RecruitingPhase 4NCT06803888

Bariatric Surgery vs. Semaglutide vs. Tirzepatide

Efficacy and Safety of Bariatric Surgery, Semaglutide Once Weekly, and Tirzepatide Once Weekly in Patients With Obesity

Sponsor

Ali Aminian

Enrollment

125 participants

Start Date

Jan 29, 2025

Study Type

INTERVENTIONAL

Conditions

Obesity and Obesity-related Medical Conditions

Summary

The recent introduction of the new generation of anti-obesity medications (AOMs) will change the future of obesity treatment. These highly effective medications, such as high-dose semaglutide and tirzepatide, are hormone analogues that augment the incretin function and exert multiple physiological effects by activating glucagon-like peptide-1 (GLP-1) and/or glucose-dependent insulinotropic polypeptide (GIP) distributed in various organs. These medications provide an average of 15-22% weight reduction in one-year trials, which had not been seen in the past with medical therapy. While the literature suggests that bariatric surgery is superior to these new highly effective medications, there is no head-to-head comparison between the most common bariatric operations (Roux-en-Y gastric bypass \[RYGB\] and sleeve gastrectomy \[SG\]) with semaglutide (once weekly) and tirzepatide (once weekly). The goal of this Randomized Clinical Trial (RCT) is to compare these effective therapies in patients with severe obesity to provide the best evidence to inform clinical decisions in treating patients with obesity.

Eligibility

Min Age: 18 YearsMax Age: 70 Years

Inclusion Criteria11

Entry into the study would require that the patient:
Is a candidate for general anesthesia
Is eligible for bariatric surgery (RYGB or SG) based on ASMBS/IFSO 2022 guidelines
Is ≥18 and ≤70 years old (both inclusive)
has a BMI ≥35 and ≤65 kg/m2 (both inclusive)
Patients with and without T2DM are eligible for the study. Patients with T2DM should have been on a stable dose of anti-diabetic medication (including insulin but not semaglutide or tirzepatide) for at least 3 months prior to entry, with HbA1c ≤12%.
No weight loss \> 20 lbs. in 3 months before screening (self-reported)
Has the ability and willingness to participate in the study, provide informed consent, and agree to any of the arms involved in the study.
Is able to understand the options and to comply with the requirements of each arm.
Has a negative urine pregnancy test at randomization visit for women of childbearing potential.
Women of childbearing age must agree to use reliable method of contraception for 2 years.

Exclusion Criteria37

Significant cardiac or atherosclerotic disease (planned to undergo cardiac, coronary, carotid, or peripheral artery revascularization procedures in the next 12 months)
Severe uncompensated cardiopulmonary disease leading to American Society of Anesthesiologists Class IV or V
Classified as New York Heart Association Class IV
Left ventricular ejection fraction \<25% at the time of screening (if already known)
Myocardial infarction, unstable angina, stroke, transient ischemic attack, heart surgery, coronary stent placement in the past 6 months
Prior bariatric surgery of any kind
• Intragastric balloon that has been removed at least 6 months prior to the first study visit is allowed.
History of solid organ transplant
Type 1 diabetes or autoimmune diabetes
eGFR \< 30 mL/min/1.73 m2 or being on dialysis
History of deep vein thrombosis, pulmonary embolism, or venous thromboembolism
On therapeutic dose of anticoagulants such as warfarin or direct oral anticoagulants (DOACs)
Decompensated cirrhosis characterized by presence of ascites, hepatic encephalopathy, portal hypertension, or esophageal varices.
History of severe anemia defined as hemoglobin less than 8 g/dL
Use of investigational therapy
Liver transaminase level or alkaline phosphatase \>200 U/L
Significant alcohol use (average \>2 drinks/day)
Presence of active malignancy (except non-melanoma skin cancer)
Life expectancy less than 3 years due to concomitant diseases
Major mental health, psychological disorders, or substance abuse disorders that in the opinion of the investigators could disqualify the patient from bariatric surgery
Any condition or major illness that, in the investigator's judgment, places the subject at undue risk by participating in the study
Unable to understand the risks, benefits and compliance requirements of study
Lack capacity to give informed consent
Plans to move outside the primary location of study (northeast Ohio) within the next 12 months
Pregnant, breast-feeding or the intention of becoming pregnant or not using adequate contraceptive measures
Hypothalamic obesity
Continuous treatment with semaglutide (once weekly) or tirzepatide (once weekly) \<60 days before screening
History of semaglutide (once weekly) or tirzepatide (once weekly) use in the past for obesity with lack of clinical response
Chronic use of systemic steroids
Uncontrolled thyroid disease: thyroid stimulating hormone (TSH) \> 6.0 mIU/L or \< 0.1 mIU/L
• Note: Patients receiving treatment for hypothyroidism can be included if their thyroid hormone replacement dose has been stable for at least 3 months.
Acute pancreatitis \< 180 days before screening
History or presence of chronic pancreatitis
History of Crohn's disease
Known or suspected allergy to semaglutide, tirzepatide, excipients, or related products
A personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Previous participation in this trial and got randomized to one of the study groups but did not proceed.

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Interventions

PROCEDUREBariatric Surgery

Patients receive either RYGB or SG. The surgical risk, the differential impact of each procedure on body weight and other obesity-related diseases, presence of other medical and mental problems, patient's behavioral factors (e.g., postoperative compliance, active smoking), medications, and goals will be considered when the patient and local medical team make a shared decision about the most appropriate surgical procedure.

DRUGSemaglutide

Semaglutide will be initiated at a dose of 0.25 mg once weekly and will be increased during the dose-escalation period to reach a maintenance dose of up to 2.4 mg once weekly by week 16. If patients do not tolerate a dose during dose escalation, we will consider delaying dose escalation until next visit (for 4 weeks). Dosing for Semaglutide is the FDA-approved dosing schedule. The maintenance dose is 2.4 mg injected subcutaneously once-weekly. The protocol allows for dose reductions in case a participant does not tolerate the recommended target dose of 2.4 mg and may stay at the lower maintenance dose level (e.g., 1.7 mg once weekly), if needed.

DRUGTirzepatide

Tirzepatide will be initiated at a dose of 2.5 mg once weekly and will be increased by 2.5 mg every week during the dose-escalation period to reach a maintenance dose of up to 15 mg once weekly by week 20. If patients do not tolerate a dose during dose escalation, we will consider delaying dose escalation until next visit (for 4 weeks). Dosing for Tirzepatide is the FDA-approved dosing schedule. The maintenance dose is 15 mg injected subcutaneously once-weekly. The protocol allows for dose reductions in case a participant does not tolerate the recommended target dose of 15 mg and may stay at the lower maintenance dose level (e.g., 10 mg once weekly), if needed.