Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later

Abstract

Importance: Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery.

Objective: To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group.

Design, setting, and participants: This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015.

Exposures: Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG).

Main outcome and measure: Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years.

Results: In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P < .001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P < .001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year.

Conclusions and relevance: Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Figure 1.. Cumulative Incidence of Antidiabetes Treatment Over 6 Years of Follow-up (2009-2015) in a Cohort of Patients Who Underwent Bariatric Surgery in 2009 and Matched Obese Controls, SNIIRAM Data

A, Among 3266 patients. P < .001 for all. B, Among 28 034 patients. P < .001 for all except for GBP vs SG (not significant). AGB indicates adjustable gastric banding; GBP, gastric bypass; SG, sleeve gastrectomy; and SNIIRAM, Système National d’Information Inter-régimes de l’Assurance Maladie.

Figure 2.. Course of Care (Sequence Charts) of Patients With Antidiabetes Treatment (Continuation, Discontinuation, or Initiation) Between the Year Before Inclusion (2008) and During Follow-up (2015) in a Cohort of Patients Who Underwent Bariatric Surgery in 2009, SNIIRAM Data

A, Among 1895 bariatric surgery patients. B, Among 3533 matched controls. The vertical red line indicates the time of inclusion (bariatric surgery for cases or hospitalization for obesity for controls). SNIIRAM indicates Système National d’Information Inter-régimes de l’Assurance Maladie.