Most Americans are aware of weight loss (bariatric) surgery, and with the explosion in popularity of weight loss medications, it’s difficult not to hear about GLP-1 drugs like Wegovy and Zepbound. But did you know these two weight loss methods can be used together?
It’s a little counterintuitive. Why use both surgery and medication when each is effective on its own? And why have surgery at all if a weight-loss medication can help?
At Novant Health Bariatric Solutions - Kernersville, Jamie Szymarek routinely fields questions like these. She and her team use weight loss medications to help patients prepare for successful weight loss surgery, especially for those with a body mass index greater than 50. (People with a BMI of 30 or greater are considered obese.)
Szymarek sat down with us to explain why Wegovy or Zepbound may not be the best long-term solution for weight loss, but how they can aid in preoperative weight loss.
Complete support before, during and after weight loss surgery.
Starting on the surgical pathway with weight loss medications
Do you meet a lot of patients who have already tried weight loss medications?
Most patients who come in for a surgical consultation have exhausted alternative interventions, including various dietary approaches, exercise regimens and appetite suppressants, as well as treatments such as Wegovy or Zepbound. Additionally, some patients may have used compounded formulations of these medications; however, it is important to note that compounded versions of Wegovy or Zepbound are not approved by the FDA.
How do you decide which medication (Wegovy or Zepbound) and which dosing is right for the patient?
A drug like Wegovy (semaglutide) is a GLP-1 agonist, while a drug like Zepbound (tirzepatide) is a GLP-1 and GIP agonist. Both types of drugs target hormones that influence hunger and satisfaction, suppressing appetite and helping patients feel full more quickly.
In many cases, insurance coverage dictates the initial medication prescribed. Many insurance plans mandate that Wegovy must be tried and found ineffective before coverage for Zepbound is authorized. Additionally, the choice of medication is often guided by the patient’s medical history.
For patients taking Wegovy, treatment begins at 0.25 mg, with doses increasing in increments every four weeks, going up to 2.4 mg. If the patient experiences good results with a lower dose, we will maintain that dose. If hunger and cravings persist, we change the dose.
Zepbound dosing involves several maintenance dose levels. Patients begin treatment with 2.5 mg once weekly for the first four weeks, then increase to 5 mg once weekly. The 5 mg dose serves as the initial maintenance dose, but there are additional maintenance options, going up to 15 mg. I typically adjust the dose based on the patient’s eating habits and overall response. It’s important to note that higher doses don’t always lead to greater weight loss; for some patients, increased doses may cause excessive fullness, which can interfere with their nutritional intake.
How do insurance and medication costs play a role?
Both insurance and potential out-of-pocket costs play a significant role in determining whether patients can access weight loss medications as part of their surgical pathway.
Because of the high cost of Wegovy and Zepbound, many companies have discontinued coverage for these medications. As a result, patients often turn to compounded versions, which are not FDA-approved and therefore cannot be recommended by our program.
At Novant Health Bariatric Solutions - Kernersville, our insurance verification team supplies us with information about the medications covered for each patient.
It can seem counterintuitive to lose weight before your weight loss surgery. Could you explain to us why this is now the standard protocol?
FDA indications for Wegovy and Zepbound
Wegovy
- To reduce the risk of major cardiac events like heart attack or stroke in adults who have established cardiovascular risk and are overweight or obese.
- To reduce excess body weight and maintain weight reduction in patients 12 years or older who are overweight or obese, and in adults who are overweight with the presence of one comorbidity, such as untreated high blood pressure.
Zepbound
- To reduce excess body weight and maintain weight reduction long-term in overweight or obese adults who have at least one comorbid condition, such as high blood pressure or cardiovascular disease.
- To treat moderate to severe obstructive sleep apnea in adults with obesity.
When patients lose weight before surgery, it can significantly lower their surgical risks. Administering anesthesia is more complex in patients with high BMI, with increased risk of airway management problems and drug dosing issues. Extra weight, particularly around the chest and abdomen, can reduce lung capacity and make ventilation during and after surgery more difficult. This increases risks of pneumonia or breathing problems. A higher BMI can also cause the surgery itself to be more challenging, leading to longer operation times.
How can drugs like Wegovy and Zepbound prepare patients for their weight loss surgery?
Drugs like Wegovy and Zepbound can help prepare patients for weight loss surgery by promoting initial weight loss, which can improve overall health before the procedure. They may also help patients develop healthier eating habits and better manage blood sugar levels, making the surgery and recovery process smoother. In addition, losing weight before surgery can reduce abdominal fat and the size of the liver, which in turn lowers the risk of surgical complications.
Are there any risks to delaying surgery for the use of weight loss medications?
Yes, delaying surgery to use weight loss medications like Wegovy or Zepbound can carry some risks, depending on the individual’s health situation and the severity of their obesity-related conditions. For example, conditions like Type 2 diabetes, high blood pressure, sleep apnea or heart disease can worsen while waiting for surgery, increasing overall health risks.
Do you tend to see the results you need to go ahead with surgery in 3 to 6 months?
Typically, yes. Our patients work with our care team before and after surgery to ensure they’re ready for surgery and that they recover well afterward.
That care team consists of:
- Bariatric surgeon Dr. James Dasher
- Nurse practitioners and physician assistants
- A nutritionist
- Behavioral health specialists to ensure mental preparedness for surgery
- A physical therapist to teach good strength training techniques, which are essential during recovery
- A nurse navigator who coordinates all appointments, schedules surgeries and makes sure patients are meeting insurance guidelines
Do most patients view bariatric surgery as the last resort, and do you, as the medical professional, view bariatric surgery as the last resort?
Surgery can feel intimidating or like a “final step” because it is invasive and involves lifelong changes. There may also be fears about risks, complications or stigma associated with surgical weight loss, so yes, I believe many patients view bariatric surgery as a last resort.
As a healthcare provider, I see bariatric surgery as a highly effective, evidence-based treatment that should be discussed at every office visit, not just a last resort.
Postoperative care and recovery
What are some of the postoperative adjustments patients may face if they choose bariatric surgery?
All patients work with our nutritionist and therapist before surgery to ensure they are ready for the changes that come after bariatric surgery.
We have a strict postoperative diet to ensure that patients recover safely. The diet consists of two weeks on a liquid diet, two weeks on a pureed diet, and one month on a soft diet. Following bariatric surgery patients also must avoid caffeine, carbonation and alcohol. They must also avoid NSAIDS (nonsteroidal inflammatory medications) permanently due to the risk of ulcer formation.
We follow up with the patients very frequently in the first several months after their surgery to promptly identify and address any issues. Long term, we follow up with all our patients annually to ensure they are properly cared for. This entails assessing nutritional status and checking routine blood work for any potential vitamin deficiencies.
Do you start patients on weight loss medications after bariatric surgery?
I generally prefer to delay initiating weight loss medications until approximately one year post-bariatric surgery. This approach is based on the understanding that during the initial months following surgery, patients experience restricted food intake, and the use of weight loss medications at this stage may contribute to nutritional deficiencies.
Within the first year after surgery, the primary focus is to encourage patients to establish sustainable behavioral changes. Introducing a weight loss medication too early may hinder the adoption of essential lifestyle modifications necessary for long-term success.
One year or more after surgery, if patients begin to experience challenges with their eating habits, we may consider initiating weight loss medication. However, we generally recommend a follow-up consultation with our nutritionist and therapist first to identify any underlying difficulties the patient may be facing. Overall, it is uncommon for us to prescribe weight loss medications postoperatively, as most patients achieve successful outcomes without the need for medication following bariatric surgery.
