Consider patient needs for optimal blood pressure benefits with obesity drugs, surgery
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Key takeaways:
- Obesity drugs induce substantial weight loss and may reduce blood pressure but are priced out of reach for many Americans.
- Some patients with obesity may require combination therapy with drugs and surgery.
Editor's Note: This is part 3 of a three-part Healio Exclusive series on the effect obesity treatments on blood pressure. Part 1 can be viewed here. Part 2 can be viewed here.
Obesity accounts for much of the risk for primary hypertension, and a treatment plan that could address both issues could substantially reduce a person’s underlying risk for cardiovascular disease and other complications.
In a scientific statement from the American Heart Association published in Hypertension in 2021, the authors noted that intentional weight-loss strategies, including lifestyle changes like diet and increased physical activity, are important ways to reduce blood pressure for people with obesity to reduce their risk for hypertension and related diseases. However, such lifestyle changes are difficult for many people to maintain; rates of weight regain are historically high.
For those reasons, the statement recommended evidence-based treatments such as pharmacotherapy and bariatric surgery, for short and long-term use. Since then, new research has reinforced that conclusion. Long-term data from the GATEWAY study show a sustained BP reduction or even hypertension remission 5 years after bariatric surgery, and emerging data suggest the dual GLP-1/GIP agonist tirzepatide (Mounjaro/Zepbound, Eli Lilly) could similarly reduce BP, although longer studies are needed.
Drugs vs. bariatric surgery
Among obesity therapies, bariatric surgery has the most robust long-term data. However, newer obesity medications have encouraging data, and a head-to-head trial with surgery has not yet occurred. Sangeeta Kashyap, MD, assistant chief of clinical affairs in the division of endocrinology, diabetes and metabolism at New York-Presbyterian/Weill Cornell Medical Center, told Healio it is important for clinicians to find the optimal treatment strategy for patients who require weight loss beyond diet and lifestyle changes.
“With bariatrics, you have to have a very select, very compliant group of people,” Kashyap said, told Healio. “They have to be psychologically sound. With [obesity] medications, that threshold is much lower. Fewer than 1% of people end up getting bariatric surgery. Most people will be treated with medications. And with medications, the earlier we get to people in the course of their disease, the greater the impact.”
Kashyap cautioned that when it comes to drugs vs. surgery, social determinants of health play an important role in what patients can access.
“If a person does not have good insurance, they will not be taking these newer, better [obesity] medications,” Kashyap said. “These are expensive drugs that need to be taken chronically. If you stop, you will relapse. It is a big commitment for people to take medication ... Things like access to appropriate providers, getting the optimal diet and exercise counseling, all of those things are an important part of management that is not always available. Without access to these things, bariatrics might be a good solution, because you have one fixed intervention. Once it is done and the patient recovers, they can sustain the benefit for 5 to 10 years, which is what we want for them.”
There are also other factors to consider, according to Michael E. Hall, MD, MSc, professor and chair of the department of medicine and director of clinical and population sciences at the Mississippi Center for Clinical and Translational Research at University of Mississippi Medical Center in Jackson.
“These medications require a supply and a prescription from a doctor,” Hall told Healio. “For bariatric surgery, we still do not have adequate [insurance] coverage across the board. It is likely that some patients should be on a pathway for surgery vs. the medications. There are opportunities to study the impact of doing surgery vs. using these drugs. That has not been done yet.”
Durable weight-loss strategies reduce CV risk
In an editorial that accompanied the latest GATEWAY study, Hall and colleagues wrote that novel medical therapies and bariatric surgery are effective ways to treat obesity and related complications, such as hypertension. However, comparative studies of obesity pharmacotherapies and bariatric surgery are needed to clarify the optimal treatment pathways for a common and growing disease.
“In addition to needing clinical trials, we need to look at long-term cost-effectiveness,” Hall said. “Right now, obesity drugs are expensive. Eventually, the cost will start to come down, but we will need to look at this because more than 10% of people now have severe obesity. This is a problem that is growing. It is one thing to have effective therapies. We also need to have effective therapies that are cost-effective.”
Luke J. Laffin, MD, co-director of the Center for Blood Pressure Disorders at Cleveland Clinic, who said obesity pharmacotherapy as a means to treat hypertension and other comorbid conditions could be a paradigm shift, said clinicians should expect pushback due to the high cost of semaglutide (Wegovy, Novo Nordisk) and tirzepatide.
“The cost for treating hypertension or elevated glucose is low,” Laffin said. “Could we have a shift where we are treating the underlying cause for some people? There will need to be a shift where we stop thinking about these conditions as separate problems — the hypertension bucket, the diabetes bucket, the obesity bucket and the cholesterol bucket. While this does not apply to everyone, for at least a quarter to a third of these patients, you treat them with one of these mechanisms — surgery or medication — and you may eliminate the need to start BP medicines, or at least push it off as far as possible.
“It is always the combination of lifestyle, medications, plus or minus surgery as well,” Laffin said. “Sometimes people, particularly on social media, like to pit one [treatment] against the other. It is not about one vs. the other. This is about working with a specialist to figure out the best combination for any individual. These new drugs potentially give us a cure for obesity, which is exciting.”
We want to hear from you:
Healio wants to hear from you: How do you determine the optimal treatment strategy for patients with obesity and uncontrolled hypertension? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or posting to X (Twitter) @CardiologyToday. We will contact you if we wish to publish any part of your story.
References:
For more information:
Michael E. Hall, MD, MSc, can be reached at mehall@umc.edu; X (Twitter): @UMMC_MCCTR.
Sangeeta Kashyap, MD, can be reached at srk4008@med.cornell.edu; X (Twitter): @CleClinicMD.
Luke J. Laffin, MD, can be reached at laffinl@ccf.org; X (Twitter): @ljlaffin.
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