Dec 19, 2023 - Health

Weight-loss drugs are increasingly paired with bariatric surgery

Illustration of a surgical scalpel and an injection syringe for medicine crossed to make a plus sign.

Illustration: Annelise Capossela/Axios

The new highly effective class of anti-obesity drugs has often been talked about as an alternative to bariatric surgery — but medications like Wegovy are increasingly being paired with the procedure.

Why it matters: While surgeons say the drugs can especially help people with severe obesity maintain weight loss after surgery, the combination presents a pricey scenario for insurers already grappling with the cost of the drugs alone.

By the numbers: The number of bariatric surgeries performed in the U.S. increased slightly between 2021 and 2022 after the drugs known as GLP-1 agonists exploded on the market, according to medical claims data from FAIR Health.

  • The number of bariatric surgery patients who were subsequently prescribed a GLP-1 more than tripled between 2021 and 2023, according to claims data from health tech company PurpleLab.
  • Roughly 16% of bariatric surgery patients were later prescribed a GLP-1 in 2023, according to the database, which includes more than 300 million claims from Medicare, Medicaid, and commercial payers over the past five years.
  • While the claims data doesn't show exactly why the surgery patients were later prescribed those drugs, it tracks with anecdotal reports from surgeons and health care experts.
  • Even companies like Johnson & Johnson, which make devices used by bariatric surgeons, have said they view the drugs as "complementary" to surgery.

State of play: GLP-1s are seen as revolutionary, helping patients lose anywhere between 15% to 20% of their weight. The evidence so far suggests patients taking GLP-1s need to stay on them long-term to maintain weight loss, but many aren't, either due to side effects, costs, or ongoing shortages of the highly sought-after drugs.

  • Patients may shed more pounds with bariatric surgery — up to 35% of their weight. And it's generally a one-time procedure.
  • The surgery isn't for everyone. It's a highly invasive procedure, with a higher risk of complications compared with other weight-loss interventions, including GLP-1s.
  • "Patients need to understand that these medications only take off a certain amount of weight, and if they really have a significant amount of weight to lose, they should consider surgery," Marina Kurian, president of the American Society for Metabolic and Bariatric Surgery, told Axios.
  • "And sometimes some patients need both," she said.

Details: Between 20% and 35% of patients who receive the most commonly performed bariatric surgery gain back most of the weight or fail to hit a certain target for body mass index.

  • Combining one of the GLP-1s with bariatric surgery or endoscopic bariatric therapy, which is a less invasive procedure, "provided significant weight loss" when compared with those procedures alone, according to a systemic review of 11 studies that was published in the Journal of the Endocrine Society this month.
  • "The drugs will revolutionize for sure the landscape of bariatric treatment," Enrique Elli, a bariatric surgeon at the Mayo Clinic, told Axios. "As a surgeon, I welcome these drugs because I think that will make bariatric surgery even more effective."
  • Kurian, who is a bariatric surgeon at NYU Langone, said she doesn't jump directly to prescribing GLP-1s after surgery, but usually waits a while to see how patients are faring.
  • "There are some patients where the surgery takes off like 100 to 150 pounds, but they still have another 80 [pounds] to go," she said. "Those are the patients who might benefit from a combination."

Yes, but: While most large employers cover bariatric surgery — and many are trying to better promote that benefit to their workers amid the rising interest in GLP-1s — far fewer cover the drugs for weight loss.

  • Surgery generally costs between $17,000 and $26,000, while GLP-1s have a list price of roughly $16,000 a year, per a recent report from EPIC Insurance Brokers and Consultants.
  • Even after accounting for discounts from the list price, the costs can add up, said Morgan Lee, EPIC's senior director of research and strategy.
  • "Knowing GLP-1 drugs are intended to be taken forever, over the lifetime of a patient, it's a lot more expensive," Lee said.
  • The idea that some patients might need both? "From a cost perspective, that sounds rough," she said.

The intrigue: Coupling the drugs with bariatric surgery is also the latest example of how GLP-1s are being seen as a tool to be used with — rather than instead of — other forms of obesity care.

  • Abbott Laboratories is making the case that patients using its continuous glucose monitoring system remain on the GLP-1 drugs longer than those receiving the medication alone.
  • Companies like WeightWatchers have embraced GLP-1s as part of their weight-loss programs.
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