COMMENTARY

Pharmacotherapy Boosts Weight Loss Effects of Intragastric Balloons

Digestive Disease Week (DDW) 2019

Alok S. Patel, MD; Reem Z. Sharaiha, MD, MSc

Disclosures

July 26, 2019

This transcript has been edited for clarity.

Alok S. Patel, MD: This is Dr Alok Patel with Medscape, here at Digestive Disease Week 2019 covering all kinds of fascinating gastrointestinal (GI) topics. I'm honored to be talking to Dr Reem Sharaiha, director of interventional gastroenterology at NewYork-Presbyterian/Weill Cornell Medical Center.

Dr Sharaiha, we're going to talk about your amazing study[1] looking at pharmacotherapy and intragastric balloons. We know that intragastric balloons can lead to about a 10%-15% total body weight loss, but some patients regain weight after they have them removed. Can you tell us a little bit about how you and your co-investigators designed this study and why you looked at what you did?

Reem Z. Sharaiha, MD, MSc: We know from the obesity data that many patients want minimally invasive procedures with very low side-effect profiles that give you a little bit more benefit than diet and exercise and medications. Balloons fit that category because they're safe and reversible; patients like them a lot. We know from US Food and Drug Administration data that patients lose weight when these balloons are present, because they decrease gastric volume and delay emptying, food stays in the stomach longer, and patients feel full. However, all balloons have to be removed at some point, usually at the 6-month mark. When that happens, patients lose these benefits and start regaining weight . We wondered what the effect would be of adding medications. There has been only one very small study[2] in Europe looking at that, but it was underpowered to show any difference. So we thought we would look at our cohort of patients and compare outcomes between those who wanted to have medications added and those who didn't.

Patel: How did you and your co-investigators decide which medications to use in the study?

Sharaiha: It was at the discretion of the gastroenterologist and endocrinologist, and also the patients. There are five approved medications for weight loss. There is also metformin, which is a medication used primarily for diabetes but we use it off-label for weight loss; that's usually the first medication that we start with because it has the safest profile. Then we make other medication decisions based on the patient's profile, by asking what causes them to have weight regain. Some people have cravings, some have nighttime eating, and some just feel hungry all the time. We use different types of medications to stop that point in time that causes them to regain weight.

What we found is that patients who have pharmacotherapy continue to lose weight even after the balloon is removed compared with the ones who didn't have any pharmacotherapy. Now, it's important to say that both groups have diet and exercise and also contacts with a dietitian or nutritionist every month. But the addition of pharmacotherapy just gave that extra bang for your buck, and they had a statistically significant weight loss at the 1-year mark.

Patel: Do you think that the real problem you're solving is curbing appetite with pharmacotherapy?

Sharaiha: It's not just curbing appetite but showing that in order to get sustained weight loss, you really have to see obesity as a chronic disease. You're going to need multiple points in the patient's life to give them some sort of treatment. Whether it's balloons now, balloons plus medications, and maybe something else down the line, that's what we have to think of. In order to get weight loss that's similar to with surgery, it may be that the combination approach of an endoscopic bariatric treatment plus medications will give them that option.

Patel: I'm glad you mentioned that balloons are becoming more popular. We know that they're safe. How do you think your study is going to affect the future? Are we entering an era of new standards with balloons and pharmacotherapy? Would you like to see gastroenterologists looking into it more?

Sharaiha: We believe that obesity is a GI disease. It affects so many things within the GI tract. It's one of the most common causes for patients to need care. Therefore, every gastroenterologist should see that if patients have a body mass index above 30, they should be offered some sort of treatment. They can start with balloons, but they also have the option of maybe adding medications to help them augment their weight loss. And if they feel they can't do it or don't feel comfortable doing it, then they can partner with an endocrinologist or an internal medicine doctor who can give medications.

Patel: Because medicine is teamwork.

Sharaiha: Exactly.

Patel: Your study looked at patients at the 12-month mark. Are you thinking about looking further than that?

Sharaiha: Yes, for sure. The 12-month mark is usually the easiest data to get and then usually after that, patients peter off. I'd obviously like to keep following this cohort longitudinally and see what happens to them. But the study I'd ideally like to do next is a prospective trial giving medications versus not, in a more rigorous fashion. The current study is obviously retrospective, so you want to see this prospectively so you have hard endpoints where you can argue that this should be the standard of care.

Patel: Dr Sharaiha, thank you so much for talking to us. We're looking forward to seeing the results in the future.

Sharaiha: Thank you for having me.

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