Bariatric surgery, novel glucose-lowering agents, and insulin for type 2 diabetes and obesity: Bayesian network meta-analysis of randomized controlled trials

Tingting Wu; Carlos K H Wong; David T W Lui; Simon K H Wong; Cindy L K Lam; Matthew S H Chung; David A McAllister; Richard Welbourn; John B Dixon

doi:10.1093/bjsopen/zrad077

Bariatric surgery, novel glucose-lowering agents, and insulin for type 2 diabetes and obesity: Bayesian network meta-analysis of randomized controlled trials

BJS Open. 2023 Jul 10;7(4):zrad077. doi: 10.1093/bjsopen/zrad077.

Authors

Tingting Wu¹, Carlos K H Wong^{1

2

3}, David T W Lui⁴, Simon K H Wong^{5

6}, Cindy L K Lam¹, Matthew S H Chung², David A McAllister⁷, Richard Welbourn⁸, John B Dixon⁹

Affiliations

¹ Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
² Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
³ Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, New Territories, Hong Kong SAR, China.
⁴ Division of Endocrinology and Metabolism, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
⁵ Division of Surgery, Chinese University of Hong Kong Medical Centre, Hong Kong SAR, China.
⁶ Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
⁷ Public Health, School of Health and Wellbeing, University of Glasgow, Glasgow, UK.
⁸ Department of Upper GI and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK.
⁹ Iverson Health Innovation Research Institute, Swinburne University of Technology, Melbourne, VIC, Australia.

Abstract

Background: This network meta-analysis aimed to compare the effects of bariatric surgery, novel glucose-lowering agents (SGLT2i, GLP1RA, DPP4i), and insulin for patients with type 2 diabetes mellitus (T2DM) and obesity.

Methods: Four databases were searched from inception to April 2023 to identify randomized controlled trials (RCTs) comparing bariatric surgery, SGLT2i, GLP1RA, DPP4i, insulin, and/or placebo/usual care among patients with T2DM and obesity in the achievement of HbA1c < 7.0 per cent within one year, and 12-month changes in HbA1c and body weight.

Results: A total of 376 eligible RCTs (149 824 patients) were analysed. Bariatric surgery had significantly higher rates of achieving HbA1c < 7.0 per cent than SGLT2i (RR = 2.46, 95 per cent c.i. = 1.28, 4.92), DPP4i (RR = 2.59, 95 per cent c.i. = 1.36, 5.13), insulin (RR = 2.27, 95 per cent c.i. = 1.18, 4.58) and placebo/usual care (RR = 4.02, 95 per cent c.i. = 2.13, 7.93), but had no statistically significant difference from GLP1RA (RR = 1.73, 95 per cent c.i. = 0.91, 3.44), regardless of oral (RR = 1.33, 95 per cent c.i. = 0.66, 2.79) or injectable (RR = 1.75, 95 per cent c.i. = 0.92, 3.45) administration. Significantly more GLP1RA patients achieved HbA1c < 7.0 per cent than other non-surgical treatments. Bariatric surgery had the greatest reductions in HbA1c (∼1 per cent more) and body weight (∼15 kg more) at 12 months. Among novel glucose-lowering medications, GLP1RA was associated with greater reductions in HbA1c than SGLT2i (-0.39 per cent, 95 per cent c.i. = -0.55, -0.22) and DPP4i (-0.51 per cent, 95 per cent c.i. = -0.64, -0.39) at 12 months, while GLP1RA (-1.74 kg, 95 per cent c.i. = -2.48, -1.01) and SGLT2i (-2.23 kg, 95 per cent c.i. = -3.07, -1.39) showed greater reductions in body weight than DPP4i at 12 months.

Conclusion: Bariatric surgery showed superiority in glycaemic control and weight management compared to non-surgical approaches. GLP1RA administered by oral or injectable form demonstrated reduced HbA1c and body weight at 12 months, and was preferable over other non-surgical treatments among patients with T2DM and obesity.

Prospero registration no: CRD42020201507.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Bariatric Surgery*
Body Weight
Diabetes Mellitus, Type 2* / drug therapy
Diabetes Mellitus, Type 2* / surgery
Dipeptidyl-Peptidase IV Inhibitors* / therapeutic use
Glucose / therapeutic use
Glycated Hemoglobin
Humans
Hypoglycemic Agents / therapeutic use
Insulin / therapeutic use
Network Meta-Analysis
Obesity / drug therapy
Obesity / surgery
Randomized Controlled Trials as Topic

Substances

Insulin
Hypoglycemic Agents
Glucose
Glycated Hemoglobin
Dipeptidyl-Peptidase IV Inhibitors