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THE DUAL EFFICACY OF PHARMACOTHERAPY WITH INTRAGASTRIC BALLOONS FOR SUSTAINED WEIGHT LO [Meeting Abstract]

Kolli, S; Maranga, G; Ren-Fielding, C; Lofton, H F
In their relative infancy, intragastric balloons (IGB) offer a solution to patients who do not qualify for bariatric surgery due to their body mass index (BMI) or those reticent about major surgery with a promise of 10-15% of total body weight loss (TBWL%). Given a short implantation period of 6 months, weight regain following IGB removal has been commonly noted. This caveat prompted analysis of the addition of weight loss medications for improved efficacy in achieving sustained weight loss results post-IGB removal. In a single-center retrospective analysis from 2015 to 2018, 18 patients (mean age 39.72, 5 males, 13 females) with a saline-filled single intragastric balloon were evaluated for 12 months following IGB insertion. Exactly half of the patients (n=9) were on weight loss medications before, during, or after placement of IGB (IGB-M cohort) to compare to patients with IGBs only (IGB-O cohort). All patients were >18 years old, non-pregnant, and with no previous bariatric surgeries. Data was collected at 0, 3, 6, and 12 month intervals. Mean weight at baseline was 198.33lbs and 223lbs (p=0.814) and mean BMI was 32.79 kg/m2 versus 35.5 kg/m2 (p=0.546), in the IGB-O cohort versus the IGB-M cohort, respectively. At six months, the TBWL% in the IGB-O cohort versus the IGB-M cohort was 12.7% versus 13.1%, while mean BMI was 28.42 versus 31.62 (p=0.645), respectively. Attrition rate was 11.1% by 6 months and 72.2% by 12 months for both cohorts combined. At 12 months, TBWL% in the IGB-O cohort versus IGB-M cohort was 2.8% and 10.7%, while mean BMI was 33.77 and 29.17 (p=0.4), respectively. The most common class of medications utilized were glucagon-like peptide-1 (GLP-1) agonists (37.5%). Phentermine was the single most commonly prescribed medication (25%). The mean number of medications needed for a patient was 1.8. The TBWL% at six months demonstrated a slightly greater 0.4 TBWL% in the IGB-M cohort. This meant weight loss achieved with a balloon or weight loss pharmacotherapy was essentially equivalent in our study at the time of IGB removal at 6 months. However, a stark variance is noted at the 12 month mark in the IGB-O cohort with patients either partially regaining their previously lost weight or losing marginally further with a mean 2.8 TBWL% post IGB removal. Comparatively, the IGB-M cohort patients continued their weight loss or maintained their initial weight loss with a 10.7% TBWL creating a 7.9 TBWL% difference at the 12 month follow up between the two arms. Administration of medications might increase follow-up post IGB removal and decrease attrition rates. Results illustrate a two-pronged approach of combining weight loss medications with IGBs would culminate in a more clinically significant TBWL% with long term sustainability post IGB removal. Larger multi-center studies are recommended in order to achieve significant conclusions. [Formula presented] [Formula presented]
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EMBASE:2006056286
ISSN: 1097-6779
CID: 4472112

Surgical and medical weight loss threshold dictates decreases in knee osteoarthritis pain but not reductions in inflammatory biomarkers [Meeting Abstract]

Bomfim, F; Chen, S; Zak, S; Jazrawi, T; Kundler, M; Qie, V; Peralta, L; Aleman, J; Ren-Fielding, C; Lofton, H; Patel, J; Attur, M; Abramson, S B; Samuels, J
Background/Purpose : Weight loss in obese patients can reduce knee osteoarthritis (OA) pain, even when physical therapy and intra-articular injections have failed. The impacts of either non-surgical or surgical weight loss on knee OA pain have been reported separately, but few studies have assessed them conjointly. While the decrease in mechanical load helps, the contribution of metabolic changes is less clear. We aimed to compare biomarker changes with weight loss as predictors of knee pain improvement, and consider a threshold of total weight loss necessary for these changes. Methods : Patients from the NYU Langone Weight Management program were screened for knee pain prior to bariatric surgery or the start of a medical weight loss (MWL) regimen. We excluded patients with autoimmune disease, recent malignancy, recent intra-articular knee injections, and lack of OA by Kellgren-Lawrence (KL) x-ray grading. The BMI, Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, and blood samples were obtained at baseline and 1, 3, 6 and 12 months for evaluation of pain and biomarker levels. Results : Of 140 patients screened, 81 were eligible and enrolled (82.7% female; BMI 45.2+/-9.6 kg/m2, 31-74; age 52+/-12 years, 30-80). A total of 49 patients had surgery (10 bypass, 30 sleeve, 9 LapBand) and 24 medical weight loss. 33 patients completed visits up to 6 months (2 bypass, 18 sleeve, 6 LapBand, 7 MWL). By 1 month, the surgical patients had lost much more total weight than the MWL group (9.8% vs 4.1 %, p=0.001), and realized marked pain relief (p< 0.001). By 6 months both groups had continued to lose weight, proportionately greater for surgical patients with further pain improvement. (Figure 1) Leptin levels dropped at 1 and then 6 months with both methods of weight loss. The pro-inflammatory protein IL-1Ra decreased significantly by 6 months in the bariatric patients, but increased with the medical regimen across both time points. Soluble vascular adhesion protein 1 (sVAP-1), another pro-inflammatory protein that facilitates leukocyte infiltration, decreased at both the 1 and 6 month intervals -but much more in MWL than in surgical patients. Consistent with the literature, the anti-inflammatory soluble receptor for advanced glycation endproducts (sRAGE) mirrored KOOS pain improvement only in surgical patients and stabilized after 1 month, but did not change in the MWL group. (Table 1) In a subgroup analysis, the 14 surgical patients who lost at least 10% of Figure 1. Surgical and medical outcomes for % total weight loss (TWL), knee pain and biomarkers Table 1. total weight by 1 month had significantly less pain at 6 months than the 12 who did not meet the threshold (DELTAKOOS 47.5 vs 29.9) but the biomarker levels were similar. (Figure 2) Conclusion : Surgical and medically supervised weight loss both lead to significant decreases in adiposity, but only those having bariatric surgery realize significant pain relief. The anatomical changes of surgical (vs. medical) weight loss result in different metabolic cascades given divergent biomarker trends. Bariatric patients who lose more than 10 percent of total body weight within the first month are more likely to have better pain relief by 6 months, but the biomarker changes reflect anatomic intervention -and are not dependent on the degree of surgical weight loss
EMBASE:633059646
ISSN: 2326-5205
CID: 4633472

Team Approach: Perioperative Optimization for Total Joint Arthroplasty

Feng, James E; Novikov, David; Anoushiravani, Afshin A; Wasterlain, Amy S; Lofton, Holly F; Oswald, William; Nazemzadeh, Milad; Weiser, Sherri; Berger, Jeffery S; Iorio, Richard
PMID: 30300250
ISSN: 2329-9185
CID: 3334902

Profound neurologic deficits secondary to thiamine and copper deficiency 20 years after roux-en-y gastric bypass [Meeting Abstract]

Hu, S; Lofton, H F; Gouller, A B
Introduction: Patients post-Roux-En-Y gastric bypass (RYGB) are at risk for developing vitamin and mineral deficiencies. Copper (Cu) deficiency manifests with anemia, neutropenia, weakness, ataxia and decreased proprioception. Thiamine (B1) deficiency presents with Wernicke's Encephalopathy (WE) characterized by confusion, memory loss, ophthalmoplegia and ataxia. We present a rare case of concomitant Cu and B1 deficiency 20 years post-RYGB. Clinical case: A 71-year woman presented for evaluation of hypoglycemia. She underwent RYGB 20 years ago and recently developed fatigue, lower extremity weakness, an unsteady gait, slurred speech, and episodes of confusion and memory loss. Cardiac and neurologic work up was negative. Fingerstick glucose (FS) of 50 mg/dL (70-100) was noted and her symptoms were attributed to hypoglycemia. CGM showed glucose of 47 mg/dL when slurry speech was noticed. Three days later patient had syncope and could not recall what happened. She was confused with slurred speech. FS was 68 mg/dL. Tilt table test was consistent with vasovagal syncope. A 72-hour fast demonstrated adequate suppression of insulin and c-peptide and high levels of beta-hydroxybutyrate, excluding insulinoma. Serum vitamins and minerals showed deficiencies of Cu 76 mcg/dL (80-175), ceruloplasmin 15 mg/dL (18-53), vitamin B6 15.9 nmol/L (20-125), carotene 31 ug/dL (60-22), vitamin K 0.21 nmol/L (0.22-4.8) and vitamin C 5 mumol/L (23-114). Serum B1 was borderline low at 80 nmol/L (70-180). Serum vitamins A, D, E, B2, B3, B12 and minerals including selenium, zinc (Zn) and iron were normal. WE was suspected and she was treated with thiamine 500 mg IV followed by thiamine 500 mg PO daily for three days, then 100 mg PO daily with resolution of slurry speech and ataxia within 2 weeks. The patient had been on zinc 50 mg daily which was discontinued and copper 2 mg BID was initiated. Her memory, ataxia and weakness improved. Hypoglycemia was managed with dietary modifications and resolved. Conclusion: Cu and B1 deficiencies are important to recognize post-RYGB as they can lead to severe irreversible neurologic deficits if not rapidly diagnosed and treated. Our patient presented with the features of WE aside from ophthalmoplegia with resolution after thiamine supplementation. Serum B1 provides blood levels rather than intracerebral levels; thus, a clinical response to thiamine supplementation is more reliable for diagnosis. Patient had insufficient Cu supplementation and was taking zinc which decreases absorption of Cu. Discontinuation of zinc and initiation of copper supplementation lead to the improvement of weakness and ataxia. Routine screening for Cu and B1 deficiency is not indicated post-RYGB, however it should be considered in patients with neurological symptoms. Our case highlights the importance of screening for hypocupremia, and early recognition and treatment for WE in patients post-RYGB
EMBASE:617152309
ISSN: 0163-769x
CID: 2632032

The effects of commuting on obesity [Meeting Abstract]

Creange, C; Hold, R; Hyde, D; Fazzolari, S; Kaufman, L; Lofton, H
Aims: Physical inactivity is proven to be correlated with obesity. Our study aim was to evaluate the relationship between commuting mode/duration and % body weight lost (%BWL) before and after weight loss intervention. Our hypothesis was that longer and inactive commuting would correlate with both a higher baseline body mass index (BMI) and lower %BWL. Methods: We collected patient commuting data from October 2015 to March 2016. Data included BMI and %BWL at one, two and three months after intervention, as well as commuting length, type of commute, and number of days at work. Weight loss intervention included dietary and exercise management, as well as pharmacotherapy. Patients were stratified into commuting and non-commuting groups. The primary outcome was %BWL after intervention, correlated to commute, commuting length, and type of commute. Results: There were 318 patients in the commuting group and 51 non-commuters. Initial BMI for the two groups was similar (37.1 vs 36.3, p=.514). Commuters were significantly younger (44 vs 62.2 years, po.0001) and had lower use of hypertensive medications (21% vs 45%, po.0001). There was no difference seen in %BWL between the two groups after one month of therapy (3.1% vs 3.0%, p=.783), two months (5.1% vs 4.9%, p=.831), or three months (6.9% vs 7.2%, p=.806). Duration of commute was also not correlated with %BWL (p=.383 at three months). Male gender, walk/biking commute mode, and hypertension medications were independently predictive of greater %BWL. Males had an average of 0.9% greater %BWL (p=0.030), subjects that used a bike or walked as their commute mode had an average of 1.7% greater %BWL (p=0.0091), and those with hypertension medications had an average of 1.0% greater %BWL (p=0.015). Conclusion: Commuting time and duration do not appear to have an effect on patient obesity. However, those with an active mode of commute were able to show greater weight loss after intervention
EMBASE:619778135
ISSN: 1878-7533
CID: 2886382

Use of liraglutide for weight loss in patients with prior bariatric surgery [Meeting Abstract]

Creange, C; Lin, E; Ren-Fielding, C; Lofton, H
Aims: Liraglutide, a GLP-1 agonist, was recently approved by the Food and Drug Administration (FDA) for use in the treatment of obesity. A large subset of patients have weight regain after bariatric surgery, but would prefer medical obesity management over revisional surgery. Our study evaluated the efficacy of liraglutide in patients with prior bariatric surgery who experienced either suboptimal weight loss or weight regain after their procedures. Methods: A review was performed of all patients at our weight loss center who had been prescribed liraglutide for weight loss and had prior bariatric surgery. Patients with o4 months of liraglutide use were excluded from analysis, as this was felt to be an insufficient time period in which to evaluate efficacy. Results: There were twenty-five patients who met all inclusion and exclusion criteria. Thirteen patients had laparoscopic adjustable gastric bands (LAGB), eight had roux-en-Y gastric bypasses (RYGB), three had longitudinal sleeve gastrectomies (LSG), and one had LAGB over RYGB. Dosages varied from 1.2 mg to 3.0 mg daily of liraglutide, depending on insurance approval and patient tolerance. Average weight prior to therapy was 237.69 lbs and average body-mass index (BMI) was 39.22. Patients showed a significant weight loss at 16 weeks (230.36 lbs, p=.002), 20 weeks (228.02 lbs, po.0001), and 24 weeks (215.2 lbs, po.0001). BMI was significantly reduced at 24 weeks as well (35.29, po.0001). Conclusions: Medical weight management with Liraglutide may be an effective alternative treatment in patients with prior bariatric surgery
EMBASE:619778130
ISSN: 1878-7533
CID: 2886392

The efficacy and safety of liraglutide 3.0 mg for weight management are similar across races: Subgroup analysis across SCALE and phase 2 randomized trials

Ard, J; Cannon, A; Lewis, C E; Lofton, H; Vang Skjoth, T; Stevenin, B; Pi-Sunyer, X
The efficacy and safety of liraglutide 3.0 mg vs. placebo, as adjunct to diet and exercise, was evaluated in racial subgroups. This post hoc analysis of pooled data from five double-blind randomized, placebo-controlled trials was conducted in 5325 adults with BMI >/=27 kg/m2 plus >/=1 comorbidity, or BMI >/=30 kg/m2 . Statistical interaction tests evaluated possible treatment effect differences between racial subgroups: White (4496, 84.4%), Black/African-American (550, 10.3%), Asian (168, 3.2%) and Other (111, 2.1%). Effects of liraglutide 3.0 mg on weight loss, associated metabolic effects and safety profile were generally consistent across racial subgroups. All achieved statistically significant mean weight loss at end-of-treatment with liraglutide 3.0 mg vs. placebo: White 7.7% vs. 2.3%, Black/African-American 6.3% vs. 1.4%, Asian 6.3% vs. 2.5%, Other 7.3% vs. 0.49%. Treatment effects on weight and cardiovascular risk markers generally showed no dependence on race (interaction-test p-values >0.05). Adverse events were comparable across racial subgroups.
PMCID:6084344
PMID: 26744025
ISSN: 1463-1326
CID: 1901202

Ghrelin Resting Energy Expenditure Number (GREEN) Study [Meeting Abstract]

Weinshel, Elizabeth; Chua, Deborah; Fielding, George; Lofton, Holly F; Ren-Fielding, Christine; Schwack, Bradley
ISI:000363715905063
ISSN: 1572-0241
CID: 1854422

Clinical efficacy of a medically supervised low-calorie diet program versus a conventional carbohydrate-restricted diet

Sethi, Monica; Youn, Heekoung; Ren-Fielding, Christine; Lofton, Holly
ORIGINAL:0010580
ISSN: 2165-7904
CID: 2462882