Conference Coverage

Endoscopic sleeve gastroplasty plus obesity drugs add up to more weight loss


AT DDW 2023

– Antiobesity medications and endoscopic sleeve gastroplasty (ESG) are popular strategies for weight loss on their own. Now researchers are looking at what happens when you combine them.

In a study presented at the annual Digestive Disease Week® (DDW), they found ESG followed by an antiobesity medication led to more total weight loss than ESG alone.

Starting medication within 6 months of ESG was more ideal than other timing intervals. Initiating medical therapy more than 6 months before ESG was associated with less weight loss.

In the single-center, retrospective study, 224 patients were enrolled, of whom 34% were on monotherapy (ESG alone), 31% had combination therapy (medication prescribed within 6 months prior to or after ESG), and 35% had sequential therapy (medication more than 6 months prior to or after ESG).

Most patients were female, ranging from 74% to 95% of each group, and baseline BMI ranged from a mean 37.5 kg/m2 to 40.1 kg/m2.

The medications involved in the study were phentermine, phentermine/topiramate extended release (Qsymia), orlistat (Xenical, Alli), bupropion/naltrexone ER (Contrave), or the glucagonlike peptide–1 receptor agonist (GLP-1RA) liraglutide (Saxenda, Victoza) or semaglutide (Ozempic, Wegovy, Rybelsus). Of the patients who underwent combination therapy, 30% were prescribed a regimen that included a GLP-1RA. Of the patients who underwent sequential therapy, 81% were prescribed a medication first and 19% underwent ESG first.

At 1 year, the greatest total weight loss was a mean 23.7% with the combination of ESG and a GLP-1RA. Total weight loss was 18% with ESG plus a non–GLP-1RA medication. ESG alone led to 17.3%. Sequential therapy that began with ESG yielded 14.7% total weight loss, whereas sequential therapy that began with medication first resulted in 12% weight loss.

Dr. Pichamol Jirapinyo

It’s possible that gastroplasty performed second was less impressive because the medications were very effective, and there was not as much weight to lose, said Pichamol Jirapinyo, MD, MPH, a bariatric endoscopist at Brigham and Women’s Hospital, Boston, and lead author of the study.

Researchers stopped medication therapy if people did not experience at least 5% total weight loss after 3 months on a maintenance dose.

Waiting for weight loss to start to plateau after gastroplasty might be an ideal time to add weight loss medication, said Dr. Jirapinyo. “Usually when I see them at 3 months, I plot how fast their weight loss has been. If it’s been going down [steadily], we do not offer an antiobesity medication until I see them again at 6 months.”

The serious adverse event (SAE) rate associated with ESG was similar among the three cohorts: 2.6% with monotherapy group, 1.4% with combination therapy, and 1.3% with sequential therapy. SAEs associated with antiobesity medication occurred in 1.3% of the sequential therapy group and was not reported in either of the other two groups.

“I certainly think combination therapy should be more effective than just gastroplasty alone and is probably better,” said Gregory L. Austin, MD, session comoderator and a gastroenterologist at the UCHealth Digestive Health Center, Denver.

“Whether you start immediately or wait 3 months afterwards is a question that still needs to be answered,” he added.

Dr. Austin agreed that taking an antiobesity medicine more than 6 months before gastroplasty might be associated with enough weight loss to make the gastroplasty look less effective.

He also noted that the study “doesn’t really address the question of whether you should offer gastroplasty to somebody who’s been on [medication] for more than 6 months because you probably still should if they haven’t achieved an appropriate weight loss that’s associated with reduced comorbidity risk going forward.”


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