Bariatric Surgery vs. GLP-1 Agonists: Which is Best for MASH/MASLD, Obesity, and Diabetes?

For individuals grappling with the trifecta of Metabolic dysfunction-associated steatohepatitis (MASH) or Metabolic dysfunction-associated steatotic liver disease (MASLD), obesity, and type 2 diabetes, weight management presents a complex challenge. New Cleveland Clinic research sheds light on the distinct benefits of bariatric surgery and GLP-1 agonists in addressing this challenge.

Key Findings: Bariatric Surgery and GLP-1s Offer Different Advantages

The study reveals that both bariatric surgery and GLP-1 agonists offer similar benefits regarding major adverse cardiovascular events and hypertension. However, crucial differences emerge:

• Bariatric Surgery: Provides superior short-term kidney protection.
• GLP-1 Agonists: Associated with improved mortality and liver-related outcomes.

This nuanced understanding underscores the need for a personalized approach. "Whenever a patient with this combination of comorbidities comes to the clinic, there should be a very personalized approach to the treatment modalities for that patient," emphasizes Dr. Zehra Naseem, the study's first author.

Comprehensive Study Comparing Bariatric Surgery and GLP-1s

This research marks the first direct comparison of bariatric surgery and GLP-1 agonists in patients with MASLD/MASH, obesity, and type 2 diabetes. Researchers analyzed data from 645 patients undergoing bariatric surgery and 645 patients receiving GLP-1 agonists, tracking outcomes over five and ten years.

Positive Outcomes of Each Approach:

• Cardiovascular Health: Both interventions demonstrate comparable positive effects on major adverse cardiovascular events and hypertension.
• Kidney Protection: Bariatric surgery exhibited a 30% lower risk of chronic kidney disease (CKD) compared to GLP-1 agonists within the first five years. Dr. Naseem explains that bariatric surgery reduces obesity, a key CKD risk factor, and improves glycemic control.
• Liver Health and Mortality: GLP-1 agonists were linked to a significant reduction in mortality risk (50-67%) and liver disease progression (37-50%) over both five- and ten-year periods.

It is important to note that the kidney benefits of bariatric surgery are most apparent in the first 6-12 months after the procedure.

The Importance of Individualized Treatment Plans

These findings emphasize the necessity of tailoring treatment strategies to each patient's unique circumstances. While GLP-1 medications show promise, a multi-modal approach is often required.

Dr. Roberto Simons-Linares, Director of Bariatric Surgery at Cleveland Clinic, stresses that "the management of obesity and metabolic syndrome requires multi-modal treatment approaches, such as medication, endoscopic procedures or surgery. Having patients receive treatment at a facility that provides that kind of treatment in a medical home setting, such as Cleveland Clinic, is paramount."

Future Research Directions: Combination Therapies and Detailed Analysis

The research team is committed to furthering our understanding of optimal treatment strategies. Future studies will investigate:

• A detailed retrospective comparison of bariatric surgery and GLP-1 agonists at Cleveland Clinic, analyzing liver fibrosis markers and biopsy samples.
• Outcomes in patients receiving a combination of both bariatric surgery and GLP-1 agonists, reflecting real-world clinical scenarios.

By exploring combination therapies, researchers aim to refine treatment approaches and achieve the best possible outcomes for patients facing these complex health challenges.