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Page 8 of 13 Fearon et al. Metab Target Organ Damage 2022;2:13 https://dx.doi.org/10.20517/mtod.2022.12

Figure 1. The ominous octet shows mechanism and site of action of medications that are used to achieve glycaemic control. GLP-1 RA:
Glucagon-like peptide-1 receptor agonists; TZD: thiazolidinedione; SGLT2i: sodium-glucose co-transporter 2 inhibitor; HGP: hepatic
glucose production; MET: metformin; DPP-4i: dipeptidyl peptidase-4 inhibitor.

interdisciplinary management of DM reduced HbA1c from a mean level of 9.0% ± 1.2% to ≤ 7.5% in three-
quarters of people five months before bariatric surgery. The individualised treatment emphasised oral
hypoglycaemics that were weight neutral or associated with weight loss, and all participants received
nutritional counselling. They had weekly phone calls and monthly reviews with the interdisciplinary team,
highlighting the benefit of outpatient support . Newer treatments in this area include Tirzepatide, a dual
[31]
glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 (GLP-1) receptor agonist, which
has shown to be more efficacious in the treatment of T2DM compared to semaglutide, and in the treatment
of obesity compared to placebo, in randomised studies [32,33] . Therefore, a short-term course of treatment
such as a GLP1 receptor agonist, which reduces HbA1c and facilitates weight loss, will be a cost-effective
intervention when balanced with the overall reduced perioperative costs.

Metabolic surgery
A meta-analysis of fifteen RCTs showed a mean reduction in HbA1c of 2% after bariatric surgery compared
to 0.5% after best medical treatment . Several studies are exploring the role of sleeve gastrectomy as a
[34]
bridging intervention to another surgical procedure. A meta-analysis from Lee et al. evaluated people with a
BMI > 50 kg/m who underwent either sleeve gastrectomy (SG), liquid low-calorie diet (LLCD), or
2
intragastric balloon (IGB) before RYGB. Those who underwent SG dropped their BMI significantly more
than LLCD; those with an IGB did not lose significant weight (although only two studies were included).
Remission or improvement in T2DM was reported in 63% of people; however, there were only 62 people
with T2DM, and the criteria for remission were not outlined .
[35]

The IGB is placed endoscopically, under sedation or general anaesthetic, and can be left in situ for up to 12
months (depending on the manufacturer). Most people experience gastrointestinal side effects, and some do
not tolerate it. A recent meta-analysis including 13 RCTs and 1523 people showed a significant difference in