Stephanie Walsh, MD - 2024 Pediatric Bariatric Surgery Update Course

All right. On that sobering note, I guess it goes to you, Stephanie. So, thank you. And actually, Tom, it was really great to have your presentation first cause you actually already presented a couple of my slides for me. So that was nice cause part of what's been great about um my role about sort of these post-op meds is that there isn't that much out there. So it's not like I had to go through a million studies, and I need to thank Tom and Evan and other folks and Jamie um more for sharing some of their slides and all this preliminary work that's out there. Do I need to, yeah, so, uh, I let, OK, you got her slides up there. So, um, again, thank you. I just think it's, this is, this is a topic that needs a lot of discussion because as we mentioned earlier, a lot of us are doing this very much off label to begin with, and I think we had a really nice discussion earlier about using GLP ones before and after and what that may look like in the future. I. OK. So, I actually put this in quotes because it's like, what is adequate weight loss? And again, going back to when I know when I tell the kids and I see them, I'm always like, OK, 25 to 35%. But then looking at some of the stuff that Tom just showed us in, in the next couple of slides is how much are, are people actually losing it? And what does adequate mean? And the reality is that that's Actually very subjective for some of these kids. You have some of them who say, you know, really just losing some and feeling a little bit better in their skin is adequate for them. So this sort of this, this group that doesn't lose as much, is that really us, or is, is that really something with the surgery, or is that really where they're pretty comfortable in their bodies? So again, Tom just showed these, again, where we're at with some of that. And the next one. Let me see if I can get you is, is the same thing you were talking about. And again, going back to that whole point of heterogeneity, and what we do know is the kids that can lose weight usually lose weight, and the kids who can't don't, and that's really that group we need to look at because what are we, what are we doing for those kids? And I just thought this was so interesting, Tom, what you were showing and how you have that whole two top groups that The top group obviously doing much, much worse, but the other group is even only down 12%. And what does that mean at, at a 10-year point for them, while we have these other groups that are super successful. So when I see kids who come back in, and either they're not losing sort of at, at the weight that we're expecting them to, you still have to go back and look at some of these lifestyle changes and review some of their current diet plan. Are they really following things? Were they doing it, looking for those sources of sugar? I actually have a saying that I put in mind, like if some of these kids, you know, they get their license over the course of this. And they have what I call the Starbucks phenomenon. And all of a sudden Frappuccino is like, you know, part of their daily diet. So really getting into that too. So as much as we want then go towards meds to really still look for what are, how are they eating? Are, are there any things that they're doing and, and I also noticed when they start to drink sugar, it's usually cause they're not eating food. And, you know, they're starting to feel bad and the sugar makes them feel a little bit better. So just using that as an opportunity to really go back to some of these lifestyle changes. And I always am a huge proponent for physical activity, and I know earlier, Karen, you were talking that exercise is sort of nice to have, but not. Um, as someone who has an exercise physiology degree, I might argue with you, but that's fair enough. And I also think that the benefits of physical activity. Long term are something that is not represented as well, and I think it's something that's coming out more and more as one of the biggest ways that we can help kids be active. In addition, we know that, uh, uh, certainly our population, we have a lot more girls than boys, and the girls and physical activity for girls is always lower than boys. So anything we can do to get that up and That physical activity for kids is predominantly influenced by their moms. So if we can get these young women moving and then showing that to their kids, it's more likely that we'll have more active kids going forward. So again, putting my prevention pediatric hat on a little. That focusing on physical activity is such an important piece and also gives them that sort of physical strength that they feel, which then also can, can go along with some of the mental strength because physical activity does impact mental health. And then, so here are all the medications, and I know everybody uses them in different ways. The, the phentermine, Topamax, just Topamax alone, GLP ones. I've actually really been using some of the bupropion post-op. Again, they have supposed to be 18, but if we can get a form, that seems to help with some of that mood piece that we see afterwards, as well as sort of just giving them that little extra bit heading towards weight loss. I haven't used Contrave at all, so I, I think that's something that's still out there for us to, to figure out how we want to use that. Some people, if you're using it more, please let me know. And again, these are slides. Thank you to Jamie and Tom. Jamie told me that this is yours too, Tom, they, kind of looking about the perioperative AOM use. And you, you can see that really that really giving all the evidence. What, what do people have as options for them. Certainly, in some of these kids who have significant comorbid conditions, it's great to get those, some of those medications in and see some weight loss for them. The biggest thing that I've found with some of these kids is that It is a psychological benefit. It's the fact that even if they can stabilize their weight or even lose a little bit, it helps them stay super engaged in the program. And I know we talked a little bit about which medicines to use. The reality is, almost all my kids can only take phentermine and Topamax. I don't really have access to GLP ones for, for most of my bariatric patients at all. So we haven't used those pre-op cause I can't really get them. And I think it's something as we look at post-op, also. How do we also make sure that if we're giving them something that decreases their hunger, when we've also given them a surgery that decreases their hunger to make sure they're still eating what they need to eat. And that's where it comes into not only do we need to think about the medications, but also about how they're eating and what they're eating, and keeping those pieces together. And again, we all have here continue looking at the Um, screening for disordered eating cause we know that that can sometimes be hidden beforehand because we may not always see our kids as having the disordered eating that they do have. And someone mentioned that they love Vyvanse. I love Vyvanse too, if I can get it for the kids. Next. And again, Tom, this is your study, but here I am gonna show it ahead of time, not quite published yet, but really looking at the phentermine and Topamax, using it it post-op, and I know this is a small group, I think, were there 12 kids, Tom? I'm trying to remember it was something relatively small, but again, just seeing that there, there was, it was, yeah. And so in the next slide you can see. that there's an improvement with all that. So, there's definitely a role for these medications. It's just a matter of which ones and who gets them and, and are we Are, are we really helping the kids that we need, we need to help with this? Next slide. And of course, if something's missing from this one, sorry. This is um the slide that Evan shared, and this is also waiting to be published out there. But the biggest thing with this is that, again, the kids who lose weight, lose weight with meds as well. So you can see improvements with all of this, but what are we doing for that? Those top couple of groups. Are those the ones that medications are gonna work for? Is that something where we start looking at some of these procedural revisions? You know, I, I don't know that a different procedure is gonna make a difference necessarily. I think this is all stuff that still has yet to be shown. So this is that the works are in progress. So be on the lookout for these two studies to be coming out shortly, hopefully, so we can have a little bit more information. But everything you think is looking pretty positive for the use of medications. It's just a matter of again, with the heterogeneity, how do we, how do we decide who, who uses what and what kids benefit from which medication. So, I wanted to throw a couple because of course, you're the, you get the pediatrician on this talk. So, again, who, who I can get these medications for and which ones I can get are almost all based on insurance, right? And the availability. We've talked about that. When I talked to my friends who make go via Novo, they say, oh, it shouldn't be a problem getting any of these anymore. Everything should be out there. But we also know that's not true. It's also not true if you do phentermine and Topamax together. In Atlanta, I can only find 15 mg in capsule form. So it's not even like you can break it in half for phentermine. So, again, realizing you gotta use what you have and we're still in that art part of using these medications. I also think it's really important to think about body image for these kids, as, as Tracy mentioned earlier. Not everybody wants to lose as much weight, and it really just depends on what works for them. And it's, I, I usually just try to do some open-ended questions like, so how are you feeling about your weight loss? Did you have a goal? How, you know, those kind of things that matter to them because there's a lot of kids who, if they can just stop taking their diabetes medication and get back to being a little more active, they're pretty happy. And so they don't necessarily want to go to those next steps. And then what's family support, but also just in general, the view on medications. It's so funny to me that I have families who are very, like, let's get the surgery and let's be done. But when it comes to medications, a lot of families are a little hesitant. We have a lot of medication hesitancy here in Atlanta that we keep working on. So, just think about that as you're, as you're moving through this. Yeah, there almost seems to be like different camps. Like there's camps of people who very much like, I'll never do surgery. I want medications. And then there's another camp that's like, I want nothing with long-term medications. I want surgery. So, it's, it's just very, it's very interesting. And it's also the psyche around, what do you mean I have to be on this forever? And they're not, not everybody is willing to look at these like, oh yeah, I might, the, the chronic disease idea is still catching up, I think, for people. So it's it's been something interesting to try to have those conversations around. What are you, how are, Karen, what are you doing sort of for, are you using any of the GLP ones? I, I think you're like me, you can't get them, so no, we can't get them. And, and actually, um, I don't know who you're talking to, but the people at Nova Nordics that I've talked to, they, they're sending out the 1.7 and 2.4, but there, there's very, very little of the, the lower doses. Um, they're just prioritizing the people who are trying to maintain. That we're already on it. And so, um, so yeah, it's, you know, again. Um. But I use a lot of medications, assuming that's what the family, if the family wants to try, right? So, and one thing, and let me know your experiences we, we sort of run into this a little bit because with a few kids that we can actually get the GLP ones we're not necessarily even post bariatric, but Doing really well at 1.7, but not necessarily as well at 2.4. And sort of this whole insurance thing about, well, the dose is 2.4, it's not 1.7. And so, how you, how we advance this, I think still needs a little bit of time to figure out. Like maybe you don't need to go up every week or every two weeks. Maybe you could go up every or go up two instead of every one week, right? So, again, with the side effects, how we're managing that. Have you found anything to be particularly useful? Sorry. Um, so, well, now they have, as of, I think last year, they, the 1.7 is considered now a maintenance dose, so there should be less issue about insurers paying for 1.7. Um, or covering 1.7, um, but, you know, it's, again, the rules are all sometimes very silly and make no clinical sense, right? You should use the lowest dose that your patient, you know, one, they can tolerate and that's effective, um, and that's gonna be different for every patient. And so, and then the same thing like you said, like the ramp up, yeah, there's guidance, but it should really be according to what's happening with your individual patient. Um, and so all of these very restrictive rules and regulations, um, from insurers and pharmacies about how you can and can't prescribe it are really, they're all just an impediment. Yes, yeah, so I, I have a question, um, and this is for Stephanie and, and Karen probably, and maybe, maybe the, the rest of the group, but do you have protocols that say that, you know, on The 3-month visit, if they're not here, we're gonna go ahead and start something, or is it, is it more like, what are the patient's expectations? Are we're looking at comorbidities? Is their diabetes resolved? Uh, how do we, you know, what is the signal to say, let's go ahead and start medications? So inadequate weight loss. Yeah, I mean, well, I struggle with the, you know, um, yeah, so we, we offer medications at 3 months for less than 10% total body weight loss and at 6 months for less than 15%. Um, those are very conservative given the teen labs data, frankly, um, and, uh, otherwise we usually wait for nadir. In our, in our practice in DC, you know, so, in our 750 patients, we've looked at the modeling and if you don't have, uh, if you're off the curve at 3 months, you're never, you're never back on that curve. So, we start medications at 3 months, or earlier if there's, um, and I, one of the things I love about Vyvanse is that for whatever reason, I had a cohort of patients who did not get satiety from their sleeve, uh, no matter, you know, and I obviously do the same. Amount of resection each time. So, those patients, we start on 2 weeks, 2 weeks post-op. If they don't have satiety, they get on Vyvanse right away. So, all the, all the studies, including my own, looking at 6 months or later time points, they're gonna be great, but they're actually way too late. The, the, the data strongly suggest starting earlier and being more aggressive. And, um, yes, you have to meet patients where they are, but those, the data are, are Clear that the earlier the better. So we got 11 question, uh, sorry, one minute left and a couple of questions from the chat that are kind of provoking a different, uh, different direction here, not meds, post-op, quote-unquote rescue, but what about starting at a lower BMI in the first place? Certainly, I'm a, I'm, I think with type 2 diabetes, I don't know why we are waiting for a BMI of 35 arbitrarily because we think the diabetes is not going to get better at a BMI of 32. Yeah. And especially if you think about, you know, if then they're on insulin, I mean, the longer they're on insulin, the less likely you are to help their diabetes. So yeah, absolutely.