Controversial issues: A practical guide to the use of weight loss medications after bariatric surgery for weight regain or inadequate weight loss

Abstract

Obesity continues to be the most prevalent chronic disease in the United States with ~40% of the adult population and ~19% of the pediatric population with this diagnosis, and the prevalence of severe obesity in the adults and pediatrics is ~8% and ~6%, respectively.[1, 2] In patients with moderate to severe obesity, bariatric surgery has the potential to provide significant and sustainable weight loss while also improving obesity related co-morbid conditions.[3] Despite its overall relative high degree of efficacy compared to other treatment strategies, patients may experience inadequate weight loss (<50% of excess weight loss (EWL)) or weight regain after bariatric surgery which warrants consideration of alternate treatment modalities. warrants consideration of alternate treatment modalities. Current data suggest that between 25–35% of patients have inadequate weight loss or experience significant weight regain.[4–6] Inadequate weight loss and weight regain is multifactorial- it may secondary to genetics, sociodemographic factors, mental health co-morbid conditions, physical inactivity, poor diet quality or secondary to pathophysiology factors specific to the type of bariatric surgery performed.[7] While revision bariatric surgery and endoscopic procedures may be entertained,[8, 9] studies have shown that weight loss medications may confer between 5– 15% of TWL after bariatric surgery without additional surgical intervention.[7, 10] The medical community has expressed interest in utilizing weight loss medications for achieving weight loss after bariatric surgery. Weight loss medications have emerged as an underutilized treatment strategy in this patient population. In our study which is the largest retrospective analysis of weight loss medications in bariatric surgery patients to date, of 15 medications evaluated, topiramate was the only medication which demonstrated statistical significance for ≥ 5% total body weight loss.[7] Yet in a recent analysis of this same patient cohort, topiramate, phentermine, and metformin appeared to be efficacious in young adults aged 21–30 years old.[6] Unfortunately, there is a paucity of research regarding the use of medications after weight loss surgery, and more research is needed to provide patients with tools to treat inadequate weight loss and weight regain. To date, there is no practical guide that provides guidance regarding this practice for practitioners who do not have specialized training (e.g. completion of an obesity medicine fellowship) in this treatment strategy. This article seeks to provide some guidance (based upon our clinical experience) to those with interest in exploring the use of weight loss medications in the population with inadequate weight loss or weight regain after weight loss surgery.