What is the use of Glucagon-like peptide (GLP) after a gastric sleeve procedure?

From the Guidelines

GLP-1 receptor agonists should be used with caution after gastric sleeve surgery, considering the potential increased risk of gastric stasis and aspiration, and typically started no sooner than 6-12 months post-surgery at the lowest dose and gradually titrated upward while monitoring for side effects, as suggested by recent studies 1.

Key Considerations

• The use of GLP-1 receptor agonists after gastric sleeve surgery requires careful consideration of the potential risks and benefits, including the increased risk of gastric stasis and aspiration 1.
• Patients who experience weight regain or inadequate weight loss after gastric sleeve surgery may benefit from GLP-1 receptor agonists, but should be closely monitored for side effects and nutritional deficiencies 1.
• The combination of gastric sleeve surgery and GLP-1 medications can enhance satiety and weight loss, but also increases the risk of nausea, vomiting, and other gastrointestinal side effects 1.

Recommendations

• GLP-1 receptor agonists, such as semaglutide, liraglutide, or tirzepatide, can be initiated at a low dose (e.g., 0.25mg weekly for semaglutide) and gradually increased every 4 weeks until reaching the therapeutic dose 1.
• Patients should be advised to maintain adequate hydration, protein intake (at least 60-80g daily), and vitamin supplementation to minimize the risk of nutritional deficiencies 1.
• Regular monitoring with healthcare providers is necessary to assess weight loss progress, nutritional status, and potential side effects, and to adjust the treatment plan as needed 1.

Rationale

• The recent studies 1 highlight the importance of careful consideration of the potential risks and benefits of GLP-1 receptor agonists after gastric sleeve surgery, and provide guidance on the safe use of these medications in this context.
• The use of GLP-1 receptor agonists after gastric sleeve surgery requires a comprehensive approach that takes into account the individual patient's needs and medical history, as well as the potential risks and benefits of these medications 1.

From the Research

Use of Glucagon-like peptide (GLP) after a gastric sleeve procedure

• The use of Glucagon-like peptide-1 (GLP-1) receptor agonists after a gastric sleeve procedure has been studied in various research papers 2, 3, 4, 5, 6.
• GLP-1 receptor agonists have been found to be effective in achieving type 2 diabetes mellitus (T2DM) remission, with studies showing higher rates of T2DM remission compared to standard glucose-lowering medications and lifestyle changes 3.
• After a gastric sleeve procedure, GLP-1 receptor agonists can be used to treat suboptimal initial clinical response and weight gain recurrence, with significant reductions in biochemical markers and adverse effects 6.
• The safety of continuing GLP-1 receptor agonists during endoscopic sleeve gastroplasty has been evaluated, with no instances of retained gastric solids, pulmonary aspiration, gastroesophageal regurgitation, or hypoxia reported in a study of 57 consecutive adults 2.
• However, the risk of aspiration during general anesthesia is unknown, and caution is advised in patients who recently commenced on GLP-1 receptor agonists 4.
• A scoping review of the available literature found significant variability in the findings reported, with most studies including confounding factors that may influence the association between GLP-1 RAs and an increased risk of aspiration and related events 5.

Efficacy and Safety of GLP-1 Receptor Agonists

• GLP-1 receptor agonists have been found to be effective in achieving significant weight loss, with pooled percentage of total weight loss (%TWL) ranging from 9.24% to 15.50% after at least 3 months of treatment 6.
• The most common adverse effects of GLP-1 receptor agonists include nausea, vomiting, diarrhea, constipation, headache, fatigue, abdominal pain, and abdominal bloating, with a proportion of patients discontinuing treatment due to adverse effects of 3% 6.
• Biochemical markers, including triglycerides, total cholesterol, low-density lipoprotein cholesterol, glycated hemoglobin, and alanine aminotransferase levels, have been found to show significant reductions after GLP-1 RA treatment 6.