Sleeve gastrectomy is associated with a higher probability of reaching both significant weight loss and glycaemic targets for patients with obesity and type 2 diabetes compared with taking semaglutide or tirzepatide, a large study has found.
The analysis, published in The Lancet Diabetes and Endocrinology, looked at outcomes for 33,846 US patients with one continuous year of treatment with semaglutide, 4,231 patients treated with tirzepatide and 7,572 who underwent sleeve gastrectomy [link here].
The investigators tracked how many participants attained at least 20% reduction in baseline bodyweight and HbA1c below 5.7% at one year, finding:
- The adjusted probability of meeting these outcomes was 3% for those taking semaglutide, 13.2% for patients on tirzepatide and 24% for patients who underwent a surgical procedure,
- Emergency department visits within one year were more common for patients who had undergone bariatric surgery,
- All groups recorded new prescriptions for GORD and nausea, but this was most common in the surgery group.
Meanwhile, the GLP-1RAs delivered superior glycaemic control relative to the amount of weight patients lost while using them.
“Although these findings provide important comparative data, they should be interpreted in the context of substantial baseline differences between treatment groups,” the research team wrote.
Patients undergoing sleeve gastrectomy were younger, had a higher baseline BMI but lower HbA1c than the GLP-1RA groups. Surgery patients also had lower use of glucose-lowering medications.
The study’s strict criteria also limited the generalisability of the findings: participants had to have a BMI of at least 35 kg/m2, type 2 diabetes and at least one follow-up after initial treatment to qualify.
“As a result, these findings might not apply to individuals with milder obesity, pre diabetes, shorter treatment exposure, or those who discontinue therapy before 1 year,” the authors said.
Despite this, the results of this analysis were broadly in line with studies looking at weight loss in adults with T2D and obesity and after sleeve gastrectomy.
“These similar findings strengthen confidence in the real-world estimates, while highlighting differences in dose titration, adherence, and follow-up windows.”
Still no conclusive winner in GLP-1RA vs surgery fight
Endocrinologist and Imperial College London academic Professor Tricia Tan said the study added valuable real-world data showing bariatric surgery was more effective for weight loss than obesity medications [link here].
Professor Tricia Tan.
Despite this, she argued a properly powered head-to-head RCT was needed before clinicians could accurately weigh up the benefits of both treatment approaches.
“This new study adds valuable data to the debate, but in common with previous studies, it cannot be conclusive,” she wrote in The Lancet.
The analysis also couldn’t take into account the impacts of the next generation of obesity medications, from weekly semaglutide dosing to new “triple agonist” therapies.
“It could be that the debate as to whether [metabolic bariatric surgery] is better than obesity medications is a sterile one: patients are likely to be better served by a holistic approach that takes into account their preferences and needs,” Professor Tan said.
This could mean some patients with type 2 diabetes and obesity might benefit most from obesity medications exclusively, some may pursue surgery, while others could take a combined approach depending on what best suited their goals, she said.