Medication discontinuation more likely after gastric bypass than sleeve gastrectomy
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Adults who underwent gastric bypass were more likely to discontinue and less likely to restart medications for hypertension, hyperlipidemia and diabetes than those who underwent sleeve gastrectomy, according to study findings.
“We found that gastric bypass and sleeve gastrectomy were both very effective for long-term discontinuation of obesity-related medications, with roughly 50% of patients coming off all antihypertensives, 60% coming off all lipid-lowering medications and 75% coming off all diabetes medications 5 years after surgery,” Ryan Howard, MD, a resident in the department of surgery at the University of Michigan, told Healio. “Although both procedures were very effective, gastric bypass was slightly more effective for medication discontinuation for all three medication classes.”
Howard and colleagues obtained data from Medicare Parts A, B and D claims for bariatric surgery for adults who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from 2012 to 2018. Participants were divided according to diagnosis of diabetes, hypertension or hyperlipidemia and at least one pharmacy claim for a drug before surgery. Medication discontinuation was defined as a 6-month lapse in claims for a medication refill after the previous medication fill. Medication restart was defined as a pharmacy claim for the relevant medication class after discontinuation.
Medication discontinuation more likely with gastric bypass
The study included 95,405 adults (74.8% women; mean age, 56.6 years), of whom 30,588 used diabetes medication at the time of surgery, 52,081 used hypertension medication and 35,055 used hyperlipidemia medication.
In the diabetes cohort, 16,809 underwent sleeve gastrectomy and 13,779 underwent gastric bypass. Those who underwent gastric bypass were more likely to discontinue diabetes medication for up to 5 years after surgery than those who underwent sleeve gastrectomy (adjusted HR = 1.3; 95% CI, 1.12-1.51). Of those who discontinued medication, adults who underwent gastric bypass were less likely to restart medication up to 5 years after surgery than those who underwent sleeve gastrectomy (aHR = 0.78; 95% CI, 0.63-0.96).
Of those on hypertension medication, 31,126 underwent sleeve gastrectomy and 20,955 underwent gastric bypass. Gastric bypass was associated with a higher likelihood for medication discontinuation up to 5 years compared with sleeve gastrectomy (aHR = 1.31; 95% CI, 1.18-1.45), and those who underwent gastric bypass were less likely to restart medication 1 year after discontinuation than sleeve gastrectomy (aHR = 0.81; 95% CI, 0.73-0.89). There was no difference in medication restart at 3 and 5 years after surgery.
In the hyperlipidemia cohort, 20,654 underwent sleeve gastrectomy and 14,401 underwent gastric bypass. Gastric bypass was associated with a higher likelihood for medication discontinuation compared with sleeve gastrectomy 1 year after surgery (aHR = 1.28; 95% CI, 1.16-1.4), but there was no difference between the two procedures at 3 and 5 years. Those who underwent gastric bypass were less likely to restart medication up to 5 years after surgery than those who underwent sleeve gastrectomy (aHR = 0.44; 95% CI, 0.38-0.5).
Long-term data needed
“These results can help inform decision-making for patients and surgeons,” Howard said. “For example, knowing that gastric bypass is slightly more effective than sleeve gastrectomy for medication discontinuation should be weighed against other evidence that sleeve gastrectomy is generally safer. These competing factors — one procedure being more effective vs. the other being safer — are crucial to inform decision-making.”
Howard noted that the findings revealed data on medication discontinuation in the immediate years after surgery, but questions still remain regarding long-term medication discontinuation.
“Even though these are the two most common bariatric operations performed, it is still relatively unclear how these procedures compare 5, 10 and 15 years out,” Howard said. “Moreover, it is important we understand their long-term effectiveness and safety. Currently, it looks like one operation is more effective while the other is safer, so future work is needed to unpack those nuanced long-term differences.”
For more information:
Ryan Howard, MD, can be reached at rhow@med.umich.edu.
Perspective
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Bariatric and metabolic surgery has demonstrated efficacy for reducing body weight. This treatment option is the most effective tool we have for long-term weight management in those with complicated or severe obesity. The research by Howard and colleagues provides even more evidence regarding the benefit of surgical treatment for obesity.
In summary, the findings indicate that gastric bypass is slightly more effective than sleeve gastrectomy in decreasing the need for medical therapy to control some of the most common complications of obesity, including type 2 diabetes, hypertension and hyperlipidemia.
While this conclusion is directly drawn from the design of the study, I believe there is another key message that should be considered. Effective treatment of obesity leads to considerable reduction and control of other chronic diseases — period. Whether one is considering gastric bypass or sleeve gastrectomy, the potential to reduce or eliminate the need for other medications to control cardiometabolic risk should be affirming enough to proceed with some type of treatment. Obesity treatment is underutilized; approximately 2% of people who might be eligible for surgical intervention are actually receiving it. This study suggests that our patients would have lower disease burden related to obesity if we were deploying these interventions more broadly.
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