Bariatric Surgery Reduces Diabetes Medications, Cost of Care

Emma Hitt, PhD

August 16, 2010

August 16, 2010 ( UPDATED August 17, 2010 ) — Bariatric surgery may reduce the use of medications and healthcare costs in patients with type 2 diabetes, according to the findings of a new study.

Martin A. Makary, MD, from the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues reported their findings in the August issue of the Archives of Surgery.

"Bariatric surgery results in long-term weight loss, improved lifestyle, and decreased mortality," the researchers note. However, "studies of its effect on type 2 diabetes and costs are limited."

To investigate this issue further, the researchers studied 2235 adults with type 2 diabetes from 7 states in the Blue Cross/Blue Shield Obesity Care Collaborative. Participants had undergone bariatric surgery from January 1, 2002, through December 31, 2005. Data regarding the use of diabetes medications and total median healthcare costs per year were assessed.

Bariatric surgery eliminated diabetes medication in 1669 of the patients (74.7%) at 6 months. This increased to 80.6% at 1 year and 84.5% at 2 years after surgery. In addition, use of all classes of diabetes medications was reduced.

Long-term cost of healthcare was also reduced. Surgery cost about $30,000; in the first year after surgery, costs increased by 9.7% ($616 per person compared with the median preoperative annual cost of $6376 per person). However in year 2 and year 3, costs decreased by 34.2% ($2179) and 70.5% ($4498) compared with the same preoperative annual cost of $6376 observed from 1 to 2 years before surgery.

"In this large national study of insured patients with obesity and type 2 diabetes mellitus, bariatric surgery was associated with subsequent independence from type 2 diabetes medications in most of the patients and reduced annual health care costs within 2 years after the procedure," Dr. Makary and colleagues conclude.

According to the researchers, the reduced cost of healthcare may represent the "improved health associated with successful therapy for obesity and type 2 diabetes."

Limitations of the trial include that all participants were covered under Blue Cross/Blue Shield health insurance, thereby limiting generalizability to uninsured, those with limited coverage plans, and patients covered by other healthcare plans. Similarly, there is high turnover of insurance policies for those covered in the United States, which limited follow-up data for subjects studied. In addition, data regarding bariatric surgery were not stratified by body mass index.

"We observed that independence from diabetes medication was almost immediate within the initial months after surgery and did not correlate with the gradual weight loss expected," the authors write. "This supports the theory that the resolution of diabetes is not due to weight loss alone but is also mediated by gastric hormones, with the three most implicated being peptide YY, glucagonlike peptide and pancreatic polypeptide."

According to the researchers, levels of glucagonlike peptide, a mediator of insulin regulation, have been noted to increase immediately after bariatric surgery, and this may explain why "surgeons have noted complete resolution of diabetes in some cases within days after surgery."

Veeraish Chauhan, MD, from the Drexel University College of Medicine Hahnemann University Hospital, Philadelphia, Pennsylvania, noted that this study assessed a "tempting" hypothesis. "Although the study results are very promising, at this point, I do not think we have good data to support the use of bariatric surgery in type 2 diabetes patients who are not morbidly obese in order to reduce medication costs."

According to Dr. Chauhan, it does make sense that being able to come off medications would decrease healthcare costs. "However, this study does help us quantify the actual cost savings, and also beautifully illustrates the reduction in the long-term cost of healthcare even if you were to factor in the $30,000 cost of surgery."

Dr. Chauhan added that primary physicians and endocrinologists involved in the postsurgical care of bariatric surgery patients need to monitor patients' diabetes very closely — especially in the first 4 to 8 weeks after surgery, when major reductions in insulin resistance might mandate a decrease in the dosage/use of diabetes medications. "Not doing so would expose the patients to the potential risks associated with hypoglycemia," he said.

The current study was not commercially supported. The authors and commentator have disclosed no relevant financial relationships. The data set used in the study was originally created for a different research project supported by unrestricted research grants from Ethicon Endo-Surgery, Inc (a Johnson & Johnson company); Pfizer, Inc; and GlaxoSmithKline.

Arch Surg. 2010;145:726-731.

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