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 The leading web portal for pharmacy resources, news, education and careers November 21, 2017
Pharmacy Choice - Bariatric Surgery and Diabetes Disease State Management - November 21, 2017

Bariatric Surgery and Diabetes Disease State Management

Diabetes treatment–is surgery a better option?
by Gina D. Moore, PharmD, MBA

Approximately 6.5% of all US citizens have diabetes.1 While the number of newly diagnosed cases has slowly declined since 2008, the disease still represents a significant burden to the U.S. healthcare system and leads to long-term complications such as end-stage renal disease (ESRD).

There are a number of medications available to treat type 2 diabetes. During the last decade, greater percentages of patients with diabetes have been treated with statin agents and have achieved recommended hemoglobin AIC, blood pressure, and LDL cholesterol targets through medication therapy. Improvement in disease management has resulted in better cardiovascular disease outcomes and reductions in microvascular complications.2 Despite progress, approximately 40% of patients with diabetes are not adequately controlled.

Recent guidelines issued by the American Diabetes Association recommend bariatric surgery in patients with type 2 diabetes with a body mass index (BMI) ≥ 40 kg/m2 (BMI ≥ 37.5 kg/m2 in Asian Americans) regardless of the level of glycemic control. Metabolic surgery is also recommended in adults with BMI of 35 - 39.9 kg/m2 (32.5 - 37.4 kg/m2 in Asian Americans) when glycemic control is not obtained despite lifestyle changes and optimized medication therapy.

A recent New England Journal of Medicine article featured five-year outcomes data from a cohort of a 150 patients with type 2 diabetes and a BMI of 27 to 43 kg/m2 that underwent bariatric surgery in addition to intensive medical therapy.3 The primary outcome measurement was a hemoglobin A1C of 6.0% or less with or without medications. Secondary end-points included weight loss, blood pressure, lipid levels, renal function and quality of life. Of the 150 patients who began the study, 134 completed 5 years of follow-up.

Only 2 of the 38 patients (5%) in the medical-therapy group achieved an AIC level of 6.0% or less. Patients randomized to bariatric surgery options fared much better. Fourteen of 49 patients (29%) who underwent gastric bypass and 11 of 47 patients (23%) who underwent sleeve-gastrectomy achieved desired A1C levels. Patients in the surgical groups also experienced greater improvement in body weight, triglyceride and HDL-cholesterol levels, and quality-of-life measures. Almost 90% of patients in the surgery groups achieved good glycemic control without the need for insulin; 6% of patients in the surgery groups required no diabetes medications at all. Patients with diabetes for less than 8 years was the primary predictor of achieving an A1C level of 6.0% or less, which the authors highlight as an important consideration for early surgical intervention in this patient population.

In respect to the two surgical procedures, sleeve gastrectomy is currently the most common metabolic operation.4 This procedure, often called "the sleeve" is done laparoscopically. Approximately 80% of the stomach is removed, and the remainder of the stomach formed into a long tubular pouch. The new stomach pouch holds a much smaller amount of food, and causes rapid and significant weight loss. Patients generally lose 50% or more of their excess weight, which is sustained over at least 3 to 5 years of follow-up. As opposed to the gastric bypass procedure, the sleeve does not entail re-routing of the food stream. In addition to decreased food intake, the procedure more importantly impacts gut hormones that decrease hunger, increase satiety, and improve blood sugar control. The procedure is, however, non-reversible, and patients may experience long-term vitamin deficiencies, namely vitamin B12, iron, calcium, and folic acid.

Other bariatric surgery options include the Roux-en-Y Gastric Bypass, usually referred to as gastric bypass, Adjustable Gastric Band, often called "the band", and Biliopancreatic Diversion with Duodenal Switch Gastric Bypass. There are various differences between the surgical procedures in terms of weight loss percentage, nutritional complications, length of hospital stay and whether or not the procedure is reversible.

The body of evidence is growing for metabolic surgery in overweight patients with diabetes. Most insurers, public and private, cover bariatric surgery in patients with a BMI greater than 35. Several organizations, in light of positive outcomes data, have recommended making bariatric surgery available to patients with a BMI as low as 30 kg/m2.5 Potential long-term benefits, such as reduction in incidence of myocardial infarction, stroke, and renal failure in this patient population still need to be assessed in larger trials of longer duration, which may lead to further coverage.
References
  1. Centers for Disease Control and Prevention National Diabetes Data. Available at: https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html# (accessed 6/6/17).
  2. Standards of Medical Care in Diabetes - 2017. Diabetes Care 2017;40(Suppl. 1):S1-S132.
  3. Schauer PR et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes. N Engl J Med 2017;376:641-651.
  4. "Bariatric Surgery Procedures." American Society for Metabolic and Bariatric Surgery. Available at: https://asmbs.org/patients/bariatric-surgery-procedures (accessed 6/7/17).
  5. Rubino F, Nathan DM, Eckel RH, et al: Delegates of the 2nd Diabetes Surgery Summit. Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care 2016: 39:861-877.


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