Is the ‘scalpel’ better against obesity or the new anti-diabetic slimming drugs from the ‘Ozempic family’? A study presented at the 2024 Congress of the American College of Surgeons (Acs), which opens today in San Francisco, attempted to answer this question by analyzing – in the US scenario – the cost-effectiveness ratio over time for pharmacological treatment compared with anti-obesity surgery. The conclusion, in summary, is that the so-called Glp-1 Ra drugs (agonists of the intestinal hormone Glp-1 receptor) “are convenient in the long term only if combined with bariatric surgery“. More precisely, if the 2 approaches are examined individually, the most cost-effective is surgery. But a combination of the 2 interventions, surgical and pharmacological, is more convenient than the scalpel alone.
Originally used to treat type 2 diabetes – the researchers recall – injections of liraglutide (brand name Saxenda*) and more recently semaglutide (Wegovy*, anti-obesity version of Ozempic*) were approved by the American FDA prescription drug for weight loss in obese or overweight patients with at least one pathological condition associated with extra pounds. These medicines help you lose weight by mimicking the action of hormones that reduce appetite and increase the feeling of satiety, and should be used indefinitely if you want to maintain weight loss. “Glp-1 Ras are lifelong drugs,” says Joseph Sanchez, MD, a general surgeon at Northwestern Medicine Hospital in Chicago and lead author of the study. In the United States “they are not always covered by insurance – he underlines – and can cost patients from 800 to 1,200 dollars a month”, but until now “we did not know how these therapies compared, in terms of cost-effectiveness, with gold standard option against obesity i.e. bariatric surgery” which is performed laparoscopically.
Shedding light on this point is crucial, highlights Anne Stey, senior researcher on the study and associate professor of surgery at the Northwestern University Feinberg School of Medicine in Chicago, because as “evidence of the health benefits of Glp-1 Ra continues to emerge, companies insurance companies will have to decide whether to cover these drugs and in which scenarios.” Therefore, “understanding whether and how these treatment options are cost-effective is critical to ensuring that as many people as possible can access them.”
The study
Sanchez and colleagues performed a cost-effectiveness analysis of Glp-1 Ra therapy alone, of bariatric surgery alone (gastric bypass or sleeve gastrectomy) and of the drug-surgery mix, predicting 3 scenarios – for thousands of patients involved in several clinical trials in the USA – the costs of treatment until death, for a period of up to 50 years. The treatment was considered cost-effective if the total cost was less than $100,000 for each quality of life-adjusted life year (Qaly), therefore for each healthy year of life gained.
On balance – the authors report – with a range of 17,400-22,850 dollars, the estimated cost per patient for bariatric surgery exceeds the average annual cost of Glp-1 Ra (9,360-16,200 dollars). However, compared to drugs alone, surgery alone adds approximately 2 Qaly and saves over $9,000 to gain one year of quality life. However, the combination between Glp-1 Ra and surgery is even better: compared to the scalpel alone, the mix saves over 7,200 dollars per Qaly and would add more than 5.
“Undergoing bariatric surgery – summarizes Sanchez – is more convenient in the long term than continuing pharmacological treatment for the rest of one’s life. The key role of these drugs, seen from a cost-effectiveness perspective, is expressed by using them after bariatric surgery to lose weight regained” possibly. The results of the study will obviously need to be revised, the author specifies, if the cost of Glp-1 Ra decreases or if new, cheaper anti-obesity drugs arrive on the market. But to change things the cost would have to drop significantly, by almost 75%.
A second study presented at the Acs meeting aimed to evaluate new anti-obesity drugs used before surgery. Research from the Indiana University (Iu) School of Medicine in Indianapolis has in fact found that since 2018 the use of Glp-1 Ra in the year before a bariatric procedure has more than tripled, from 8% to 24%. The idea is that losing weight before entering the operating room, especially in patients with a BMI body mass index greater than 50, “can make the surgery easier and safer”, explains Tarik Yuce, senior researcher of the study, Acs Associate Fellow and associate professor of surgery at the IU School of Medicine. However, it must be clarified whether there are risks by taking Glp-1 Ra, such as antidiabetics and/or antiobesity, before the operation.
Scientists analyzed information from 2,169 patients who underwent bariatric surgery at 3 IU-affiliated hospitals from 2018 to 2023. The data evaluated included differences in 30-day hospital admissions, emergency room visits, and complications among those who used Glp-1 Ra in preoperative phase (293 patients) and among those who had not taken them (1,876 patients). The researchers report no statistically significant differences between treatment groups in these short-term outcomes, or in weight loss 1 year after surgery: patients who used Glp-1 Ra before surgery lost on average 25.5% of their total weight, those who had not used drugs 27.3%.
“It may be safe to use Glp-1 Ra in the preoperative period – concludes Qais AbuHasan, associate researcher at the IU School of Medicine and lead author of the work – But we need to investigate further to understand whether factors such as dose and duration of treatment can produce or not differences in results”.
The analysis of Marco Antonio Zappa, Fedez’s surgeon
The new anti-diabetic slimming drugs are not ‘rivals’ of anti-obesity bariatric surgery. In some moments they can instead be valid allies of the ‘scalpel’, provided however that you “respect the instructions”. Because if on the one hand “bariatric surgery should not be done on just anyone”, on the other “the drug should not be given to everyone”. Appropriateness must be the guiding light for Marco Antonio Zappa, past president of Sicob (Italian Society for Surgery of Obesity and Metabolic Diseases) and world leader in abdominal surgery.
In September 2023, then director of the General Surgery Unit of the Fatebenefratelli-Sacco Asst in Milan, Zappa urgently treated Fedez for a haemorrhage from 2 ulcers. Today he heads the surgical department of the Iseni Sanità group, after last March he left the National Health Service denouncing the anomalies of “a system to which I have dedicated my life, but where 1 is equal to 1”. At Adnkronos Salute he comments on the studies presented at the ACS congress, which provide “indications with which I absolutely agree”.
The specialist’s premise is that “the good of the patient is what we must look to, therefore any solution, medical or surgical, that helps the patient heal is welcome”. The gold standard treatment in cases of severe obesity is bariatric surgery, for which “there is an absolute indication”, underlines Zappa. As for the drugs, “they are innovative, they are welcome, even the surgeons are happy that they are there and I also prescribe them”, but they must be used “in compliance with the indications”. In cases of severe obesity they can be complementary to the intervention “at specific times. Before and after surgery, above all”.
Targeting the solution to the patient’s needs is crucial, explains Zappa. “The drug, which has excellent efficacy, produces weight losses of a maximum of 10-12-15% in 1 year”. This is why in cases of severe obesity the indication is surgery, which allows you to lose “40-50% in 1 year and then more weight subsequently”. If to maintain the result and not gain weight again, Glp-1 analogues “must be taken for life” and there is the cost issue, “for bariatric surgery it is important that the intervention is part of a program in which the patient is assisted in a specialized center, by a multidisciplinary team, monitored and accompanied over time. Because if the operated patient does not follow up – warns the expert – he risks gaining weight again even after surgery”, nullifying the benefits. operation costs.
So “the drug can be useful and effective in 2 moments”, describes Zappa. First of all, “it is fundamental, before surgery to reduce the weight and with the weight the surgical risk: the patient is brought to a lower BMI body mass index and the operation is carried out with fewer risks”. Then, “equally fundamental is the potential use of the drug in post-surgery. In cases of ‘weight regain’, the surgeon first found himself in the dilemma of what to do, of having to re-operate with a very high risk higher. Now, thanks to the drug, the surgeon has a tool that he can use to help the patient regain weight loss while also strengthening himself psychologically. In these cases the therapy may not be lifelong”, the surgeon points out: “Yes can give the drug for 6-7 months and then the patient resumes his journey.” In short, appropriateness and customization. Scalpels and injections can coexist, helping each other, used on the right patient, at the right time.
