Comprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) Algorithm: An Evidenced Based Proposal

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However, the timing of OMM utilization remains uncertain. With the increasing usage of OMMs, there is interest in combining OMMs with MBS in the adjuvant and neoadjuvant setting. However, there is no algorithm to assist physicians in this. The purpose of this article is to review and grade the current literature to formulate an algorithm to guide usage of neoadjuvant and adjuvant OMMs along with bariatric surgery. Figures Figure 1 Figure 2 Introduction Obesity is a significant public health challenge, and metabolic/bariatric surgery (MBS) has emerged as one of the most effective interventions for both severe obesity and its associated conditions with studies showing 30%-50% reduction in premature death [ 1 – 2 ]. In the United States (US), the number of MBS procedures has increased significantly, to 280,000 in 2022 from 216,000 in 2016 [ 3 ]. Recently, obesity management medications (OMMs) have been thrust to the forefront. There has been significant interest in the weight loss efficacy of glucagon-like peptide (GLP-1) analogs including liraglutide, semaglutide, and, most recently, the dual gastric inhibitory polypeptide (GIP)/GLP-1 receptor agonist tirzepatide [ 4 ] While MBS effectively aids weight loss, many individuals can benefit from the use of OMMs. However, the timing of OMM utilization remains uncertain. We have previously published on the importance of viewing OMM as neoadjuvant and adjuvant therapies in the spectrum of obesity treatment [ 5 ]. In some cases, patients will need OMM treatment prior to surgery or following surgery as patients may not achieve their targeted weight goals [ 6 ]. Retrospective studies indicate that MBS patients may respond favorably to OMMs after surgery, with various studies exploring medication use from 18 months to 8 years post-operation. However, comprehensive investigations into preoperative medication use and the immediate postoperative period—particularly within the first year—are scarce [ 7 – 14 ]. Higher preoperative BMIs also suggest a worse percentage of total weight loss (%TWL), suggesting neoadjuvant treatment prior to MBS may improve outcomes [ 15 ]. As the landscape of the treatment of obesity evolves, further interrogation on the usage and timing (adjuvant vs neoadjuvant) of OMMs is required. Currently there are 10 FDA-approved OMMs in the US [ 16 ]. The most prescribed OMMs are orlistat, phentermine, phentermine-topiramate, naltrexone-bupropion, liraglutide, and semaglutide according to a meta-analysis by Khera et al. (2016) which reviewed the efficacy of OMMs in non-surgical patients [ 17 ]. The Longitudinal Assessment of Bariatric Surgery (LABS), a prospective observational study, analyzed 1406 patients following Roux-en-Y gastric bypass (RYGB) over 5 years postoperatively and found weight recurrence can occur as early as one year post RYGB [ 18 ]. Furthermore, Baig et al. (2019) reviewed 9617 patients in 26 weight centers throughout India with a mean weight recurrence of up to 22% at 5 years depending on the type of MBS the patient received [ 19 ]. With the increasing usage of OMMs, there is interest in combining OMMs with MBS in the adjuvant and neoadjuvant setting. However, there is no algorithm to assist physicians in this. The purpose of this article is to review and grade the current literature to formulate an algorithm to guide usage of neoadjuvant and adjuvant OMMs. Methods A literature search was conducted in a systematic fashion and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA Fig. 1 ). PubMed and Embase were queried for articles published from 2000 through 2025. The following search terms were used: “preop anti-obesity medications, preoperative anti-obesity agents AND surgery AND bariatric surgery”, “neo-adjuvant anti-obesity medications AND bariatric surgery”, “pre- operative anti-obesity medications AND bariatric surgery”, “roux-en-y gastric bypass AND pre- operative anti-obesity medications”, “sleeve gastrectomy AND pre-operative anti-obesity medications”, “duodenal switch AND pre-operative anti-obesity medications”, “post-operative anti-obesity medications AND post-operative anti-obesity agents”, “adjuvant anti-obesity agents AND adjuvant anti-obesity medications”, “adjuvant anti-obesity agents AND adjuvant anti- obesity medications AND post-operative anti-obesity medications”. Filter was applied encompassing the following: Clinical trial, Meta analysis, Randomized controlled trial, Systematic review) Definitions used were as follows: weight recurrence = > 10%, weight recurrence from lowest post-surgical weight [ 20 ], inadequate weight loss = < 20–30%, weight loss from initial clinic visit at 3 months, or < 50% at 6 months [ 21 – 22 ], weight plateau = patient desired more weight loss, but does not fit either category (weight recurrence or inadequate weight loss) We entered our results into the GradePro system, which is a guideline development tool that helps to summarize the data collected in the literature search and grade the evidence to make guidelines. The questions entered in the GradePro system were, "Is there use for OMMs in the perioperative setting for MBS?" The grading table developed was then used to develop an algorithm to assist in guidance in use of OMMs in the neoadjuvant and adjuvant setting of MBS. The evidence collected from randomized controlled trials (RCTs), observational studies, systematic reviews, and meta-analyses was assessed for quality using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. It was done using the GradePro GDT (Guidelines Development Tool, Evidence Prime Inc.) tool, a guideline development tool used to develop evidence-based healthcare guidelines. The question entered in the system was “Is there use of anti-obesity medications in the perioperative setting for bariatric surgery?” The analysis was characterized by the Study design which included randomized trials and non-randomized trials. ROBINS-i tool (Risk of Bias in Non-randomized Studies of Interventions) to assess the risk of bias in non- randomized trials. Number of studies involved in a study. It varied from one study in randomized trials to many systematic reviews and meta-analyses. Inconsistency, which is assessed using variability in results across studies to determine if findings were consistent and reproducible. Indirectness of the study as to whether the research question was directly answered, which was in turn evaluated taking into consideration the study population, intervention, comparator, and outcome differences. Imprecision by calculating the confidence intervals and sample sizes to know the precision of effects. Other considerations include publication bias, dose-response gradients, magnitude of effect whether small, large or very large. The questions utilized for evaluation were "anti-obesity medications as neoadjuvant therapy," "anti-obesity medications as adjuvant therapy," and "timeline of anti-obesity medications for obesity,” and “anti-obesity medications for insufficient weight loss”. All the above data was used to grade the evidence was graded as very low, low, moderate, or high. We created a summary of findings table and evidence profiles for all the outcomes. Results Using the PRISMA guidelines for literature review (Fig. 1 ), the initial search identified 323 records. After removal of duplicate records, irrelevant studies, letters to the editor, reviews, pediatric publications, and MBS vs OMMs, and only screening for clinical trials, meta-analyses, randomized controlled trials, and systematic reviews, 29 studies remained. Entering the remaining studies into GradePro we were able to grade the current literature on the use of neoadjuvant and adjuvant OMMs. Neoadjuvant (Table 1) Adjuvant (Table 2) Timing (Table 3) Discussion The objective of this paper is to assess the current body of literature regarding the application of neoadjuvant and adjuvant OMMs. By conducting this review, we aim to create an algorithm that can assist healthcare professionals in deciding the optimal timing and method for integrating these medications into clinical practice. At present, there is no existing algorithm or guideline to determine the initiation of OMMs during the perioperative period. Numerous meta-analyses have already established the efficacy of MBS [ 23 – 26 ]. Nonetheless, the introduction of OMMs suggests potential for enhancing weight loss or mitigating weight recurrence during the perioperative phase. Many surgical disciplines already employ an integrated approach by combining systemic therapy with surgical interventions, such as the use of chemotherapy in surgical oncology, aspirin and statin drugs in vascular surgery, or specific endocrine medications in endocrine surgeries. Given the variety of OMMs available to aid in weight reduction and the management of conditions associated with obesity, surgeons should consider these adjunctive options to improve patient outcomes (Fig. 2 ) Neoadjuvant Setting a. Patients on OMM’s who do not reach their weight loss goals The data regarding the application of OMMs in the neoadjuvant context is limited but shows potential in patients with a BMI over 60 or those with type 2 diabetes (T2D) approximately three months prior to MBS [ 20 , 3 , 27 ]. The studies predominantly address long-available drugs, such as phentermine and topiramate [ 20 ]. Although research examining preoperative A1c levels and the management of T2D often lacks specifics on OMMs, it indicates poorer outcomes and reduced weight loss post-surgery without controlled A1c levels [ 27 ]. This underlines the potential utility of OMMs, especially GLP-1 agonists, in specific preoperative situations. Despite the effectiveness of GLP-1 agonists in managing weight loss and T2D [ 28 ], comprehensive data on the neoadjuvant use of OMMs, including these drugs, remains scarce. Patients should be carefully evaluated to determine when a referral for MBS is appropriate. Current research assesses the efficacy and weight loss timeline associated with OMMs, particularly GLP-1s. Evidence indicates that these medications typically achieve their maximum or "nadir" weight loss within 6 to 12 months of initiation [ 29 – 31 ]. Recommendation: Based on this data, it is recommended that patients who have utilized OMM and reached their nadir weight but desire or require additional weight loss—particularly to address comorbid conditions—be referred for further evaluation by an MBS surgeon. This proactive approach ensures that patients receive comprehensive treatment tailored to their weight management needs. b. Patients on Neoadjuvant OMM’s as a Bridge to Surgery As illustrated in Table 1, there is substantial evidence supporting OMMs use in the neoadjuvant setting, with patients weighing approximately 2.4% less than predicted according to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) curve [ 32 ]. High-quality evidence indicates that stringent diabetes management preoperatively results in fewer complications and greater postoperative weight loss if the patient’s A1c levels are appropriately managed [ 33 , 27 ]. Additionally, lower-quality evidence supports the neoadjuvant use of OMM such as orlistat, phentermine, and topiramate [ 34 – 36 ]. Recommendation: Low-quality evidence supports the neoadjuvant use of OMMs such as orlistat, phentermine, and topiramate [ 34 – 36 ], prior to MBS. Adjuvant Setting Weight recurrence affects up to 20% of MBS patients [ 37 ]. The evidence supporting the use of OMMs postoperatively is more extensive compared to preoperative applications, especially concerning recurrence of weight and associated conditions [ 13 , 38 , 9 ]. Weight recurrence may arise from multiple factors, including pouch dilation, gastrogastric fistula formation, and socio- economic and psychosocial issues [ 39 , 40 ]. This has sparked interest in OMMs for patients who cannot, should not, or opt not to undergo additional MBS. Some studies note that some patients with minimal weight loss post-surgery have unfavorable circulating gut hormone profiles, including GLP-1 [ 40 – 43 ]. Liraglutide, a well-studied GLP-1 agonist administered at 3.0 mg for 24 weeks, significantly reduces body weight and metabolic conditions compared to placebo in patients experiencing weight recurrence [ 38 ]. This evidence suggests that OMMs could effectively augment weight loss in the perioperative period and lead to a more targeted treatment for MBS. Table 2 demonstrates strong evidence for the effectiveness of liraglutide in the adjuvant setting for controlling weight recurrence and managing diabetes [ 12 , 9 , 38 ]. This suggests potential benefits from neoadjuvant OMM use, paralleling other surgical fields that integrate systemic medical therapies and operations. Moreover, low-quality evidence supports adjuvant OMM use, including medications like topiramate and phentermine [ 10 , 11 ]. Recommendation: Determining the optimal initiation time for OMM in either neoadjuvant or adjuvant settings to maximize patient weight loss is critical. High and moderate-quality data [ 21 , 42 , 19 , 32 , 27 ] recommend starting OMM approximately three months before MBS in the neoadjuvant framework and postoperatively if weight loss remains inadequate at about three months post-surgery in the adjuvant context. Limitations While the methods in this study adhered to systematic review protocols and utilized recognized reporting standards, several limitations are present. First, the scope of the data present on this topic is minimal, especially in the neoadjuvant period. Most OMM used were phentermine and topiramate, which are currently used but not nearly as commonly as GLP-1 medications. Nevertheless, data is lacking on the use of GLP-1 type medications in the perioperative period with MBS. Second, although the review attempts to generalize findings across MBS patients, there is an inherent limitation due to varying demographic and clinical profiles—such as differing baseline BMIs or metabolic condition profiles, which can affect the generalizability of the results. Third, we highlighted a notable paucity of robust data in the neoadjuvant setting, particularly regarding newer classes of GLP-1 type medications. This lack of comprehensive data limits the ability to draw definitive conclusions about neoadjuvant OMMs. However, with the data available we provide the most accurate guidelines possible. Fourth, there is variability in definitions present in the current data and in this manuscript. For example, regarding “weight recurrence” or “inadequate weight loss” there are multiple definitions in the literature, and we had to choose our own definitions. Fifth, while GradePro provides a systematic approach to rate evidence, the subjective nature of certain evaluations and the reliance on existing data quality could influence the interpretations and recommendations derived from this analysis. Sixth, there was a multitude of follow-up time periods from the studies analyzed. This could impact assessments of OMM efficacy, particularly in longer-term weight management and resolution of metabolic conditions. Addressing these limitations could strengthen future research efforts by broadening inclusion criteria, extending database searches, and incorporating a wider array of evidence types to form a more holistic view of OMM in the neoadjuvant or adjuvant setting surrounding MBS. We narrowed our inclusion criteria to attempt to provide the strongest evidence-based algorithm. Conclusions Obesity continues to pose a substantial challenge to public health, necessitating effective interventions such as MBS, which has proven highly beneficial for weight loss and improvement of associated conditions. However, the complexity of patient outcomes post-surgery, including the prevalence of weight recurrence, calls for a more nuanced approach to treatment, specifically through the integration of OMM both pre- and postoperatively. Therefore, utilizing an evidence- based approach, we present our Comprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) algorithm to guide the MBS patient across the obesity treatment spectrum. This review has underscored the potential advantages of employing OMM in both neoadjuvant and adjuvant settings, particularly for patients who struggle with significant obesity or have conditions such as T2D. While data on neoadjuvant OMM use remains limited, preliminary findings suggest that medications, especially GLP-1 agonists, could enhance preoperative weight loss and improve metabolic control. In the adjuvant setting, existing literature supports the effectiveness of OMM in mitigating weight recurrence and managing weight-related conditions post-surgery. Given the high rates of weight recurrence among MBS patients, it is imperative that we adopt a more proactive stance on the integration of OMM into treatment plans. The development of a structured algorithm for the timely application of these medications during crucial perioperative periods could empower healthcare providers to optimize patient outcomes. As demonstrated in comparative studies across various surgical fields, embracing multi-faceted therapeutic approaches can yield superior results. Moving forward, comprehensive research is needed to explore the full spectrum of OMM in the surgical obesity management paradigm. 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Mok J, Adeleke MO, Brown A, Magee CG, Firman C, Makahamadze C, Jassil FC, Marvasti P, Carnemolla A, Devalia K, Fakih N, Elkalaawy M, Pucci A, Jenkinson A, Adamo M, Omar RZ, Batterham RL, Makaronidis J. Safety and efficacy of Liraglutide, mg, once daily vs placebo in patients with poor weight loss following metabolic surgery: The BARI-OPTIMISE randomized clinical trial. JAMA Surg. 2023 Oct 1;158(10):1003-1011. doi: 10.1001/jamasurg.2023.2930. PMID: 37494014; PMCID: PMC10372755. de Gara CJ, Karmali S. The anatomy of a weight recidivism and revision bariatric surgical clinic. Gastroenterol Res Pract. 2014;2014:721095. doi: 10.1155/2014/721095. Epub 2014 Feb 11. PMID: 24672540; PMCID: PMC3942332. Papamargaritis D, le Roux CW. Do gut hormones contribute to weight loss and glycaemic outcomes after bariatric surgery? Nutrients. 2021 Feb 26;13(3):762. doi: 10.3390/ nu13030762. PMID: 33652862; PMCID: PMC7996890. le Roux CW, Welbourn R, Werling M, Osborne A, Kokkinos A, Laurenius A, Lönroth H, Fändriks L, Ghatei MA, Bloom SR, Olbers T. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg. 2007 Nov;246(5):780-5. doi: 10.1097/SLA.0b013e3180caa3e3. PMID: 17968169. El Ansari W, Elhag W. Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps-a scoping review. Obes Surg. 2021 Apr;31(4):1755-1766. doi: 10.1007/s11695-020-05160-5. Epub 2021 Feb 8. PMID: 33555451; PMCID: PMC8012333. Nedelcu M, Khwaja HA, Rogula TG. Weight regain after bariatric surgery-how should it be defined? Surg Obes Relat Dis. 2016 Jun;12(5):1129-1130. doi: 10.1016/ j.soard.2016.04.028. Epub 2016 Apr 29. PMID: 27350180. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in Obesity Surgery → Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviews received at journal 10 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor assigned by journal 01 Oct, 2025 Submission checks completed at journal 30 Sep, 2025 First submitted to journal 09 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7577921","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":532421890,"identity":"270e388e-94fe-4383-9924-bfa2a09a1372","order_by":0,"name":"Charles Campbell","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"","lastName":"Campbell","suffix":""},{"id":532421891,"identity":"ea402809-a7b7-4643-adf6-21cfd59b2c96","order_by":1,"name":"Pavaani peddi","email":"","orcid":"","institution":"University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Pavaani","middleName":"","lastName":"peddi","suffix":""},{"id":532421892,"identity":"35c2ae82-2914-4159-8ecb-dc9b2fc239de","order_by":2,"name":"ann rogers","email":"","orcid":"","institution":"Penn State Milton S. 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1","display":"","copyAsset":false,"role":"figure","size":54503,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1PRISMA.png","url":"https://assets-eu.researchsquare.com/files/rs-7577921/v1/d1055919765cd084311b8ce4.png"},{"id":94204835,"identity":"7d182463-6bd5-40f4-9db5-0c976b8fb81a","added_by":"auto","created_at":"2025-10-23 14:26:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35004,"visible":true,"origin":"","legend":"\u003cp\u003eComprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) algorithm\u003c/p\u003e","description":"","filename":"Figure2COMMBSAlgorithm.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7577921/v1/090fe74ddb779ddabb8ee48c.jpg"},{"id":99172882,"identity":"7b672aa7-44f5-4401-b318-ba59357c1145","added_by":"auto","created_at":"2025-12-29 16:11:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":557163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7577921/v1/c41ebb58-5cfe-4daa-acc3-9501e938dc7c.pdf"},{"id":94205243,"identity":"70786eb0-f02f-47ff-9d32-14add3c3a33f","added_by":"auto","created_at":"2025-10-23 14:34:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":801886,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7577921/v1/e27c65dadcb11c69063acd9b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) Algorithm: An Evidenced Based Proposal","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObesity is a significant public health challenge, and metabolic/bariatric surgery (MBS) has emerged as one of the most effective interventions for both severe obesity and its associated conditions with studies showing 30%-50% reduction in premature death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the United States (US), the number of MBS procedures has increased significantly, to 280,000 in 2022 from 216,000 in 2016 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recently, obesity management medications (OMMs) have been thrust to the forefront. There has been significant interest in the weight loss efficacy of glucagon-like peptide (GLP-1) analogs including liraglutide, semaglutide, and, most recently, the dual gastric inhibitory polypeptide (GIP)/GLP-1 receptor agonist tirzepatide [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWhile MBS effectively aids weight loss, many individuals can benefit from the use of OMMs. However, the timing of OMM utilization remains uncertain. We have previously published on the importance of viewing OMM as neoadjuvant and adjuvant therapies in the spectrum of obesity treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In some cases, patients will need OMM treatment prior to surgery or following surgery as patients may not achieve their targeted weight goals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRetrospective studies indicate that MBS patients may respond favorably to OMMs after surgery, with various studies exploring medication use from 18 months to 8 years post-operation.\u003c/p\u003e\u003cp\u003eHowever, comprehensive investigations into preoperative medication use and the immediate postoperative period\u0026mdash;particularly within the first year\u0026mdash;are scarce [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Higher preoperative BMIs also suggest a worse percentage of total weight loss (%TWL), suggesting neoadjuvant treatment prior to MBS may improve outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As the landscape of the treatment of obesity evolves, further interrogation on the usage and timing (adjuvant vs neoadjuvant) of OMMs is required.\u003c/p\u003e\u003cp\u003eCurrently there are 10 FDA-approved OMMs in the US [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The most prescribed OMMs are orlistat, phentermine, phentermine-topiramate, naltrexone-bupropion, liraglutide, and semaglutide according to a meta-analysis by Khera et al. (2016) which reviewed the efficacy of OMMs in non-surgical patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Longitudinal Assessment of Bariatric Surgery (LABS), a prospective observational study, analyzed 1406 patients following Roux-en-Y gastric bypass (RYGB) over 5 years postoperatively and found weight recurrence can occur as early as one year post RYGB [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, Baig et al. (2019) reviewed 9617 patients in 26 weight centers throughout India with a mean weight recurrence of up to 22% at 5 years depending on the type of MBS the patient received [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith the increasing usage of OMMs, there is interest in combining OMMs with MBS in the adjuvant and neoadjuvant setting. However, there is no algorithm to assist physicians in this. The purpose of this article is to review and grade the current literature to formulate an algorithm to guide usage of neoadjuvant and adjuvant OMMs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA literature search was conducted in a systematic fashion and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). PubMed and Embase were queried for articles published from 2000 through 2025. The following search terms were used: \u0026ldquo;preop anti-obesity medications, preoperative anti-obesity agents AND surgery AND bariatric surgery\u0026rdquo;, \u0026ldquo;neo-adjuvant anti-obesity medications AND bariatric surgery\u0026rdquo;, \u0026ldquo;pre- operative anti-obesity medications AND bariatric surgery\u0026rdquo;, \u0026ldquo;roux-en-y gastric bypass AND pre- operative anti-obesity medications\u0026rdquo;, \u0026ldquo;sleeve gastrectomy AND pre-operative anti-obesity medications\u0026rdquo;, \u0026ldquo;duodenal switch AND pre-operative anti-obesity medications\u0026rdquo;, \u0026ldquo;post-operative anti-obesity medications AND post-operative anti-obesity agents\u0026rdquo;, \u0026ldquo;adjuvant anti-obesity agents AND adjuvant anti-obesity medications\u0026rdquo;, \u0026ldquo;adjuvant anti-obesity agents AND adjuvant anti- obesity medications AND post-operative anti-obesity medications\u0026rdquo;. Filter was applied encompassing the following: Clinical trial, Meta analysis, Randomized controlled trial, Systematic review)\u003c/p\u003e\u003cp\u003eDefinitions used were as follows: weight recurrence\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;10%, weight recurrence from lowest post-surgical weight [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], inadequate weight loss\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;20\u0026ndash;30%, weight loss from initial clinic visit at 3 months, or \u0026lt;\u0026thinsp;50% at 6 months [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], weight plateau\u0026thinsp;=\u0026thinsp;patient desired more weight loss, but does not fit either category (weight recurrence or inadequate weight loss)\u003c/p\u003e\u003cp\u003e We entered our results into the GradePro system, which is a guideline development tool that helps to summarize the data collected in the literature search and grade the evidence to make guidelines. The questions entered in the GradePro system were, \"Is there use for OMMs in the perioperative setting for MBS?\" The grading table developed was then used to develop an algorithm to assist in guidance in use of OMMs in the neoadjuvant and adjuvant setting of MBS. The evidence collected from randomized controlled trials (RCTs), observational studies, systematic reviews, and meta-analyses was assessed for quality using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. It was done using the GradePro GDT (Guidelines Development Tool, Evidence Prime Inc.) tool, a guideline development tool used to develop evidence-based healthcare guidelines. The question entered in the system was \u0026ldquo;Is there use of anti-obesity medications in the perioperative setting for bariatric surgery?\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe analysis was characterized by the\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStudy design which included randomized trials and non-randomized trials. ROBINS-i tool (Risk of Bias in Non-randomized Studies of Interventions) to assess the risk of bias in non- randomized trials.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNumber of studies involved in a study. It varied from one study in randomized trials to many systematic reviews and meta-analyses.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInconsistency, which is assessed using variability in results across studies to determine if findings were consistent and reproducible.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIndirectness of the study as to whether the research question was directly answered, which was in turn evaluated taking into consideration the study population, intervention, comparator, and outcome differences.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eImprecision by calculating the confidence intervals and sample sizes to know the precision of effects.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOther considerations include publication bias, dose-response gradients, magnitude of effect whether small, large or very large.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe questions utilized for evaluation were \"anti-obesity medications as neoadjuvant therapy,\" \"anti-obesity medications as adjuvant therapy,\" and \"timeline of anti-obesity medications for obesity,\u0026rdquo; and \u0026ldquo;anti-obesity medications for insufficient weight loss\u0026rdquo;. All the above data was used to grade the evidence was graded as very low, low, moderate, or high. We created a summary of findings table and evidence profiles for all the outcomes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e Using the PRISMA guidelines for literature review (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), the initial search identified 323 records. After removal of duplicate records, irrelevant studies, letters to the editor, reviews, pediatric publications, and MBS vs OMMs, and only screening for clinical trials, meta-analyses, randomized controlled trials, and systematic reviews, 29 studies remained.\u003c/p\u003e\u003cp\u003eEntering the remaining studies into GradePro we were able to grade the current literature on the use of neoadjuvant and adjuvant OMMs.\u003c/p\u003e\n\u003ch3\u003eNeoadjuvant (Table 1)\u003c/h3\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eAdjuvant (Table 2)\u003c/h3\u003e\n\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTiming (Table\u0026nbsp;3)\u003c/b\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe objective of this paper is to assess the current body of literature regarding the application of neoadjuvant and adjuvant OMMs. By conducting this review, we aim to create an algorithm that\u003c/p\u003e\u003cp\u003ecan assist healthcare professionals in deciding the optimal timing and method for integrating these medications into clinical practice. At present, there is no existing algorithm or guideline to determine the initiation of OMMs during the perioperative period. Numerous meta-analyses have already established the efficacy of MBS [\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Nonetheless, the introduction of OMMs suggests potential for enhancing weight loss or mitigating weight recurrence during the perioperative phase. Many surgical disciplines already employ an integrated approach by combining systemic therapy with surgical interventions, such as the use of chemotherapy in surgical oncology, aspirin and statin drugs in vascular surgery, or specific endocrine medications in endocrine surgeries. Given the variety of OMMs available to aid in weight reduction and the management of conditions associated with obesity, surgeons should consider these adjunctive options to improve patient outcomes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eNeoadjuvant Setting\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003ea. Patients on OMM’s who do not reach their weight loss goals\u003c/h3\u003e\n\u003cp\u003eThe data regarding the application of OMMs in the neoadjuvant context is limited but shows potential in patients with a BMI over 60 or those with type 2 diabetes (T2D) approximately three months prior to MBS [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The studies predominantly address long-available drugs, such as phentermine and topiramate [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Although research examining preoperative A1c levels and the management of T2D often lacks specifics on OMMs, it indicates poorer outcomes and reduced weight loss post-surgery without controlled A1c levels [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This underlines the potential utility of OMMs, especially GLP-1 agonists, in specific preoperative situations. Despite the effectiveness of GLP-1 agonists in managing weight loss and T2D [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e], comprehensive data on the neoadjuvant use of OMMs, including these drugs, remains scarce.\u003c/p\u003e\u003cp\u003ePatients should be carefully evaluated to determine when a referral for MBS is appropriate. Current research assesses the efficacy and weight loss timeline associated with OMMs, particularly GLP-1s. Evidence indicates that these medications typically achieve their maximum or \"nadir\" weight loss within 6 to 12 months of initiation [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecommendation: \u003cem\u003eBased on this data, it is recommended that patients who have utilized OMM and reached their nadir weight but desire or require additional weight loss\u0026mdash;particularly to address comorbid conditions\u0026mdash;be referred for further evaluation by an MBS surgeon. This proactive approach ensures that patients receive comprehensive treatment tailored to their weight management needs.\u003c/em\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eb. Patients on Neoadjuvant OMM\u0026rsquo;s as a Bridge to Surgery\u003c/h2\u003e\u003cp\u003eAs illustrated in Table\u0026nbsp;1, there is substantial evidence supporting OMMs use in the neoadjuvant setting, with patients weighing approximately 2.4% less than predicted according to the\u003c/p\u003e\u003cp\u003eMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) curve [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. High-quality evidence indicates that stringent diabetes management preoperatively results in fewer complications and greater postoperative weight loss if the patient\u0026rsquo;s A1c levels are appropriately managed [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, lower-quality evidence supports the neoadjuvant use of OMM such as orlistat, phentermine, and topiramate [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecommendation: \u003cem\u003eLow-quality evidence supports the neoadjuvant use of OMMs such as orlistat, phentermine, and topiramate\u003c/em\u003e [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e], \u003cem\u003eprior to MBS.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAdjuvant Setting\u003c/h3\u003e\n\u003cp\u003eWeight recurrence affects up to 20% of MBS patients [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The evidence supporting the use of OMMs postoperatively is more extensive compared to preoperative applications, especially concerning recurrence of weight and associated conditions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Weight recurrence may arise from multiple factors, including pouch dilation, gastrogastric fistula formation, and socio- economic and psychosocial issues [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This has sparked interest in OMMs for patients who cannot, should not, or opt not to undergo additional MBS. Some studies note that some patients with minimal weight loss post-surgery have unfavorable circulating gut hormone profiles, including GLP-1 [\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Liraglutide, a well-studied GLP-1 agonist administered at 3.0 mg for 24 weeks, significantly reduces body weight and metabolic conditions compared to placebo in patients experiencing weight recurrence [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This evidence suggests that OMMs could effectively augment weight loss in the perioperative period and lead to a more targeted treatment for MBS.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;2 demonstrates strong evidence for the effectiveness of liraglutide in the adjuvant setting for controlling weight recurrence and managing diabetes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This suggests potential benefits from neoadjuvant OMM use, paralleling other surgical fields that integrate systemic medical therapies and operations. Moreover, low-quality evidence supports adjuvant OMM use, including medications like topiramate and phentermine [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecommendation: \u003cem\u003eDetermining the optimal initiation time for OMM in either neoadjuvant or adjuvant settings to maximize patient weight loss is critical. High and moderate-quality data\u003c/em\u003e [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] \u003cem\u003erecommend starting OMM approximately three months before MBS in the neoadjuvant framework and postoperatively if weight loss remains inadequate at about three months post-surgery in the adjuvant context.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eWhile the methods in this study adhered to systematic review protocols and utilized recognized reporting standards, several limitations are present.\u003c/p\u003e\u003cp\u003eFirst, the scope of the data present on this topic is minimal, especially in the neoadjuvant period. Most OMM used were phentermine and topiramate, which are currently used but not nearly as commonly as GLP-1 medications. Nevertheless, data is lacking on the use of GLP-1 type medications in the perioperative period with MBS.\u003c/p\u003e\u003cp\u003eSecond, although the review attempts to generalize findings across MBS patients, there is an inherent limitation due to varying demographic and clinical profiles\u0026mdash;such as differing baseline BMIs or metabolic condition profiles, which can affect the generalizability of the results.\u003c/p\u003e\u003cp\u003eThird, we highlighted a notable paucity of robust data in the neoadjuvant setting, particularly regarding newer classes of GLP-1 type medications. This lack of comprehensive data limits the ability to draw definitive conclusions about neoadjuvant OMMs. However, with the data available we provide the most accurate guidelines possible.\u003c/p\u003e\u003cp\u003eFourth, there is variability in definitions present in the current data and in this manuscript. For example, regarding \u0026ldquo;weight recurrence\u0026rdquo; or \u0026ldquo;inadequate weight loss\u0026rdquo; there are multiple definitions in the literature, and we had to choose our own definitions.\u003c/p\u003e\u003cp\u003eFifth, while GradePro provides a systematic approach to rate evidence, the subjective nature of certain evaluations and the reliance on existing data quality could influence the interpretations and recommendations derived from this analysis.\u003c/p\u003e\u003cp\u003eSixth, there was a multitude of follow-up time periods from the studies analyzed. This could impact assessments of OMM efficacy, particularly in longer-term weight management and resolution of metabolic conditions.\u003c/p\u003e\u003cp\u003eAddressing these limitations could strengthen future research efforts by broadening inclusion criteria, extending database searches, and incorporating a wider array of evidence types to form a more holistic view of OMM in the neoadjuvant or adjuvant setting surrounding MBS. We narrowed our inclusion criteria to attempt to provide the strongest evidence-based algorithm.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eObesity continues to pose a substantial challenge to public health, necessitating effective interventions such as MBS, which has proven highly beneficial for weight loss and improvement of associated conditions. However, the complexity of patient outcomes post-surgery, including the prevalence of weight recurrence, calls for a more nuanced approach to treatment, specifically through the integration of OMM both pre- and postoperatively. Therefore, utilizing an evidence- based approach, we present our Comprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) algorithm to guide the MBS patient across the obesity treatment spectrum.\u003c/p\u003e\u003cp\u003eThis review has underscored the potential advantages of employing OMM in both neoadjuvant and adjuvant settings, particularly for patients who struggle with significant obesity or have conditions such as T2D. While data on neoadjuvant OMM use remains limited, preliminary findings suggest that medications, especially GLP-1 agonists, could enhance preoperative weight loss and improve metabolic control. In the adjuvant setting, existing literature supports the effectiveness of OMM in mitigating weight recurrence and managing weight-related conditions post-surgery.\u003c/p\u003e\u003cp\u003eGiven the high rates of weight recurrence among MBS patients, it is imperative that we adopt a more proactive stance on the integration of OMM into treatment plans. The development of a structured algorithm for the timely application of these medications during crucial perioperative periods could empower healthcare providers to optimize patient outcomes. As demonstrated in comparative studies across various surgical fields, embracing multi-faceted therapeutic approaches can yield superior results.\u003c/p\u003e\u003cp\u003eMoving forward, comprehensive research is needed to explore the full spectrum of OMM in the surgical obesity management paradigm. This investigation should specifically focus on establishing robust protocols for OMM use, ultimately contributing to enhanced efficacy of MBS interventions and improved long-term health outcomes for patients combating obesity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCC, SD, PP performed data collection and analysis. SD, CD, JS assisted in methodology developmentSD, CC, and AR were involved in manuscript textAll authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSj\u0026ouml;str\u0026ouml;m L, Narbro K, Sj\u0026ouml;str\u0026ouml;m CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, L\u0026ouml;nroth H, N\u0026auml;slund I, Olbers T, Stenl\u0026ouml;f K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study. 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PMID: 32732966; PMCID: PMC7393109.\u003c/li\u003e\n \u003cli\u003eBuchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37. doi: 10.1001/jama.292.14.1724. Erratum in: JAMA. 2005 Apr 13;293(14):1728. PMID: 15479938.\u003c/li\u003e\n \u003cli\u003eAdams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007 Aug 23;357(8):753-61. doi: 10.1056/NEJMoa066603. PMID: 17715409.\u003c/li\u003e\n \u003cli\u003ePope GD, Finlayson SR, Kemp JA, Birkmeyer JD. Life expectancy benefits of gastric bypass surgery. Surg Innov. 2006 Dec;13(4):265-73. doi: 10.1177/1553350606296324. PMID: 17227925.\u003c/li\u003e\n \u003cli\u003eSj\u0026ouml;str\u0026ouml;m L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sj\u0026ouml;str\u0026ouml;m CD, Sullivan M, Wedel H; Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004 Dec 23;351(26):2683-93. doi: 10.1056/ NEJMoa035622. PMID: 15616203.\u003c/li\u003e\n \u003cli\u003ePerna M, Romagnuolo J, Morgan K, Byrne TK, Baker M. Preoperative hemoglobin A1c and postoperative glucose control in outcomes after gastric bypass for obesity. Surg Obes Relat Dis. 2012 Nov-Dec;8(6):685-90. doi: 10.1016/j.soard.2011.08.002. Epub 2011 Aug 10. PMID: 21982941.\u003c/li\u003e\n \u003cli\u003eYao H, Zhang A, Li D, Wu Y, Wang CZ, Wan JY, Yuan CS. Comparative effectiveness of GLP-1 receptor agonists on glycaemic control, body weight, and lipid profile for type 2 diabetes: systematic review and network meta-analysis. BMJ. 2024 Jan 29;384:e076410. doi: 10.1136/bmj-2023-076410. PMID: 38286487; PMCID: PMC10823535.\u003c/li\u003e\n \u003cli\u003eMozaffarian D. GLP-1 agonists for obesity-A new recipe for success? JAMA. 2024 Mar 26;331(12):1007-1008. doi: 10.1001/jama.2024.2252. PMID: 38421659.\u003c/li\u003e\n \u003cli\u003eRyan DH, Lingvay I, Deanfield J, Kahn SE, Barros E, Burguera B, Colhoun HM, Cercato C, Dicker D, Horn DB, Hovingh GK, Jeppesen OK, Kokkinos A, Lincoff AM, Meyh\u0026ouml;fer SM, Oral TK, Plutzky J, van Beek AP, Wilding JPH, Kushner RF. Long-term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial. Nat Med. 2024 Jul;30(7):2049-2057. doi: 10.1038/s41591-024-02996-7. Epub 2024 May 13. PMID: 38740993; PMCID: PMC11271387.\u003c/li\u003e\n \u003cli\u003eHall KD. Physiology of the weight-loss plateau in response to diet restriction, GLP-1 receptor agonism, and bariatric surgery. Obesity (Silver Spring). 2024 Jun;32(6):1163-1168. doi: 10.1002/oby. 24027. Epub 2024 Apr 22. PMID: 38644683; PMCID: PMC11132924.\u003c/li\u003e\n \u003cli\u003eCunningham JG, Szoka N, Tabone LE, Cox S, Aylward L, Abunnaja S. Preoperative and early adjuvant weight loss medications in bariatric surgery patients with body mass index over 60 or suboptimal initial response to surgery. Surg Obes Relat Dis. 2023 Aug;19(8):832-840. doi: 10.1016/j.soard.2023.01.021. Epub 2023 Feb 15. PMID: 36948971.\u003c/li\u003e\n \u003cli\u003eThorell A, Hagstr\u0026ouml;m-Toft E. Treatment of diabetes prior to and after bariatric surgery. J Diabetes Sci Technol. 2012 Sep 1;6(5):1226-32. doi: 10.1177/193229681200600528. PMID: 23063050; PMCID: PMC3570858.\u003c/li\u003e\n \u003cli\u003eMalone M, Alger-Mayer SA, Lindstrom J. Use of Orlistat 60 mg in the management of weight loss before bariatric surgery. Ann Pharmacother. 2012 Jun;46(6):779-84. doi: 10.1345/aph.1Q556. Epub 2012 May 8. PMID: 22570428.\u003c/li\u003e\n \u003cli\u003eArd JD, Beavers DP, Hale E, Miller G, McNatt S, Fernandez A. Use of phentermine- topiramate extended release in combination with sleeve gastrectomy in patients with BMI 50 kg/m2 or more. Surg Obes Relat Dis. 2019 Jul;15(7):1039-1043. doi: 10.1016/ j.soard.2019.04.017. Epub 2019 Apr 19. PMID: 31147285.\u003c/li\u003e\n \u003cli\u003eSari C, Seip RL, Umashanker D. Case Report: Off label utilization of topiramate and metformin in patients with BMI \u0026ge;50 kg/m2 prior to bariatric surgery. Front Endocrinol (Lausanne). 2021 Feb 25;12:588016. doi: 10.3389/fendo.2021.588016. PMID: 33716960; PMCID: PMC7947603.\u003c/li\u003e\n \u003cli\u003eSj\u0026ouml;str\u0026ouml;m CD, Lissner L, Wedel H, Sj\u0026ouml;str\u0026ouml;m L. 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Epub 2014 Feb 11. PMID: 24672540; PMCID: PMC3942332.\u003c/li\u003e\n \u003cli\u003ePapamargaritis D, le Roux CW. Do gut hormones contribute to weight loss and glycaemic outcomes after bariatric surgery? Nutrients. 2021 Feb 26;13(3):762. doi: 10.3390/ nu13030762. PMID: 33652862; PMCID: PMC7996890.\u003c/li\u003e\n \u003cli\u003ele Roux CW, Welbourn R, Werling M, Osborne A, Kokkinos A, Laurenius A, L\u0026ouml;nroth H, F\u0026auml;ndriks L, Ghatei MA, Bloom SR, Olbers T. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg. 2007 Nov;246(5):780-5. doi: 10.1097/SLA.0b013e3180caa3e3. PMID: 17968169.\u003c/li\u003e\n \u003cli\u003eEl Ansari W, Elhag W. Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps-a scoping review. Obes Surg. 2021 Apr;31(4):1755-1766. doi: 10.1007/s11695-020-05160-5. Epub 2021 Feb 8. 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PMID: 27350180.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7577921/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7577921/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"While metabolic and bariatric surgery effectively aids weight loss, many individuals can benefit from the use of obesity management medications (OMMS). However, the timing of OMM utilization remains uncertain. With the increasing usage of OMMs, there is interest in combining OMMs with MBS in the adjuvant and neoadjuvant setting. However, there is no algorithm to assist physicians in this. The purpose of this article is to review and grade the current literature to formulate an algorithm to guide usage of neoadjuvant and adjuvant OMMs along with bariatric surgery.","manuscriptTitle":"Comprehensive Obesity Medicine Management in Metabolic and Bariatric Surgery (COMMMBS) Algorithm: An Evidenced Based Proposal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 14:26:05","doi":"10.21203/rs.3.rs-7577921/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T16:02:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T16:00:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-10T12:07:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84365835248984230580348809722251136933","date":"2025-10-09T15:38:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158629668496822568511441965729735957406","date":"2025-10-09T15:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T15:25:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-01T14:50:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-30T09:16:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2025-09-10T02:17:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"422a14ca-08b6-4a6b-9952-3276f4da4601","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:09:31+00:00","versionOfRecord":{"articleIdentity":"rs-7577921","link":"https://doi.org/10.1007/s11695-025-08412-4","journal":{"identity":"obesity-surgery","isVorOnly":false,"title":"Obesity Surgery"},"publishedOn":"2025-12-26 15:57:41","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2025-10-23 14:26:05","video":"","vorDoi":"10.1007/s11695-025-08412-4","vorDoiUrl":"https://doi.org/10.1007/s11695-025-08412-4","workflowStages":[]},"version":"v1","identity":"rs-7577921","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7577921","identity":"rs-7577921","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}