Early Reinitiation of Obesity Pharmacotherapy Post Laparoscopic Sleeve Gastrectomy in Youth: A Retrospective Cohort Study

Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s featured study examines the impact of early reinitiation of anti-obesity medications (AOM) following bariatric surgery in adolescents. Findings suggest that restarting AOM shortly after surgery—rather than waiting for weight regain—can lead to greater weight loss and improved eating behaviors, offering a potential new approach for long-term obesity management in youth.

Article Summary

This retrospective study found that in adolescents who had bariatric surgery, standard post-operative care plus early reinitiation of anti-obesity medication (AOM) led to greater weight loss and better eating behaviors than standard post-operative care alone.

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Article Review

Bariatric surgery is an effective treatment option for both adults and adolescents with obesity. While outcomes in the adolescent population are generally favorable, the amount of weight loss varies. Many achieve substantial weight loss of 30-40%, while a subset achieves weight loss of less than 20% or weight gain over the long term. Reasons for the suboptimal weight loss in some patients include variable glucagon-like peptide 1 (GLP1) levels as well as emotional eating.

Patients often took AOM to assist with weight reduction as they completed the requirements to be considered an appropriate candidate for bariatric surgery. Current protocols involve discontinuation of AOM prior to bariatric surgery, often due to side effects that can increase risk of perioperative complications. These medications are generally not resumed after surgery, except in the setting of insufficient weight loss or weight regain within 1-2 years post-operatively. Standard protocols for AOM reinitiation following bariatric surgery in adolescents do not exist, and studies to address this have not been identified, leaving a significant gap in the literature with respect to management of obesity following bariatric surgery.

The purpose of this study is to evaluate the safety, tolerability and efficacy of a protocol for early reinitiation of AOM in adolescents who have undergone bariatric surgery at a tertiary care center. The group hypothesizes that early reinitiation of AOM, compared to standard care, will be safe, well tolerated, and result in greater weight loss and less emotional eating.

The study is a retrospective analysis of data from a repository to evaluate outcomes in youth who underwent laparoscopic sleeve gastrectomy at a children’s hospital between November 2023 and July 2024. Study participants were 10-21 years of age who were at least 3 months post-surgery at the time of the study window. An assessment was conducted at 2 weeks post-surgery for patients who were taking anti-obesity medication (AOM) prior to surgery, following the early reinitiation of anti-obesity medication protocol (RAMP) developed by the multidisciplinary metabolic bariatric surgery team at Children’s Hospital of Los Angeles. The assessment involves a checklist of the patient’s hydration status, nutrient intake, presence of gastrointestinal issues, healing status, mental health status as well as desire to resume AOM. For patients who were interested in resuming AOM, the multidisciplinary team reviewed the checklist and decided if this was an appropriate step. If so, the patient was restarted on their prior AOM according to the RAMP protocol. All participants received standard of care post-operative follow up, regardless of their decision to resume medication. Primary outcomes assessed were percent change in body mass index (BMI), weight, excess weight and absolute change in BMI at 3 and 6 months after surgery. Secondary outcomes assessed were complications, hospital readmissions and eating behavior changes.

At the time of study enrollment, 46 patients had a laparoscopic sleeve gastrectomy, of which 93% were on anti-obesity pharmacotherapy prior to surgery, 54% of whom followed the early reinitiation protocol. Medications reinitiated were semaglutide, phentermine, topiramate, metformin and tirzepatide. At 6 months post-surgery, the early reinitiation group lost 6.5% more in BMI %, 4.6 kg/m² more in BMI, 5.9% more total weight loss and 8.2% more excess weight loss than the standard care group, all of which were statistically significant. Similar findings were noted when patients who were using semaglutide were analyzed separately. Again, all findings were statistically significant. Eating behaviors, assessed via the Adult Eating Behavior Questionnaire, showed that those in the early reinitiation group had a bigger reduction in hunger, emotional eating, food responsiveness and eating speed than those in the standard of care group, with all parameters achieving statistical significance. There were no differences in hospital readmissions or complications between the two groups.

The study provides a novel treatment option for adolescent obesity by offering a more aggressive approach to achieve weight loss, through early reintroduction of AOM after bariatric surgery. There is evidence of the more aggressive nature of comorbidities of obesity when they develop in adolescence, along with the increase in comorbidity development in adolescents who carry their obesity into adulthood. More weight loss during the first 1-2 years after surgery, when the highest amount of weight loss is achieved, offers adolescents a greater chance of comorbidity resolution, comorbidity risk reduction and obesity treatment success. It is still not clear which patients would benefit from early reinitiation of AOM; more studies are needed to determine this.

The authors note that concern regarding cost of medications for obesity, particularly the GLP1 receptor agonists, needs to be considered, as third-party payor coverage becomes less consistent, making use of these medications more difficult for most. Continued assessment of the cost-effectiveness of bariatric surgery plus AOM in adolescents with obesity, both short-term and long-term, is important to determine the health and financial outcomes of such a treatment approach.

Study limitations are cited, including the retrospective nature of the study, the use of only one bariatric surgery procedure in the analysis, the short follow-up period and the lack of demographic variability, as most patients were of Hispanic background and had public health insurance.

The authors conclude that early reinitiation of AOM after bariatric surgery may help adolescents achieve more weight loss and promote healthier eating behaviors better than bariatric surgery alone. Larger scale studies are needed to validate these findings and provide evidence to consider re-evaluation of current protocols with respect to AOM after weight loss surgery.