.482 [95% CI 0.459-0.507]). The bariatric surgery group had lower incidence proportions for de novo breast cancer (HR 0.753 [CI 0.678-0.836]), colon cancer (HR 0.638 [CI 0.541-0.752]), liver cancer (HR 0.370 [CI 0.345-0.396]), ovarian cancer (HR 0.654 [CI 0.531-0.806]), and endometrial cancer (HR 0.448 [CI 0.362-0.556]) when compared to the nonsurgical control group.

CONCLUSION

We noted that bariatric surgery is associated with a significantly lower cumulative incidence of de novo obesity-associated cancer compared to a nonsurgical matched control group. Incidence proportions of de novo breast, colon, liver, ovarian, and endometrial cancer were significantly lower in adult patients with obesity in the bariatric surgery group compared to the nonsurgical group.

Mixed Martial Arts: Comparing the King-Devick and Sport Concussion Assessment Tool 5 in knockouts, technical knockouts and choke holds

Objective

To compare validity indices of the King-Devick (KD) test and Sport Concussion Assessment Tool 5 (SCAT5) for traumatic events in MMA, and to determine if perfusion events (alterations in consciousness as the result of choke holds) cause similar changes in KD/SCAT5 scores.

Design

A prospective cohort study in MMA fighters who completed KD and SCAT5 assessments before and after a match. Outcomes were categorized as non-event, traumatic event, or perfusion event. KD/SCAT5 changes were compared between all athletes.

Participants

One hundred forty MMA athletes (7 women, 133 men), mean age=27.1 ± 4.9 years.

Intervention

N/A.

Main outcome measures

King-Devick (KD) test and Sport Concussion Assessment Tool 5 (SCAT5).

Results

Among the 140 athletes, 19 sustained traumatic and 15 perfusion events. Testing provided sensitivities/specificities of 21.05%/93.39% (KD) and 77.78%/52.99% (SCAT5) in detecting a traumatic event. KD and SCAT5 Symptom Severity scores differed between athletes with and without traumatic events (P=.041 and .014). KD and SCAT5 Symptoms Score changes were observed between athletes with and without traumatic events (P=.023 and .042). Neither KD nor SCAT5 differed significantly between athletes with and without perfusion events.

Conclusions

The KD test provides high specificity and the SCAT5 demonstrates reasonable sensitivity when detecting a traumatic event. Of the SCAT5, symptoms-related scores may most effectively identify a traumatic event. A traumatic event may cause KD/SCAT5 changes similar to a concussion, while perfusion events did not.

Lower Interobserver Reliability for Nondimensional Intracystic Features Among Abdominal Radiologists for Characterizing Intraductal Papillary Mucinous Neoplasms Using Magnetic Resonance Imaging

OBJECTIVES

Current guidelines recommend magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) for risk stratification of intraductal papillary mucinous neoplasms (IPMNs). We assessed the interobserver agreement among radiologists in evaluating and risk stratifying IPMNs.

METHODS

This single-center study evaluated 30 patients with IPMNs who had undergone MRI/MRCP, endoscopic ultrasound, and/or surgical resection. Six abdominal radiologists evaluated the MRI/MRCPs to document multiple parameters. The analysis applied Landis and Koch κ interpretation for categorical variables and intraclass correlation coefficient (r) for continuous variables.

RESULTS

Radiologists demonstrated almost perfect agreement for location (κ = 0.81, 95% confidence interval [CI], 0.74-0.87), size (r = 0.95; 95% CI, 0.89-0.98), and main pancreatic duct diameter (r = 0.98; 95% CI, 0.96-0.99). Substantial agreement was observed for communication with the main pancreatic duct (κ = 0.66; 95% CI, 0.57-0.75) and classification of IPMN subtype (κ = 0.77; 95% CI, 0.67-0.86). Presence of intracystic nodules (κ = 0.31; 95% CI, 0.21-0.42) and wall thickening (κ = 0.09; 95% CI, -0.01 to 0.18) reached only fair and slight agreement, respectively.

CONCLUSIONS

Although MRI/MRCP is excellent in the evaluation of spatial aspects, there is lower reliability for nondimensional characteristics of IPMNs. These data support guideline-recommended complementary evaluation of IPMNs with MRI/MRCP and endoscopic ultrasound.

Incidence and Risk Factors for New-Onset Diabetes Mellitus After Surgical Resection of Pancreatic Cystic Lesions: A MarketScan Study

OBJECTIVES

There is a paucity of literature evaluating new-onset diabetes mellitus (NODM) after resection of pancreatic cystic lesions (PCLs). We sought to characterize the incidence and risk factors associated with NODM after partial pancreatectomy for PCLs.

METHODS

We utilized the IBM MarketScan Database (2012-2018) to identify all nondiabetic adults who underwent partial pancreatectomy for PCLs. Patients with any other pancreatic disease were excluded. We performed Kaplan-Meier analysis and multivariable Cox proportional hazards regression to define the incidence and risk factors of postoperative NODM.

RESULTS

Among 311 patients, the overall risk (95% confidence interval) of NODM was 9.1% (6.3-12.9%), 15.1% (11.3-20.2%), and 20.2% (15.3-26.4%) at 6, 12 and 24 months, respectively. Multivariable analysis (adjusted hazard ratio; 95% confidence interval) revealed that older age (1.97; 1.04-3.72; 55-64 vs 18-54 years), obesity (2.63; 1.35-5.12), hypertension (1.79; 1.01-3.17), and cardiovascular disease (2.54; 1.02-6.28) were independent predictors of NODM. Rates of NODM were similar after distal pancreatectomy versus pancreaticoduodenectomy.

CONCLUSIONS

Within 2 years, 1 in 5 patients without any other pancreatic disease will develop NODM after partial pancreatectomy for PCLs. Those with advanced age, metabolic syndrome features, and/or cardiovascular disease may benefit from preoperative counseling and intensive postoperative monitoring, education, and treatment for diabetes mellitus.