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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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Device Description Total
Body
Weight
Loss
(%)
FDA
Approval
AspireAssist
87
Endoscopically placed
percutaneous gastrostomy
aspiration tube
12.1
Lifestyle
alone:
3.5
12 mo
88
2016
BMI 3555 kg/m
2
vBloc
Therapy/Maestro
Rechargeable
System
89
Laparoscopically implanted device
providing intermittent vagal
blockade
9.2
Sham:
6.0
12 mo
90
2015
BMI 4045 kg/m
2
or 3540 kg/m2
+ at least
one
weight- related
comorbid
condition
Adapted by permission from Springer: Saunders KH, Igel LI, Saumoy M,
Sharaiha RZ, Aronne LJ. Devices and endoscopic bariatric therapies for obesity.
Curr Obes Rep. 2018;7(2):162-171. Copyright © 2018 Springer
Science+Business Media, LLC, part of Springer Nature. BMI, body mass index;
lifestyle, lifestyle counseling (diet + exercise).
Intragastric Balloons
Intragastric balloons (Orbera; Apollo Endosurgery, Austin,
TX, ReShape; ReShape Lifesciences, San Clemente, CA,
Obalon; Obalon Theraputics, Inc., Carlsbad, CA) are spaceoccupying devices, which are deployed in the stomach and
expand, thus reducing functional gastric volume. Proposed
mechanisms of action include delayed gastric emptying and
hormonal alterations affecting appetite and satiety. The
balloons were approved in 2015-2016 for patients with a BMI
of 30 to 40 kg/m2.
78-80
Balloons are swallowed or placed
endoscopically, filled with gas or fluid, and removed
endoscopically after 6 months. Serial balloon placement has
demonstrated additional weight loss; however, these protocols
are not currently approved. Total body weight loss ranges from
6.6% to 10.2% compared with 3.3% to 3.4% with sham.
Contraindications include history of gastrointestinal surgery,
clotting/bleeding disorders, large hiatal hernia or other
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structural abnormality, gastric mass and pregnancy. The most
common TEAEs include abdominal pain, nausea, vomiting,
intolerance, and early explantation. Migration, deflation,
perforation, and gastric ulcers have also been reported.
Aspiration Therapy
The AspireAssist device (Aspire Bariatrics, King of Prussia,
PA) is a percutaneous gastrostomy tube that facilitates partial
aspiration of each meal after ingestion. It was approved in
2016 for patients with a BMI of 35 to 55 kg/m2. 87 After the
tube is placed endoscopically, an external aspiration port is
created at the abdominal surface. After meal ingestion,
patients attach an aspiration device to the port for infusion of
water followed by aspiration of ∼30% of the meal.
AspireAssist leads to weight loss not only by direct calorie
loss but also by smaller meal portions. Food particles can flow
through the tube only if they are 5 mm or less in diameter and
in a slurry, so patients must take time to chew thoroughly and
drink sufficient liquid with each meal. AspireAssist is
associated with 12.1% total body weight loss compared with
3.5% with lifestyle counseling alone. 88 There has been no
evidence of eating disorder development or device overuse
and no reported increase in food intake during or between
meals to compensate for the aspirated calories. The most
frequently reported TEAEs included postoperative abdominal
pain, nausea, vomiting, peristomal irritation, and peristomal
granulation tissue.
88
Vagal Blockade
The Maestro Rechargeable System or vBloc (ReShape
Lifesciences, San Clemente, CA) is a device that provides
intermittent electrical blockade to the vagus nerve. It was
approved in 2015 for patients with a BMI of 40 to 45 kg/m2 or
35 to 40 kg/m2 with at least one weight-related comorbidity.
89
vBloc is implanted laparoscopically. Two leads are placed
around the vagal trunks near the gastroesophageal junction,
and a rechargeable neuroregulator is placed subcutaneously on
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the thoracic wall. The device is recharged transcutaneously.
The vagus nerve plays a role in weight regulation via effects
on appetite, metabolism, and autonomic control of the upper
gastrointestinal track. vBloc is associated with 9.2% total body
weight loss compared with 6.0% with a sham intervention as
well as reductions in hunger and improved food-related
cognitive restraint. 90 The most frequently reported TEAEs are
dyspepsia, heartburn, and implant site pain.
90,91
Impact of Obesity Treatment on Multiple
Sclerosis
Recently, it has been hypothesized that weight loss can delay
the development of MS, so obesity treatment is particularly
important among patients with concurrent MS. 92 Furthermore,
interferon beta is a cornerstone of disease-modifying treatment
for MS that can reduce the number of relapses, delay
disability, and limit new disease activity seen on magnetic
resonance imaging (MRI). There is a reduction in treatment
effect in patients with excess weight, so it is particularly
important to treat obesity in patients who would benefit from
interferon beta therapy.
93
Lifestyle Modifications
The National Multiple Sclerosis Society recommends a wellbalanced and planned diet for patients with MS. 94 Although
there is no “MS diet,” it is suggested that patients follow a
low-fat, high-fiber diet similar to the diets recommended by
the American Heart Association and the American Cancer
Society. Sodium is a dietary factor that has been linked to MS.
A recent observational study reported that patients who
consumed moderate to high amounts of sodium had increased
rates of relapse and a greater risk of developing new MRI
lesions than patients who consumed a low-sodium diet.
95
Diet may play an important role in risk of MS, disease
progression, and symptom management, especially energy
level and bladder and bowel function. Possible mechanisms
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through which diet can affect MS include direct effect on the
immune system or indirectly through changes in a patient’s gut
microbiome. Currently there is insufficient evidence to
recommend particular dietary interventions; however, there are
several ongoing pilot studies investigating the role of the
Mediterranean diet and other diets in inflammation associated
with MS.
Limited animal studies have led to theories that a ketogenic
diet could improve the neurodegenerative (vs. inflammatory)
component of MS. 96 Ketogenic diets have been shown to
promote mitochondrial biogenesis and thus increase
antioxidant levels and decrease oxidative damage, which
eventually leads to less neuronal damage. Further studies on
ketogenic diets among human patients with MS are needed
before broad dietary recommendations can be made.
Although physical activity plays an important role in weight
loss, weight loss maintenance, and overall metabolic health,
exercise can be difficult for patients with MS because of pain
and physical limitations. Pain affects quality of life both
physically and emotionally. Patients with pain tend to reduce
physical activity and, as a result, suffer from worsening
stiffness, reduced flexibility, increasing weakness, and overall
deconditioning. 97 A recent systemic review and meta-analysis
found that exercise has a small to moderate effect size in
reducing pain and thereby improving quality of life in patients
with MS. 97 Physical therapy, stretching, and low-impact
exercise such as swimming can be reasonable options for
patients with MS.
Antiobesity Medications
When prescribing antiobesity medications to patients with MS,
it is important to consider potential interactions with MS
medications as well as possible adverse events that could
exacerbate symptoms of MS. There are limited data on the
effect of antiobesity medications in patients with MS
specifically; however, there is some evidence that several of
the antiobesity drugs (or components of combination
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medications) could provide benefit beyond weight loss to
patients with MS.
Among the six most widely prescribed antiobesity agents
approved by the FDA—phentermine, orlistat,
phentermine/topiramate extended release (ER); lorcaserin,
naltrexone sustained release (SR)/bupropion SR, and
liraglutide 3.0 mg—there are potential benefits associated with
phentermine, topiramate, naltrexone, bupropion, and
liraglutide. There are no data on orlistat or lorcaserin.
Phentermine and bupropion are both activating medications
that can increase energy. Although there are no studies of
phentermine in patients with MS, bupropion has been reported
to improve fatigue among patients with MS. Over 80% of
patients with MS report symptoms of fatigue, which is a
poorly understood interplay between disease, physical fatigue,
psychological factors, drug-induced/side effect, and sleep
dysfunction. 98 Patients with MS treated with bupropion have
shown higher fatigue remission rates and improved reward
responsive rates thereby enriching quality of life.
98,99
Topiramate has been shown to improve cerebellar tremors and
dysesthetic pain, both of which can be symptoms of MS.
Cerebellar tremors, which are action-mediated tremors that
most frequently affect the arms, and can also involve the head,
trunk, and voice, are common in patients with MS.
100
These
tremors affect 25% to 60% of patients with MS and have been
historically difficult to treat pharmacologically. Per a single
case report, topiramate was shown to improve symptoms of
cerebellar ataxia and tremor in a patient with MS who was
followed over a 2-year period.
101
Dysesthetic pain is a type of neuropathic pain found
commonly in patients with MS. It is a constant, mostly
burning pain affecting the legs and feet.
102
First-line treatment
for this pain includes tricyclic antidepressants (such as
amitriptyline) and antiepileptic medications (carbamezapine,
gabapentin, and pregabalin), many of which can induce
significant weight gain. Although topiramate can sometimes
lead to paresthesias, it can also improve such neuropathic pain.
One case report described resolution of dysesthetic pain in a
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patient with MS who had suffered from treatment-resistant
pain for over 8 years.
102
Low-dose naltrexone (LDN) has been used off-label for the
treatment of pain and inflammation in many chronic
inflammatory diseases, including MS, Crohn disease, and
fibromyalgia.
103
It is hypothesized that lower-than-standard
doses of naltrexone inhibit cellular proliferation of T and B
cells and block Toll-like receptor 4, resulting in analgesia and
an anti-inflammatory effect. Numerous studies have explored
the effects of LDN on MS. It has been shown to reduce
fatigue; however, it has not been shown to alter the disease
course in MS.
103
In addition to treating diabetes and obesity, GLP-1 agonists
have demonstrated a range of other physiological effects in the
body. In preclinical trials, a substantial body of evidence has
shown that these incretin mimetics have neuroprotective and
anti-inflammatory effects.
104
In animal models for other
neurodegenerative diseases, GLP-1 was found to cross the
blood-brain barrier and reduce CNS inflammation. The
neuroprotective effect is thought to be secondary to
neurogenesis and increased neuronal repair, protection against
oxidative stress, and reduction in plaque formation.
104,105
A
recent study in animals models of MS found that liraglutide
delays disease onset and progression.
105
These preliminary
results in animal models are promising for potentially using
GLP-1 receptor agonists to concurrently treat obesity and MS.
Finally, metformin is FDA approved for the treatment of type
2 diabetes but is commonly used off-label for other conditions,
including type 2 diabetes prevention in patients with
prediabetes or impaired fasting glucose, treatment of
polycystic ovarian syndrome, and obesity/overweight.
106
Metformin has been shown to reduce disease severity in
animal models of MS by downregulating the proinflammatory
response in the CNS.
107,108
These benefits observed in animal
models have been confirmed in human subjects with both
metabolic syndrome and MS: metformin reduces disease
activity in these patients as evidenced by fewer MRI lesions.
93
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Bariatric Surgery
Although there are no studies evaluating antiobesity devices
and endoscopic bariatric therapies in patients with MS, there
are a few studies examining bariatric surgery outcomes. After
bariatric surgery, patients with MS experience weight loss
similar to that seen in the general population.
109
Small
retrospective studies and case reports confirm that bariatric
surgery is safe in patients with MS. In general, these patients
have improved ambulation from the significant weight loss
and do not have worsening disease progression or increased
relapse rates when compared with patients with MS and
obesity who do not undergo bariatric surgery.
30,109
Following
bariatric surgery, patients with MS have improved Patient
Health Questionnaire (PHQ-9) depression scores for the first
year; however, rates of depression reach the MS control rates
after about 3 years post surgery. 16 Although patients with MS
are often at higher risk for surgery, preliminary studies show
good outcomes in this patient population. Larger studies are
necessary to further optimize treatment.
As rates of obesity and MS increase, bariatric surgery may
play an important role in a multidimensional treatment plan. It
is important that practitioners who follow these patients post
surgery have a heightened awareness of nutritional
deficiencies. Bariatric patients in the general population are at
risk for neurological complications due to deficiencies in
vitamin B12, thiamine, and copper. In patients with underlying
MS, these deficiencies could lead to more severe symptoms,
so long-term monitoring of vitamin levels is necessary.
Vitamin D deficiency is also of particular concern for patients
following bariatric surgery, as it may be an independent risk
factor for the development of MS as well as increased relapse
rate, severity of disease, and degree of disease-related
disability.
Conclusion
Not only is obesity a risk factor for MS, but obesity can also
worsen symptoms of MS and complicate treatment. As a
result, it is important to treat obesity in patients with MS.
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Lifestyle modifications are the cornerstones of weight
management; however, such interventions are insufficient for
clinically significant weight loss in the majority of patients.
Health care providers who treat patients with MS should be
familiar with more advanced options for patients with obesity,
including antiobesity pharmacotherapy, devices, endoscopic
bariatric procedures, and bariatric surgery. The future of
obesity treatment is a multidisciplinary approach, as
combinations of strategies can lead to additive or synergistic
weight loss. This is an area that requires further investigation.
Case Study
A 56-year-old woman presented to our center 2 years ago for
weight management. Her BMI was 39 kg/m2. She had
undergone a Roux-en-Y gastric bypass in 1999 and
exceeded her expectations losing 147 lbs (297 → 150 lbs);
however, she then regained 61 lbs gradually over the years.
Her comorbidities included MS, type 2 diabetes, and
hyperlipidemia. MS had been diagnosed 25 years earlier.
She required intravenous steroids once years ago and
described occasional right arm numbness but did not take an
ongoing medication for MS. She noted fatigue, generalized
weakness and bilateral lower extremity paresthesias. She had
not seen her bariatric surgeon in years.
Laboratory evaluation revealed:
hemoglobin A1c 8.5%
comprehensive metabolic panel notable for fasting
glucose of 206
complete blood count notable for mean corpuscular
volume 75
bariatric laboratory tests notable for iron saturation
12%, vitamin B12 93, vitamin D 17
The patient was educated about a low-carbohydrate diet and
an exercise regimen and was prescribed metformin, which
was titrated up to 1000 mg twice daily by 500 mg per week.
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She was also prescribed intramuscular vitamin B12, vitamin
D 50,000 mg, iron supplements, and a multivitamin.
Over the next 6 months, she lost 30 lbs. Her iron and vitamin
levels normalized, and her hemoglobin A1c decreased to
5.7%. Her energy improved and weakness and paresthesias
resolved. At this point, she had reached a weight plateau and
her hunger was increasing. She was given lorcaserin and was
able to lose another 45 lbs over the next few months. She is
now maintaining her weight with a low-carbohydrate diet,
daily exercise routine, metformin, and lorcaserin.
This case illustrates several important points.
Patients with obesity and MS can present with
symptoms common to both diseases, including fatigue
and weakness. Treating a patient’s obesity can improve
these symptoms.
Patients who have undergone bariatric surgery and
present with neurologic symptoms should be evaluated
for vitamin deficiencies (especially iron, thiamine, and
vitamin B12). Patients who have undergone bariatric
surgery require life-long follow-up, including yearly
laboratory tests to evaluate for these deficiencies.
The patient had difficulty maintaining her weight loss
after surgery and reached a weight plateau a few
months after initial presentation because of metabolic
adaptation (described in the chapter).
Weight-centric diabetes management includes
prioritizing medications that can help with weight loss
(metformin, GLP-1 agonists, SGLT2 inhibitors) instead
of medications that can lead to weight gain. See Table
11.1.
Metformin is FDA approved for the treatment of type 2
diabetes but is commonly used off-label for other
conditions, including type 2 diabetes prevention in
patients with prediabetes or impaired fasting glucose,
treatment of polycystic ovarian syndrome, and
obesity/overweight.
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Successful weight loss requires a comprehensive
approach including diet, exercise, and behavioral
modifications.
Antiobesity medications can be used after surgery to
help patients lose more weight, maintain weight loss, or
lose regained weight.
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