Can a 64-year-old female with a history of bowel obstruction and bariatric surgery (bariatric surgery) be started on Glucagon-like peptide (GLP) for further weight loss?

From the Guidelines

GLP-1 receptor agonists can be considered for weight loss in a 64-year-old female with a history of bariatric surgery and bowel obstruction, but caution is warranted. Before starting, a thorough evaluation by her healthcare provider is essential to assess her current gastrointestinal function and the specific type of bariatric procedure she underwent. GLP-1 medications like semaglutide (Wegovy) or liraglutide (Saxenda) may help with further weight loss by slowing gastric emptying and reducing appetite, but they can also cause gastrointestinal side effects including nausea, vomiting, and constipation, which could be problematic given her history of bowel obstruction.

Key Considerations

• The patient's history of bowel obstruction requires careful consideration when initiating GLP-1 receptor agonists, as these medications can exacerbate gastrointestinal issues 1.
• Starting at the lowest possible dose with very gradual titration would be recommended, such as semaglutide 0.25mg weekly for the first month before any dose increases, to minimize the risk of adverse effects 1.
• Adequate hydration, a low-fiber diet initially, and close monitoring for any signs of gastrointestinal distress are crucial to prevent complications 1.
• The patient should immediately report symptoms like severe abdominal pain, persistent vomiting, or constipation, as these could indicate recurrent bowel issues requiring prompt medical attention.

Evidence-Based Recommendations

• According to a recent study published in 2024, GLP-1 receptor agonists have been shown to result in substantially greater weight loss in those without diabetes, with a mean weight loss of 6.1-17.4% 1.
• The STEP trial demonstrated that weekly semaglutide (2.4 mg) reduced the mean body weight from baseline by 14.9% in patients who were non-diabetic, overweight or obese 1.
• However, it is essential to weigh the potential benefits of GLP-1 receptor agonists against the potential risks, particularly in patients with a history of gastrointestinal issues, and to closely monitor the patient's response to treatment.

From the FDA Drug Label

Liraglutide injection slows gastric emptying. Liraglutide injection has not been studied in patients with pre-existing gastroparesis.

The patient has a history of bowel obstruction and has undergone bariatric surgery. Gastric emptying is slowed by liraglutide, which may be a concern in this patient.

• The FDA drug label does not provide direct information on the use of liraglutide in patients with a history of bowel obstruction or bariatric surgery.
• Caution should be exercised when considering the use of liraglutide in this patient due to the potential risk of exacerbating gastrointestinal symptoms.
• The decision to start liraglutide for weight loss should be made on a case-by-case basis, taking into account the patient's individual medical history and potential risks. 2 2

From the Research

GLP-1 Agonists for Weight Loss After Bariatric Surgery

• The use of GLP-1 agonists for weight loss after bariatric surgery has been studied in several research papers 3, 4, 5.
• A systematic review and meta-analysis found that GLP-1 agonists have a moderate effect on weight loss after failed weight loss or weight regain following metabolic/bariatric surgery, with a Cohen's d-score of 0.470 (p ≤ 0.001) 3.
• Another study found that GLP-1 agonist use in patients with a BMI > 50 kg/m2 results in significantly more weight loss prior to bariatric surgery, without increased time to surgery or complication rate 4.
• A systematic review and meta-analysis also found that using GLP-1 receptor agonists is a safe and effective treatment for weight regain and insufficient weight loss after metabolic bariatric surgery, with a mean difference in weight of -7.02 kg or 3.07 kg/m2 5.

Considerations for Patients with a History of Bowel Obstruction

• Bowel obstruction after bariatric surgery could require markedly different management strategies and have different outcomes compared to non-bariatric patients 6.
• The management algorithms for bowel obstruction in patients who have undergone bariatric surgery should consider the significant differences in the cause of obstruction and the need for early operative intervention in this special patient population 6.
• However, there is no direct evidence to suggest that a history of bowel obstruction would preclude the use of GLP-1 agonists for weight loss after bariatric surgery.

Safety and Efficacy of GLP-1 Agonists

• Common complications of GLP-1 agonist use include nausea, constipation, abdominal pain, and vomiting 5.
• However, the use of GLP-1 receptor agonists has been found to be safe and effective for the management of postprandial hypoglycemia following bariatric surgery, and may even reduce the number of postprandial hypoglycemic episodes and improve glycemic variability 7.