Thoughts on GLP-1 Agonists affecting Bariatrics prospects

[Malenkaya]

Hey all!

Apologies if this is not the right place to post, but I haven't seen much of any other threads on this topic. I'm currently an M2 and my goal for the past couple years has been to match Gen Surg and then do a bariatrics fellowship. I shadowed a bariatric surgeon as a pre-med and I really enjoyed it. However I've been hearing from physicians and students at my school that GLP-1 analog drugs like semaglutide, tirzepatide, etc, will kill the bariatrics industry and decrease the need for patients to get bariatric surgeries. Is this true? I wanted other thoughts on it, one of the physicians at my school said bariatric surgeries are already down 30% this year. Should I rethink another specialty before it's too late or is this all just unfounded theory, I would appreciate any other perspectives or input!

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[deleted1168269]

No one (who isn't a scammer) has a crystal ball to predict the future. Lucky for you, you'd have to do a Gen Surg residency before a bariatrics fellowship anyway. If you are currently an M2, you still have several years to worry about this since there are several things you can do with Gen Surg training before committing to bariatrics. When the time to apply to fellowship comes, you'll have much more information on how GLP-1 agonists are changing the market.

 

[Goro]

FYI:
Weight loss can vary depending on which GLP-1 drug you use and your dose. Studies have found that all GLP-1 drugs can lead to weight loss of about 10.5 to 15.8 pounds (4.8 to 7.2 kilograms, or kg) when using liraglutide. Studies found people using semaglutide and making lifestyle changes lost about 33.7 pounds (15.3 kilograms) versus 5.7 pounds (2.6 kilograms) in those who didn't use the drug.

Do any diabetes drugs help you lose weight?

Noninsulin drugs for diabetes improve blood sugar control and may also support weight loss.

www.mayoclinic.org

I'd say that for the morbidly obese and merely obese, bariatric surgeons have nothing to worry about.

 

[VA Hopeful Dr]

FYI:
Weight loss can vary depending on which GLP-1 drug you use and your dose. Studies have found that all GLP-1 drugs can lead to weight loss of about 10.5 to 15.8 pounds (4.8 to 7.2 kilograms, or kg) when using liraglutide. Studies found people using semaglutide and making lifestyle changes lost about 33.7 pounds (15.3 kilograms) versus 5.7 pounds (2.6 kilograms) in those who didn't use the drug.

Do any diabetes drugs help you lose weight?

Noninsulin drugs for diabetes improve blood sugar control and may also support weight loss.

www.mayoclinic.org

I'd say that for the morbidly obese and merely obese, bariatric surgeons have nothing to worry about.

Yeah I've had patients lose way more weight than that.

 

[Goro]

Yeah I've had patients lose way more weight than that.

Ahhh...what was the largest loss you've seen?

 

[hopefulraddaddypls]

Hey all!

Apologies if this is not the right place to post, but I haven't seen much of any other threads on this topic. I'm currently an M2 and my goal for the past couple years has been to match Gen Surg and then do a bariatrics fellowship. I shadowed a bariatric surgeon as a pre-med and I really enjoyed it. However I've been hearing from physicians and students at my school that GLP-1 analog drugs like semaglutide, tirzepatide, etc, will kill the bariatrics industry and decrease the need for patients to get bariatric surgeries. Is this true? I wanted other thoughts on it, one of the physicians at my school said bariatric surgeries are already down 30% this year. Should I rethink another specialty before it's too late or is this all just unfounded theory, I would appreciate any other perspectives or input!

treadmills, gyms, and trails exist and bariatric surgeons survived that

 

[VA Hopeful Dr]

Ahhh...what was the largest loss you've seen?

60 pounds. And this was all Olympic, I haven't put enough people on high enough doses of mounjaro to know what that's going to do.

I know one of my daughters kindergarten teachers also lost about 60 lb on Mounjaro.

 

[Drrrrrr. Celty]

Mounjaro is gonna take a big piece of the pie honestly.

However I think Bariatric surgery is gonna work a lot better for supermorbid obesity and it likely has less weight regain as it is permanent as opposed to a medication which will have an end date.

 

[VA Hopeful Dr]

Mounjaro is gonna take a big piece of the pie honestly.

However I think Bariatric surgery is gonna work a lot better for supermorbid obesity and it likely has less weight regain as it is permanent as opposed to a medication which will have an end date.

Ha, you haven't seen many multiple-year post-bypass surgery have you?

Why would the medication have an end date? If we treat obesity as a chronic disease, we keep treating it even if in remission.

 

[deleted1168269]

Ha, you haven't seen many multiple-year post-bypass surgery have you?

Why would the medication have an end date? If we treat obesity as a chronic disease, we keep treating it even if in remission.

In your experience, do some patients take GLP1 agonists as a license to refuse lifestyle modifications?

 

[Tenk]

Bariatrics is the least in danger specialty in the US.

 

[Drrrrrr. Celty]

Ha, you haven't seen many multiple-year post-bypass surgery have you?

Why would the medication have an end date? If we treat obesity as a chronic disease, we keep treating it even if in remission.

Insurance pushes back against its use in non-diabetics. I need to do PAs even with good insurance. I can't imagine what headache it will be to get them approved when it's year 2 and the weight is gone.

Further we as a health system can't make enough of it. I'm back to using Victoza because Trulicity and Ozempic/Wegovy are out of stock.

And I think another the question becomes whether it has good effect as a consolidating therapy or whether it like we are seeing in a lot of patients starts to not work as well after 12 months and A1cs start to creep up. Though the question of whether DM v.s Non-DM obesity have different behavior with GLP-1s is an area of study.

Finally it's not harm free as well. Bowel obstructions, pancreatitis, and probably non-medullary thyroid cancer are real consequences of it.

But I guess TBD.

In your experience, do some patients take GLP1 agonists as a license to refuse lifestyle modifications?

If you're not going to make lifestyle modifications on a GLP-1 then you're going to end up in the hospital.

Most people who tolerate GLP-1s quickly start modifying their diets to avoid feeling like they're dying.

 

[Dr. Doctor MD]

Most people who tolerate GLP-1s quickly start modifying their diets to avoid feeling like they're dying.

Just curious, could you clarify what you mean by this? Why do they modify their diets or feel like they're dying while on a GLP-1?

 

[VA Hopeful Dr]

Insurance pushes back against its use in non-diabetics. I need to do PAs even with good insurance. I can't imagine what headache it will be to get them approved when it's year 2 and the weight is gone.

Further we as a health system can't make enough of it. I'm back to using Victoza because Trulicity and Ozempic/Wegovy are out of stock.

And I think another the question becomes whether it has good effect as a consolidating therapy or whether it like we are seeing in a lot of patients starts to not work as well after 12 months and A1cs start to creep up. Though the question of whether DM v.s Non-DM obesity have different behavior with GLP-1s is an area of study.

Finally it's not harm free as well. Bowel obstructions, pancreatitis, and probably non-medullary thyroid cancer are real consequences of it.

But I guess TBD.



If you're not going to make lifestyle modifications on a GLP-1 then you're going to end up in the hospital.

Most people who tolerate GLP-1s quickly start modifying their diets to avoid feeling like they're dying.

So you have trouble getting Ozempic approved for your diabetics with an A1c less than 6?

 

[Drrrrrr. Celty]

Just curious, could you clarify what you mean by this? Why do they modify their diets or feel like they're dying while on a GLP-1?

GLP-1s make you feel like you're full. Overeating on a GLP-1 makes you incredibly sick and feel ill. Even when people cut back they basically take on bariatric like diets and generally feel satiated. And then they lose weight and have far easier controlled blood sugars because they treat their prandial sugars.

 

[Drrrrrr. Celty]

So you have trouble getting Ozempic approved for your diabetics with an A1c less than 6?

As a first agent? Sometimes. Though I've had better outcomes with it.
Keeping people on it as monotherapy I don't generally see a lot of push back especially if a1c is around 6.5-7.
But eventually if the A1c is under 6 I probably push towards getting them to a lower dose or off of it and seeing if they can stay off. But I leave it up to the patient to drive the conversation.

But I think I get what you're saying. I just don't have a lot of obesity medicine experience sans diabetes. I still use a lot of Qsimya and Contrave in Non-Diabetic Obese patients.

 

[VA Hopeful Dr]

As a first agent? Sometimes. Though I've had better outcomes with it.
Keeping people on it as monotherapy I don't generally see a lot of push back especially if a1c is around 6.5-7.
But eventually if the A1c is under 6 I probably push towards getting them to a lower dose or off of it and seeing if they can stay off. But I leave it up to the patient to drive the conversation.

But I think I get what you're saying. I just don't have a lot of obesity medicine experience sans diabetes. I still use a lot of Qsimya and Contrave in Non-Diabetic Obese patients.

That's about what I do, but I'll stop the metformin first and then adjust the ozempic until weight stabilizes at a decent place.

I've had more luck lately getting Wegovy covered lately, I expect that to improve even more next year.

 

[cj_cregg]

In your experience, do some patients take GLP1 agonists as a license to refuse lifestyle modifications?

Personally, I see the GLPs as helping people make lifestyle modifications. Universally, I have seen that patients who lose weight on GLPs report they are eating smaller portions, less frequently, and making healthier choices. They're no longer constantly hungry, constantly thinking about food, unable to control cravings. They also feel full much sooner when they do eat, eating maybe 25-50% of what they previously would have and feeling satisfied, and feeling sick if they do try to overeat. Obviously it remains to be seen what will happen long term, but I think it's a great option for patients who are struggling to make those dietary changes in the first place to give them a little extra oomph. I have seen fantastic outcomes in some patients and at least modest weight loss in most.

I can't imagine GLPs will phase out bariatric surgery anytime soon. I would bet insurance companies will continue to make it cost prohibitive to be on a GLP1 for the indication of weight loss/obesity alone, and I am also getting issues with insurance denials for GLP1s in patients who are diabetic but have A1c at goal without them. Moreover, there are currently HUGE supply shortage issues for many of these drugs - seeing them in my rural practice for Wegovy, Saxenda and Ozempic currently...Mounjaro and Victoza seem to be fine so far. I imagine it would take years to build up the infrastructure needed to put a large number of non-diabetic patients on these drugs, especially the way the epidemiology of obesity is trending. There will also always be patients who can't/won't take these medications for whatever reason, be that contraindications, side effects, etc. I suspect in the long term the market for bariatric surgery may decrease but will still be there, but we're probably a decade or two away from that at least. ETA: That said, your friendly local bariatric surgeons will probably have a better sense than I do of if/how this is affecting volumes for them already.

 

[SurfingDoctor]

They might as well put a GLP-1 agonist in every happy meal.

It's the most impressive drug trial I've ever seen in my career.

 

[esob]

As noted, no one knows the future. Still, I was reading an article the other day about a downturn in bariatric surgery-related stocks due to the expected impact of GLP-1 agonists. There likely will be some impact on demand, but not enough to worry about it at this stage of the game.

 

[DOVinciRobot]

There will always be a role for surgery. Similar to improvements in cardiac medications, stenting and CABGs, some patients just do better with surgery and going forward I suspect it will be similar with bariatrics.

Pure bariatrics are probably going to have to adjust their practices, but most surgeons aren’t straight bariatrics and still do a lot of general surgery as part of their practice.

 

[wxman]

I practice obesity medicine. We look for sustained weight loss for about 4-6 months before considering surgical intervention. As others have pointed out, sustained weight loss is going to be a challenge we will need to address, particularly in patients utilizing pharmacotherapy alone (versus pharmacotherapy and a bariatric procedure). I am always fearful of the day that my patients on Mounjaro 15 mg end up getting a denial and we can't get their medications refilled. This is where the lifestyle interventions/modifications shine, +/- surgical intervention.

 

[ACSurgeon]

There will always be a role for surgery. Similar to improvements in cardiac medications, stenting and CABGs, some patients just do better with surgery and going forward I suspect it will be similar with bariatrics.

Pure bariatrics are probably going to have to adjust their practices, but most surgeons aren’t straight bariatrics and still do a lot of general surgery as part of their practice.

This. If you do a bariatrics fellowship you’ll have other advanced MIS skills to make sure you can remain a busy general surgeon, even if you do fewer bariatric cases.

 

[Keona]

Ahhh...what was the largest loss you've seen?

100 lbs and they’re still losing. They feel like it’s fixed something messed up in their head. They feel fantastic and are entirely off the 80 units of long acting insulin they were on. That was with mounjaro.

 

[SurfingDoctor]

100 lbs and they’re still losing. They feel like it’s fixed something messed up in their head. They feel fantastic and are entirely off the 80 units of long acting insulin they were on. That was with mounjaro.

This is absolutely true. That’s why it’s being used to treat alcoholism and other addictions…

Did Scientists Accidentally Invent an Anti-addiction Drug?

People taking Ozempic for weight loss say they have also stopped drinking, smoking, shopping, and even nail biting.

www.theatlantic.com

To some degree, obesity is just addiction to food.

 

[JAK2-STAT3]

I used to work in a clinic that saw a lot of bariatric surgery patients. Many insurance companies do not cover weight loss medications. Medicare Part D will not cover weight loss medications. Many Medicaids are the same way. Who knows what the future holds, but for now there's a huge swath of the population that cannot access these drugs.

 

[Tangerine123]

If you're not going to make lifestyle modifications on a GLP-1 then you're going to end up in the hospital.

Most people who tolerate GLP-1s quickly start modifying their diets to avoid feeling like they're dying.

A patient of mine mentioned this, but I was sceptical at first. Now I'm on my first week and it's scary. It's really changing my behavior regarding food in a positive way. Used to binge eat, now just thinking about that makes me sick. It cut my appetite more than half, now I have to "plan" my meals in order to eat a balanced meal while not overeating