Bariatric surgery tied to lower mortality versus GLP-1 receptor agonists if diabetes duration is 10 years or less: JAMA

The cohort study comprising 6070 patients suggests that bariatric metabolic surgery (BMS) was associated with greater reduced mortality compared with GLP-1RAs among patients with a diabetes duration of 10 years or less, mediated via a greater weight loss.

"BMS was associated with a 62% reduction in mortality compared with GLP-1RAs, with weight reduction mediating the association among individuals with a diabetes duration of 10 years or less," the researchers reported in JAMA Network Open. "No difference was observed in mortality risk among those with a diabetes duration, nor in the major adverse cardiovascular events (MACEs) risk among all patients."

Bariatric Metabolic Surgery, comprising procedures such as gastric bypass and sleeve gastrectomy, has long been recognized as an effective means of achieving significant weight loss and improving metabolic health in severely obese individuals. Conversely, GLP-1 RAs, a class of injectable medications, have gained traction for their ability to reduce appetite, promote weight loss, and improve glycemic control in patients with type 2 diabetes and obesity.

Dror Dicker, Rabin Medical Center, Petah Tikva, Israel, and colleagues aimed to compare all-cause mortality and nonfatal MACEs associated with BMS versus GLP-1RAs for adults with obesity and diabetes, and without known cardiovascular disease (CVD).

For this purpose, the researchers conducted an observational, retrospective cohort study based on data obtained from the electronic medical records of Clalit Health Services (Clalit), the largest healthcare organization in Israel. The study comprised 6070 members aged 24 years or older, with diabetes and obesity and a prior history of congestive heart failure, ischemic stroke, or ischemic heart disease.

Patients who underwent BMS and patients who received GLP-1RAs from 2008 through 2021 were matched 1:1 by sex, age, and clinical characteristics. Follow-up ended December 31, 2022.

The primary outcome was all-cause mortality. The secondary outcome was nonfatal MACEs.

The following were the key findings of the study:

• The study included 3035 matched pairs of patients (total, 6070; mean age, 51.0 years; 64.9% women), followed up for a median of 6.8 years.
• Among those with a diabetes duration of 10 years or less (2371 pairs), mortality was lower for those who underwent BMS than for those treated with GLP-1RAs (hazard ratio [HR], 0.38). This association became nonsignificant when weight loss during the follow-up period was also included in the model (HR, 0.79).
• No survival advantage was demonstrated for BMS over GLP-1RA (HR, 0.65) among patients with a duration of diabetes longer than ten years (664 pairs).
• The risk for nonfatal MACEs did not differ between the treatment groups (HR, 0.74 among patients with a diabetes duration of ≤10 years; HR, 1.21 among patients with a diabetes duration of >10 years).

To summarize, the study found that over a median follow-up of 6.8 years, BMS was associated with lower all-cause mortality compared with GLP-1RA treatment among individuals with a diabetes duration of 10 years or less and without a prior history of CVD or congestive heart failure. In this association, weight reduction was identified as a mediating factor.

"No difference between BMS and treatment with GLP-1RAs was observed in mortality risk among individuals with a longer diabetes duration (>10 years), nor the risk of MACEs among all patients," the researchers wrote.

Reference:

Dicker D, Sagy YW, Ramot N, et al. Bariatric Metabolic Surgery vs Glucagon-Like Peptide-1 Receptor Agonists and Mortality. JAMA Netw Open. 2024;7(6):e2415392. doi:10.1001/jamanetworkopen.2024.15392