Anti-Obesity Pharmacotherapy After Bariatric Surgery

Abstract

A 63-year-old man is referred from his bariatric surgeon to an obesity medicine specialist for weight management. Four years ago, he underwent Roux-en-Y gastric bypass and lost 129 lbs or 38% of his total body weight (BMI 48.5 kg/m², 348 lbs, 5′11″ ➔ BMI 30.5 kg/m², 219 lbs). He maintained this weight for 2 years; however, he has since regained 27 lbs (BMI 30.5 kg/m², 219 lbs ➔ BMI 34.3 kg/m², 246 lbs). In addition to obesity, he suffers from type 2 diabetes, congestive heart failure, coronary artery disease, and hyperlipidemia. A recent transthoracic echocardiogram revealed normal valvular function. Following bariatric surgery, his hemoglobin A1c (HbA1c) improved, and he was able to discontinue all of his antidiabetic medications; however, his HbA1c increased to 7.9% last year, so metformin was restarted and titrated up to 1000 mg twice daily. His other medications are aspirin 81 mg daily, carvedilol 25 mg twice daily, lisinopril 10 mg daily, and rosuvastatin 10 mg daily. He follows a low-carbohydrate diet and exercises for 60 min most days of the week. He is concerned about his increasing weight and blood sugar. He denies pancreatitis and a personal or family history of medullary thyroid carcinoma. His exam is within normal limits, and his laboratory data reveal no abnormalities besides HbA1c of 7.4%. A few months ago, his primary care doctor initiated lorcaserin 10 mg twice daily for weight management. After 12 weeks, he had not lost any weight so the medication was discontinued.