The future of obesity treatment

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has released a consensus position statement addressing the integration of obesity management medications (OMMs) with metabolic bariatric surgery (MBS)1.

Currently, obesity treatment encompasses four primary modalities: lifestyle modification, OMMs, endoscopic bariatric and metabolic therapies (EBMTs), and MBS. The recent introduction of newer-generation OMMs, such as semaglutide and tirzepatide, has sparked a surge in their use and increased awareness of obesity as a treatable chronic disease2,3. While these medications show significant promise, they also have limitations, including non-response rates, potential adverse events, and challenges with long-term adherence.

This position statement is particularly timely, as an increasing number of patients who have tried or discontinued OMMs are now seeking additional interventions to support their weight management or maintenance goals. Furthermore, since not all patients respond optimally to MBS, incorporating adjunctive therapies, such as adding OMMs after surgery, should enhance outcomes.

To date, most studies on the combination therapy of MBS with OMMs have focused on adjunctive rather than neoadjuvant use, often using older-generation OMMs. Nonetheless, the available data consistently indicate that combination therapy is associated with greater weight loss compared to monotherapy. Additionally, the degree of weight loss achieved after introducing OMMs following MBS appears comparable to that observed in patients with normal anatomy4.

Regarding timing, most studies initiated OMMs years after the index MBS, likely reflecting the retrospective nature of these studies and the more recent adoption of OMMs. As a result, the panel recommends initiating OMMs after weight stabilization post-MBS4. This aligns with evidence from combination therapy involving EBMTs and OMMs, where adding medication within six months when weight plateaus yields superior outcomes5. Nonetheless, emerging evidence suggests earlier addition of OMMs post-surgery may improve results, particularly in specific populations, such as those with a body mass index (BMI) of greater than 50 kg/m²6. This highlights patient heterogeneity and the need for further research to refine combination therapy strategies, including optimal timing, dosing, and tailoring for responders, non-responders, and those with recurrent weight gain.

For patients at the extreme end of the spectrum who experience recurrent weight gain and are considering revisional or conversion surgery, the panel suggests that OMMs and/or endoscopic therapies be explored before surgical intervention, given the favorable benefit-risk ratio1,7,8. Additionally, a recent study demonstrated that the combination therapy of transoral outlet reduction (TORe), the most commonly performed endoscopic revision procedure following MBS, and OMMs offers benefits comparable to revisional or conversion surgery, with a lower rate of serious adverse events9. As such, this approach may represent another viable alternative for patients experiencing recurrent weight gain.