International consensus position statement on the role of obesity management medications in the context of metabolic bariatric surgery: expert guideline by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)

Résumé fourni par la source

Metabolic bariatric surgery (MBS) is the most effective long-term treatment option for clinical obesity and its complications1. Nonetheless, modern pharmacotherapy involving intestinal hormonal analogues, such as semaglutide and tirzepatide, have shown good weight loss outcomes in the short and medium term2–4. Potentially, such obesity management medications (OMMs) may be synergistic with or additive to MBS for selected patients before and/or after MBS regarding improved outcomes. The impact of pharmacotherapy before surgery is unclear, with a lack of high-level evidence regarding the efficacy of preoperative OMMs in reducing intraoperative risks and complications5. Similarly, the evidence is scarce for the use of OMMs as an adjunct therapy to MBS or in patients with a suboptimal initial clinical response or with recurrent weight gain after surgery6–8. For these reasons, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) asked a multidisciplinary group of international experts in obesity management to develop evidence-based recommendations to serve as a global reference for using OMMs before and after MBS. These recommendations were developed through a Delphi process, identifying areas of expert consensus after a systematic review of the published literature and highlighting areas warranting further research9. Clinical obesity is a condition in which the risk to health associated with excess adiposity has already materialized and can be objectively documented by specific signs and symptoms reflecting biological alterations of tissues and organs that are consistent with extant illness10. In 2023, IFSO created a global consensus to standardize MBS outcomes11, defining a suboptimal initial clinical response and recurrent weight gain as the standard nomenclature. Modern OMMs are the second-generation intestinal hormonal analogues (single or dual analogues), whereas OMMs include all available pharmacotherapy that may be adjunctive to MBS and are not restricted to only modern agents. The core scientific committee (R.V.C., G.P., and L.B.) and the partner organizations—the World Obesity Federation (WOF), the European Association for the Study of Obesity (EASO), and the International Diabetes Federation (IDF)—tasked a multidisciplinary group of 40 international authorities to develop evidence-based recommendations. Voting experts were entirely chosen from academia, without representatives from industry. The names and details of these experts, as well as those of an internationally recognized Delphi expert (R.L.), with knowledge of endocrinology and metabolism, and a patient representative, are provided in the Collaborators section. The preset research questions for the systematic review of evidence included preoperative and postoperative use of pharmacotherapy, the class of drugs employed, the impact on weight and obesity-related complications, and the effectiveness and complications of using medications before and after MBS. Given the objectives of the consensus conference, the relatively short duration of availability and clinical use of modern pharmacotherapy, and the heterogeneous publications on the use of other OMMs, it was decided to adopt a relatively low threshold for the selection of evidence, including not only RCTs but also published systematic reviews and observational studies. A document with the results of this systematic review was circulated among the whole group in preparation for the Delphi process. The core scientific committee prepared a list of issues for each statement and a first draft of the rationale for each statement was sent to the experts before the start of the Delphi process. Furthermore, each expert was asked to contribute three to four statements within their field of expertise. The statements were then revised by the core scientific committee and by the Delphi expert. An initial Delphi process, referred to as the online Delphi process, was conducted by e-mail among the full expert panel, beginning on 25 March 2024. The patient representative was not involved in the online Delphi process. Each expert returned their completed questionnaire to the Delphi expert without sharing their votes or comments with the other expert panel members. The second part of the Delphi process was conducted as a 2-day in-person meeting, with the full voting expert panel and the patient representative, without voting capacity, but actively involved in the discussions, from 30 April 2024 to 1 May 2024, in Vienna, Austria. The first day consisted of expert presentations and a discussion of the available evidence on using OMMs and MBS. All experts who submitted statements for the Delphi voting presented the topics related to their statements to the entire group before the open discussion. The voting took place on the second day of the in-person meeting. The core scientific committee divided the topics for discussion and voting into three modules: module 1, common understanding of obesity as a disease, the benefits of the extent of weight loss on obesity-related health risks, and the use of OMMs before MBS; module 2, use of OMMs after MBS; and module 3, future perspectives. The Delphi expert counted the votes for each statement to discern the percentage consensus support for each statement. Statements that received 100% consensus support were considered grade A+, statements that received 90–99.9% consensus support were considered grade A, statements that received 80–89.9% consensus support were considered grade B, statements that received 70–79.9% consensus support were considered grade C, and statements that received 66–69.9% consensus support were considered grade D. Statements that received less than 66% consensus support were considered to have failed consensus12. After the initial round of the online Delphi process, statements that were considered grade A or higher were closed for further voting. Statements that were considered less than grade A, but for which the expert feedback was conflicting or insufficient to suggest a means to edit the statement to achieve higher consensus, were tabled for further discussion during the in-person Delphi process. The Delphi expert edited the remaining statements, incorporating the feedback from the expert panel, and a new questionnaire was distributed to each expert panel member. In total, three rounds of the online Delphi process were conducted. During the in-person Delphi voting, each statement, including the revised versions developed during the online Delphi process, was presented to the expert panel for further discussion. Each statement considered grade A+ or A during the online Delphi process was individually discussed and edited by the Delphi expert, considering the comments raised by the panel experts. After each set of discussions, a new vote was taken for the statement using a smartphone app to maintain the confidentiality of the vote. When a revised statement did not receive grade A support, discussion regarding further edits took place and a new vote was taken. During the in-person Delphi voting, 12 of the original statements were voted to be deleted by the expert panel due to redundancy with other statements, due to a lack of relevance regarding the aims of the consensus document, or due to conflicts with other statements. Furthermore, five new statements were added and voted on during the in-person Delphi voting. Due to various valid circumstances, not every expert panel member voted for every statement during the online or in-person Delphi process. Thus, the percentage consensus and the number of total votes are indicated for each statement in each module. The statements from the Delphi process and the consensus grade, percentage consensus, number of voting rounds, and number of total votes are reported in detail in Table 1 (module 1), Table 2 (module 2), and Table 3 (module 3). Delphi results, module 1: common understanding of obesity as a disease, the ben

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