Liraglutide could help avoid need for follow-up bariatric surgery

Combining bariatric surgery with the weight loss medication liraglutide can help people who need to lose more weight post-metabolic bariatric surgery (MBS), Monash University and Alfred Health-led research has found.

Wendy Brown

"We have shown that for people who regain weight or don't have an optimal weight loss effect from bariatric surgery, adding in a weight loss drug will help them to lose weight, often at a lower dose than is needed in people who have not had surgery," explained first author of the study, Professor Wendy Brown, who heads the Monash University Department of Surgery and is The Alfred's Oesophago-Gastric-Bariatric Unit Director. "We are the first to show that the full dose of obesity management medication may not be needed in the post-bariatric surgery setting, and importantly, quality of life is not affected by introducing the obesity management medication. This raises the possibility of avoiding risky repeat surgery, which is the current main option when people need more weight loss after bariatric surgery."

Metabolic bariatric surgery (MBS) is the most effective and durable treatment, with most patients losing 20–30 % of their total body weight. However, 10–15% do not have an optimal weight loss or they regain weight after the operation. It is not possible to predict who these people will be prior to surgery, and the only option to induce further weight loss has been more surgery, which carries a risk of serious complication that is 4 to 5 times higher.

This prospective, double-blinded, single-centre randomised clinical trial compared the effect of daily liraglutide with placebo in adults treated at an academic surgical department. Patients with anatomically correct adjustable gastric band, sleeve gastrectomy, one anastomosis gastric bypass, or Roux-en-Y gastric bypass (confirmed with barium swallow and/or endoscopy) were invited to participate at 12 to 36 months after surgery if they had a body mass index greater than 35 (calculated as weight in kilograms divided by height in meters squared), were aged 20 to 65 years, and had achieved a stable weight (defined as a weight consistently within a 4kg range during a three-month period) with an excess body weight loss (defined using body mass index threshold of 25) of 25% to 40% or total body weight loss of 5% to 12% for anatomically correct adjustable gastric band and excess body weight loss of 25% to 60% or total body weight loss of 10% to 20% for sleeve gastrectomy, Roux-en-Y gastric bypass, and one anastomosis gastric bypass.

The first participant was randomised in January 2019 and the last in June 2023. Primary data analysis occurred on July 15, 2024. Primary outcome was weight loss at 12 months. Change in health and quality of life were secondary measures.

The study included 24 participants in each arm (liraglutide arm: mean [SD] age, 48.7 [10.5] years; 22 [92%] female; placebo arm: mean [SD] age, 43.6 [11.4] years; 20 [83%] female). In the liraglutide arm, four patients withdrew and one was lost to follow-up. In the placebo arm, six patients withdrew and six were lost to follow-up. At 12 months, mean (SE) weight loss in the liraglutide group was 5.7 (1.1) kg with a mean (SD) weight gain of 1.4 (1.2) kg in the placebo group (between-group difference, 7.1 kg [95% CI, 3.9-10.3 kg]; p<0.001). There were no adverse effects on health or quality of life.

"Our demonstration that incretin drugs enhance weight loss following bariatric surgery provides great hope," added co- author, Professor John Wentworth, an adult endocrinologist at the Royal Melbourne Hospital. "Excitingly, newer, more effective drugs have become available and should help our patients achieve even better weight and health outcomes."

Co-author and Adjunct Associate Professor Paul Burton from the Monash University School of Translational Medicine's Department of Surgery, and The Alfred's Oesophago-Gastric and Bariatric Unit, said MBS enabled durable weight loss, improved a range of obesity-associated diseases and increased life expectancy. However, he said up to 15 % of patients experienced suboptimal weight loss and therefore less improvement in health outcomes.

"A multimodal approach has long been the guiding principle in care following weight loss surgery, but until now rested on a limited evidence base," Burton said. "The results reinforce that personalised treatment, careful patient selection, sustained lifestyle change, and ongoing adherence are essential to managing obesity as a lifelong disease we can remit but not cure. There are no quick fixes, but we now have increasingly effective, evidence-based treatment options. These findings support a personalized, long-term strategy that pairs surgical expertise with medication, lifestyle support, and ongoing engagement to achieve durable remission rather than a cure."

“These results suggest that combining obesity management medications with MBS affords the opportunity to increase weight loss for those with a suboptimal initial response or weight regain, potentially avoiding conversion surgery,” the authors concluded. “The advent of effective OMMs is reframing the place of MBS in the obesity treatment paradigm. Combining OMMs with MBS affords the opportunity to increase weight loss for those with a suboptimal initial response or weight regain, potentially avoiding conversion surgery. OMMs might also enable more frequent use of less invasive, reversible procedures, such as AGB. Data from this study will contribute to our understanding of these important clinical issues.”

The findings were reported in the paper, ‘Liraglutide and Weight Loss Among Suboptimal Responders to Metabolic Bariatric Surgery’, published in JAMA Network Open. To access this paper, please click here