Bariatric Times

MAR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Editorial Message 3 Bariatric Times • March 2017 Dear Friends and Readers of BT, We start this month's editorial with the sad news of the passing of our dear friend and colleague Dr. George Blackburn. I am thankful to Dr. Daniel Jones and Ms. Angela Saba for writing this wonderful "In Memoriam" that summarizes Dr. Blackburn's outstanding achievements and contributions to the field of Obesity and Nutrition. George was indeed a role model to many, an innovator, and a great friend. He will be missed by all of us. This month we also feature an interview with Dr. Sangeeta Kashyap on the five-year outcome data of the STAMPEDE (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently) trial. Evaluating medical versus surgical treatment and comparing Roux-en-Y gastric bypass (RYGB) to laparoscopic sleeve gastrectomy (LSG), this trial clearly demonstrates the superiority of surgical treatment in patients with obesity and type 2 diabetes mellitus (T2DM). It also shows that weight loss after RYGB is superior to LSG, although when it comes to HbA1c, it seems that both are equally effective. Two questions remain to be answered: 1) What were the complications of the RYGB population vs. the ones of the LSG group? and 2) How important is it to achieve more weight loss at the risk of increased morbidity? RYGB is an outstanding operation that has proven to be safe and efficacious, but when compared to the LSG, it has significant higher long-term morbidty. 1 ,2 Contrary to what many might think, LSG is a simple procedure but not an easy one. Acute complications of sleeve are among the most challenging ones for us to manage. Obesity as we know, is a predisposing factor for other serious medical conditions, such as cancer, and we should always attempt to achieve maximal weight loss to prevent these terrible complications from happening. So can we accept less weight loss at the expense of less complications ? I hope that with time, we will be able to better identify which patients with metabolic syndrome are candidates for the bypass and which ones for the sleeve. I also believe that medical treatment of any disease process, including obesity, should always be our first choice. I would like to congratulate and comment on the excellent article in this month's installment of The Medical Student Notebook. Leith Hathout provides a thorough review on idiopathic intracranial hypertension, also known as pseudotumor cerebri. He discusses literature showing improvement of pseudotumor cerebri with bariatric surgery. I have personally operated on a young adult woman with severe obesity with impending blindness due to pseudotumor cerebri. After gastric bypass and rapid weight loss, her eye exam normalized completely. Why did this happen? Chronic and acute elevation of intraabdominal pressure (IAP) have been a passion of mine for the last 20 years. I have published extensively on this subject and the pathophysiology, though complex, is directly related to the increased IAP that results in decreased venous return from the central nervous system (CNS) resulting in elevated Dear Readers, We now know that obesity is a complex disease with many identified contributing factors, including genes, energy-balance dysregulation, hormones, and gut microbiota. Obesity also has many less common secondary "causes," such as hypothyroidism and polycystic ovarian syndrome (PCOS). Another important, and common, contributor to obesity is seen in prescription drugs that can promote weight gain or hinder weight loss in patients. In 2015, The Endocrine Society released a clinical practice guideline on the pharmacological management of obesity. 1 This guideline provides specific recommendations for transitioning patients off drugs that cause weight gain. Classes of drugs associated with weight gain include the following: anti-diabetic therapy, steroid hormones, psychotropic agents, antiepileptic drugs, and miscellaneous drugs, such as antihistamines and progestin only contraceptives. This month I'd like to focus on anti- diabetic therapy and psychotropic drugs. Anti-diabetic medication. Given that type 2 diabetes mellitus (T2DM) is prevalent in individuals with obesity, it is likely that your patients will already be receiving treatment. It's important for the provider to evaluate their patient's current medications, especially because he or she might be on something that has been shown to have a negative effect on weight loss. For instance, sulfonylureas (e.g., glipizide, glyburide, glimepiride), which work by stimulating insulin release from pancreatic β cells, have been associated with weight gain of 4.4 to 8.8 pounds. 2 Meglitinides, another class of oral antidiabetic agents that include repaglinide and nateglinide, have also been associated with weight gain of up to 6.6 pounds in three months. 3 The Endocrine Society Guidelines recommend that weight-losing and weight-neutral medications be prescribed as first- and second- line agents in the management of a patient with T2DM with overweight or obesity. The following drugs, which the guidelines suggest adding to a T2DM, have been shown to help mitigate associated weight gain: metformin, pramlintide, the SGLT2 inhibitors and GLP-1 agonists. Psychotropic drugs. While many psychotropic drugs are effective in patients in whom they are indicated, some have been shown to product weight gain. When conducting a medication evaluation, providers should be on the lookout for the following: amitriptyline, mirtazapine, olanzapine, quetiapine, risperidone, and paroxetine. The Endocrine Society Guidelines recommend using weight-neutral antipsychotic alternatives when clinically indicated, rather than those that cause weight gain. Alternative antipsychotropic drugs found to be either weight neutral or associated with weight loss include bupropion and fluoxetine. 4 While patients and providers must always discuss the risk/benefit equation of being on a medication, evidence-based guidelines may help in offering a solution that allows patients to receive treatment without untoward side effects on weight. A shared-decision making "Medical Treatment of any Disease Process, including Obesity, Should Always be Our First Choice" Another Important Contributor to Obesity in the United States: Drug-Induced Weight Gain/Weight Loss Hindrance A Message from Dr. Christopher Still Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity R esearch Institute, Geisinger Medical Center, Danville, Pennsylvania. Continued on following page... Continued on following page... A Message from Dr. Raul J. Rosenthal Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor, Bariatric Times; Chief of Staff, Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida

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