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Obesity Management FAQs

CE / CME

Improving Obesity Management: Expert Answers to Frequently Asked Questions

Physician Assistants/Physician Associates: 0.25 AAPA Category 1 CME credit

Nurses: 0.25 Nursing contact hour

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Released: December 19, 2023

Expiration: December 18, 2024

Jaime Almandoz
Jaime Almandoz, MD, MBA, MRCPI, FTOS
CME/CE Information

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Key Takeaways
  • Meaningful weight reduction with nonincretin therapies such as phentermine/topiramate, bupropion/naltrexone, and others in combination with lifestyle modifications can be achieved in patients who do not have access to newer antiobesity medications.
  • Bariatric surgery remains a good option for people who do not have access to antiobesity medications.
  • Endoscopic therapy or revision surgeries after bariatric surgery may be helpful for people who regain weight after bariatric surgery.

In this commentary adapted from a webinar question and answer session, Jaime Almandoz, MD, MBA, FTOS, answers frequently asked clinical questions about obtaining antiobesity medications (AOMs) for patients with and without type 2 diabetes (T2D) and recommendations for patients who are experiencing weight regain post bariatric surgery.

How do you obtain AOMs for patients who do not have T2D?
I think the cost of AOMs—including incretin-based therapies such as glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) and the glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 coagonist—presents a real challenge for many patients because, unfortunately, often health insurance will cover these therapies only for patients with T2D. Because prediabetes and a family history of T2D alone are not accepted diagnoses to obtain these medications through insurance, healthcare professionals are not always in a position to use evidence-based therapies to prevent disease from occurring. Unfortunately, it may feel like we must wait for the patient’s health to deteriorate before we are able to provide evidence-based therapies, but there are alternatives to these newer therapies.

In this situation, sometimes we feel that the only and best option is an incretin-type therapy, but the data show that we can get meaningful weight reduction with nonincretin therapies such as phentermine/topiramate, bupropion/naltrexone, and others in combination with lifestyle modifications. There is also the option of bariatric surgery, which is covered by Medicare for patients who meet the criteria and may also be covered by Medicaid. Therefore, we should be open to considering viable alternatives. Earlier this year, Weintraub and colleagues showed sustained weight loss of greater than 10% maintained for more than 4 years with off-label use of medications for treating weight. Combinations of medications such as metformin plus bupropion plus topiramate can help people lose significant amounts of weight. Therefore, looking at what options are available and appropriate can help in overcoming the obesity treatment inertia that many providers have because of perceived lack of access to other therapies.

Should patients who have had bariatric surgery but did not meet weight loss goals undergo additional surgery?
We can approach insufficient weight reduction after bariatric surgery in lots of different ways. There is the potential for revisional surgeries for many people, but that may not be covered by their insurance plan. Some insurance plans may cover revision surgery if patients are having significant gastroesophageal reflux. For example, Roux-en-Y gastric bypass (RYGB) is an anti-reflux procedure, and revision from gastric sleeve to RYGB may be indicated and covered by insurance for people with significant post-bariatric reflux disease.

Endoscopic procedures also can be useful for weight regain and complications such as dumping syndrome after bariatric surgery. There is revisional sleeve gastroplasty (ESG), where the endoscopist performs suturing and placation of the gastric sleeve that decreases the stomach volume. The data show that the average weight reduction at 1 year post ESG is approximately 12% to 15%, which is superior to some AOMs. Therefore, ESG is an effective treatment option for post-gastric sleeve weight regain. For those who experience weight regain during the post-RYGB surgery period, patients can undergo pouch reduction and/or outlet reduction procedures by endoscopy, which also can be helpful for the resolution of several complications. Endoscopic procedures also can be helpful for reactive hypoglycemia, which can occur in some post-bariatric patients after ingestion of carbohydrates due to the change in intestinal anatomy and incretins, which results in an amplified insulin surge and sometimes symptomatic reductions in blood glucose.

What are the options for patients who have gained back some of the weight they lost post bariatric surgery if their insurance does not cover AOMs?
The amount of weight that people lose with bariatric surgery is highly variable. In addition, weight regain is almost universal for bariatric patients, at least to some degree. Unfortunately, patients and many healthcare providers feel frustrated and defeated when weight regain occurs, which can be due to many factors. There is metabolic adaptation and other physiologic changes that are working against the patient’s ability to maintain their healthier, lower body weight. From a treatment perspective, if the patient has T2D, they could be started on a GLP-1 RA or a GIP/GLP-1 coagonist. Studies have shown that incretin-based therapies are the most effective class of medications for weight reduction in people after bariatric surgery. But in the absence of T2D, there is data showing that using medications such as phentermine and topiramate can help people with insufficient weight loss and weight regain after bariatric surgery achieve a healthier weight. Revisional procedures, like the endoscopic procedures we discussed, or conversion to RYGB if the patient has persistent class II or greater obesity could be considered.

I think the lack of insurance coverage for AOMs is a real challenge to how people in the United States must access medications. However, discounts and savings plans may make evidence-based therapies more affordable. For branded fixed-dose combinations, many healthcare professionals resort to prescribing their generic components separately so that they are more affordable. In fact, many prefer prescribing medications such as phentermine and topiramate separately for flexibility with selecting the most effective dose. This individualized type of treatment can mitigate side effects and thereby promote patient adherence, which may lead to better outcomes for weight, health, and quality of life.

Your Thoughts?
In your practice, how often do you see patients with weight regain after bariatric surgery? Answer the question and comment below to join the discussion.

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In your practice, how often do you see patients with weight regain after bariatric surgery?

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