Patterns and Predictors of GLP-1 Agonist Use After Bariatric Surgery in US Adults

Highlight

In a retrospective study of over 112,000 US adults undergoing bariatric surgery, 14% initiated glucagon-like peptide-1 receptor agonists (GLP-1s) postoperatively. Women, patients treated with sleeve gastrectomy, and those with type 2 diabetes and higher postsurgical BMI were more likely to start GLP-1 therapy.

GLP-1 agonist initiation often occurred years after surgery, correlating with BMI regain, underscoring the potential role of GLP-1s in managing weight recurrence after bariatric procedures.

Study Background

Obesity remains a significant public health challenge linked to increased morbidity and mortality worldwide. Bariatric surgery is among the most effective long-term weight loss interventions but not without limitations. A substantial subset of patients experience weight regain following surgery, diminishing health benefits over time.

Glucagon-like peptide-1 receptor agonists (GLP-1s), originally developed for diabetes management, have demonstrated robust efficacy in inducing weight loss in randomized controlled trials, including among post-bariatric surgery patients. However, real-world data on the frequency and predictors of GLP-1 use after bariatric surgery have been limited, complicating understanding of their integration into postoperative care.

Study Design

This retrospective cohort study utilized a large, multicenter national electronic health record database comprising approximately 113 million US adults. Adults who underwent bariatric surgery between January 2015 and May 2023 and had no GLP-1 use during the year preceding surgery were included.

Clinical and sociodemographic variables analyzed included age, sex, race/ethnicity, geographic region, type of bariatric surgery procedure (such as sleeve gastrectomy vs. other procedures), pre- and postsurgery body mass index (BMI), presence of comorbidities such as type 2 diabetes, and concurrent medications.

The primary outcome was initiation of GLP-1 receptor agonists after surgery. Cox proportional hazards models identified baseline predictors of initiation, while time-dependent models evaluated the association between postsurgical BMI and GLP-1 use.

Key Findings

The cohort included 112,858 adults undergoing bariatric surgery with a mean age of 45.2 years; 78.9% were female. Racial distribution was 64.2% White, 22.1% Black/African American, 1.1% Asian, and 12.6% other or unknown.

Overall, 15,749 patients (14.0%) initiated GLP-1 therapy after bariatric surgery. The timing of initiation varied: 21.5% began within the first two years post-surgery, 32.3% during years 3-4, 25.2% during years 5-6, and 21.0% beyond 6 years, suggesting GLP-1 use commonly occurs in the longer-term postoperative period.

The median BMI at initiation was 42.0, indicating patients tended to start therapy after notable weight regain.

In adjusted analyses, female sex was associated with a 61% higher likelihood of GLP-1 initiation compared to males (adjusted hazard ratio [aHR] 1.61; 95% CI, 1.54-1.69). Patients who underwent sleeve gastrectomy were 42% more likely to start GLP-1s than those who had other procedures (aHR 1.42; 95% CI, 1.37-1.47).

Presence of type 2 diabetes also increased initiation likelihood by 34% (aHR 1.34; 95% CI, 1.28-1.39). Importantly, each 1-unit increase in postsurgical BMI raised the chance of GLP-1 initiation by 8% (aHR 1.08; 95% CI, 1.08-1.08), emphasizing BMI regain as a major driver of therapy initiation.

Expert Commentary

This comprehensive analysis provides valuable real-world insights into the adoption of GLP-1 receptor agonists for weight management following bariatric surgery across the US healthcare system. It highlights a substantial proportion of patients who ultimately receive adjunctive pharmacotherapy, particularly those experiencing weight recurrence.

The findings that female sex and sleeve gastrectomy are associated with increased use may reflect differences in patient or provider preferences, recognition of weight regain risk, or other psychosocial factors warranting further qualitative research.

While randomized trials have demonstrated GLP-1 efficacy post-bariatric surgery, this study underscores clinical inertia and possible barriers delaying initiation in practice until later postsurgical years. Clinicians should be aware of the benefits of early implementation in patients with risk factors for weight regain or unstable metabolic status.

Study limitations include retrospective design, reliance on electronic health records which may have incomplete medication or BMI data, and potential unmeasured confounding. The generalizability to populations outside the US or those without comprehensive EHR data may be limited.

Conclusion

Approximately 1 in 7 US adults undergoing bariatric surgery initiates GLP-1 receptor agonists within several years postoperatively, predominantly among women, those receiving sleeve gastrectomy, and patients with type 2 diabetes or greater postsurgical BMI regain. These data highlight an evolving multimodal strategy to optimize long-term weight management and metabolic health in bariatric patients.

Future prospective studies should evaluate timing, dosing, and long-term outcomes of GLP-1 use in this population to inform evidence-based guidelines and address barriers to earlier pharmacologic intervention.

References

Kim M, Schweitzer MA, Kim JS, Alexander GC, Mehta HB. Use of Glucagon-Like Peptide-1 Agonists Among Individuals Undergoing Bariatric Surgery in the US. JAMA Surg. 2025 Oct 1;160(10):1058-1066. doi:10.1001/jamasurg.2025.3089. PMID: 40864458; PMCID: PMC12392147.