Internal Medicine Department D and Obesity Clinic, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Israel.
School of Medicine, Tel Aviv University, Tel Aviv, Israel.
JAMA Netw Open. 2024 Jun 3;7(6):e2415392. doi: 10.1001/jamanetworkopen.2024.15392.
Evidence regarding the relative effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in reducing mortality and major adverse cardiovascular events (MACEs) is limited.
To compare all-cause mortality and nonfatal MACEs associated with BMS vs GLP-1RAs for adults with obesity and diabetes and without known cardiovascular disease.
DESIGN, SETTING, AND PARTICIPANTS: This observational, retrospective cohort study was based on data obtained from the electronic medical records of Clalit Health Services (Clalit), the largest health care organization in Israel. The study included 6070 members aged 24 years or older, who had diabetes and obesity and no prior history of ischemic heart disease, ischemic stroke, or congestive heart failure. Patients who underwent BMS and patients who received GLP-1RAs from January 1, 2008, through December 31, 2021, were matched 1:1 by age, sex, and clinical characteristics. Follow-up ended December 31, 2022.
Initiation of BMS or GLP-1RAs.
The primary outcome was all-cause mortality, assessed by multivariate Cox proportional hazards regression models. The secondary outcome was nonfatal MACEs, assessed by multivariate competing risk models.
The study included 3035 matched pairs of patients (total, 6070; mean [SD] age, 51.0 [9.5] years; 3938 women [64.9%]), who were followed up for a median of 6.8 years (IQR, 4.1-9.4 years). Among those with a diabetes duration of 10 years or less (2371 pairs), mortality was lower for those who underwent BMS than for those treated with GLP-1RAs (hazard ratio [HR], 0.38; 95% CI, 0.25-0.58). This association became nonsignificant when weight loss during the follow-up period was also included in the model (HR, 0.79; 95% CI, 0.43-1.48). Among patients with a duration of diabetes longer than 10 years (664 pairs), no survival advantage was demonstrated for BMS over GLP-1RA (HR, 0.65; 95% CI, 0.39-1.08). The risk for nonfatal MACEs did not differ between the treatment groups (HR, 0.74; 95% CI, 0.49-1.10 among patients with a diabetes duration of ≤10 years; HR, 1.21; 95% CI, 0.80-1.85 among patients with a diabetes duration of >10 years).
In this cohort study, BMS was associated with greater reduced mortality compared with first-generation GLP-1RAs among individuals with a diabetes duration of 10 years or less, mediated via greater weight loss. No differences in the risk for mortality were observed between the treatment modalities among individuals with a longer duration of diabetes, nor in the occurrence of nonfatal MACEs among all patients.
关于减重代谢手术（BMS）和胰高血糖素样肽-1 受体激动剂（GLP-1RAs）在降低死亡率和主要不良心血管事件（MACEs）方面的相对有效性的证据有限。
比较 BMS 与 GLP-1RAs 用于治疗肥胖和糖尿病且无已知心血管疾病的成年人的全因死亡率和非致死性 MACEs。
设计、设置和参与者：这是一项基于从以色列最大的医疗保健组织 Clalit 健康服务（Clalit）的电子病历中获取的数据的观察性、回顾性队列研究。研究纳入了 6070 名年龄在 24 岁或以上、患有糖尿病和肥胖且无既往缺血性心脏病、缺血性卒中和充血性心力衰竭病史的患者。从 2008 年 1 月 1 日至 2021 年 12 月 31 日，对接受 BMS 和 GLP-1RAs 的患者进行了 1:1 匹配，匹配因素包括年龄、性别和临床特征。随访于 2022 年 12 月 31 日结束。
接受 BMS 或 GLP-1RAs 治疗。
主要结局是全因死亡率，通过多变量 Cox 比例风险回归模型评估。次要结局是非致死性 MACEs，通过多变量竞争风险模型评估。
研究纳入了 3035 对匹配的患者（总计 6070 例；平均[标准差]年龄为 51.0[9.5]岁；3938 名女性[64.9%]），中位随访时间为 6.8 年（IQR，4.1-9.4 年）。在糖尿病病程 10 年或以下的患者中（2371 对），与接受 GLP-1RAs 治疗的患者相比，接受 BMS 治疗的患者死亡率较低（风险比[HR]，0.38；95%CI，0.25-0.58）。当在模型中纳入随访期间的体重减轻时，这种关联变得不显著（HR，0.79；95%CI，0.43-1.48）。在糖尿病病程超过 10 年的患者中（664 对），BMS 与 GLP-1RA 相比并未显示出生存优势（HR，0.65；95%CI，0.39-1.08）。两组之间非致死性 MACEs 的风险无差异（在糖尿病病程≤10 年的患者中 HR，0.74；95%CI，0.49-1.10；在糖尿病病程>10 年的患者中 HR，1.21；95%CI，0.80-1.85）。
在这项队列研究中，与第一代 GLP-1RAs 相比，BMS 与糖尿病病程 10 年或以下的个体的死亡率降低有关，这与体重减轻有关。在糖尿病病程较长的个体中，两种治疗方法之间未观察到死亡率的差异，也未观察到所有患者非致死性 MACEs 的发生率差异。
