Weight Loss Strategies for Osteoarthritis

Overseen By Christopher A Worgul, MD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Boston Medical Center

Disqualifiers: Substance use disorder, Prior surgeries, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 6

Duration: 12 months

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial examines how different weight loss methods can prepare people with severe obesity and advanced osteoarthritis for joint replacement surgery. It compares bariatric surgery, medical weight loss through diet and exercise, and the usual care approach to determine which most effectively helps patients reduce their BMI to 40 or less. The trial targets individuals with hip or knee osteoarthritis who have a BMI over 40, have tried other treatments like physical therapy and medications, and are interested in joint replacement surgery. As an unphased trial, it offers a unique opportunity to explore various weight loss strategies to improve surgical outcomes.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Past studies have found weight-loss surgeries like sleeve gastrectomy and gastric bypass to be relatively safe for people with severe obesity. Research shows that sleeve gastrectomy has the lowest rates of complications and the need for additional surgeries compared to similar procedures. Specifically, one study found that sleeve gastrectomy resulted in fewer complications and follow-up surgeries over five years compared to gastric bypass.

Medical weight loss carries some risks. Studies suggest that rapid weight loss can lead to joint problems, loss of muscle and bone, and even malnutrition. However, gradual weight loss through diet and exercise has proven effective. For instance, about 32% of participants in one study lost 10% of their body weight over 18 months, significantly reducing knee joint pain.

Both treatments have been used safely in various settings and show promise for people with high BMI and osteoarthritis who want to lose weight before joint surgery. ^{1 2 3 4 5}

Why are researchers excited about this trial's treatments?

Researchers are excited about the weight loss strategies being explored for osteoarthritis because they offer different approaches beyond the typical recommendations of exercise and lifestyle changes. Bariatric surgery, such as laparoscopic sleeve gastrectomy or gastric bypass, is a surgical option that can significantly reduce body mass index (BMI) and may alleviate joint stress more directly and rapidly than non-surgical methods. Meanwhile, the medical weight loss approach focuses on a combination of diet, exercise, and possibly medications, offering a less invasive alternative that can still effectively lower BMI. These strategies are promising because they target weight reduction, which is a major factor in managing osteoarthritis symptoms, potentially leading to improved mobility and quality of life for patients.

What evidence suggests that this trial's treatments could be effective for optimizing morbidly obese patients with osteoarthritis for total joint arthroplasty?

Research has shown that weight-loss surgery, one of the treatments under study in this trial, can reduce pain and improve quality of life for people with knee arthritis. This surgery offers short-term benefits, such as reducing knee pain within a year, but its long-term effects on arthritis remain unclear.

In contrast, losing weight through diet and exercise, another treatment option in this trial, can be very effective. Studies have found that losing just 5-10% of body weight can significantly reduce symptoms and improve movement in people with arthritis. These methods have also been shown to lower the risk of developing knee arthritis. ^{3 6 7 8 9}

Who Is on the Research Team?

David M Freccero, MD

Principal Investigator

Boston Medical Center

Are You a Good Fit for This Trial?

This trial is for adults with severe hip or knee osteoarthritis and obesity (BMI > 40 kg/m2) who have tried other treatments without success. They must be considering total joint replacement surgery but haven't had previous replacements in the affected joints, no active substance use disorders, and not be pregnant.

Inclusion Criteria

I am over 18, have severe hip or knee arthritis, tried all other treatments, and my BMI is over 40.

I am open to being assigned to any type of weight loss treatment group in the study.

I am considering total joint replacement surgery.

Exclusion Criteria

I am a woman who can become pregnant.

I have had weight loss surgery in the past.

I have had a hip or knee replacement surgery.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants are randomized to either bariatric surgery, medical weight loss, or usual standard of care to achieve a BMI ≤ 40 kg/m2

12 months

Telemedicine visits every 3 months

Surgery

Participants undergo total joint arthroplasty (TJA) after achieving a BMI ≤ 40 kg/m2

Day of surgery

Follow-up

Participants are monitored for safety and effectiveness after TJA, including maintaining a BMI ≤ 40 kg/m2

24 months

Routine follow-up visits and telemedicine every 3 months

What Are the Treatments Tested in This Trial?

Interventions

• Bariatric Surgery
• Medical Weight Loss
• Total Joint Arthroplasty (TJA)

Trial Overview The study compares three approaches to help morbidly obese patients prepare for joint replacement surgery: bariatric surgery, medical weight loss programs, and usual care. It aims to see which method is best at reducing BMI to ≤ 40 kg/m2 before surgery.

How Is the Trial Designed?

Group I: Medical weight loss group Experimental Treatment 3 Interventions

Participants randomized to the medical weight loss study arm will attempt to lose weight through diet, exercise, and potentially pharmacotherapy an effort to lower their BMI to ≤ 40 kg/m2.

Group II: Bariatric surgery group Experimental Treatment 3 Interventions

Participants randomized to the bariatric surgery arm will undergo either a laparoscopic sleeve gastrectomy or a laparoscopic gastric bypass to achieve a BMI ≤ 40 kg/m2.

Group III: "Usual Standard of Care" Experimental Treatment 2 Interventions

Patients randomized to the "usual standard of care" study arm will be counseled on the importance of losing weight to optimize their BMI and will be provided with referral information (name and clinic number) to either the bariatric surgery or medical weight loss clinics.

Bariatric Surgery is already approved in European Union, United States, Canada for the following indications:

Approved in European Union as Bariatric Surgery for:

• Severe obesity (BMI ≥35 kg/m2) with comorbidities
• Type 2 diabetes
• Hypertension
• Sleep apnea
• High-risk cardiovascular disease

Approved in United States as Bariatric Surgery for:

• Severe obesity (BMI ≥35 kg/m2) with comorbidities
• Type 2 diabetes
• Hypertension
• Sleep apnea
• High-risk cardiovascular disease

Approved in Canada as Bariatric Surgery for:

• Severe obesity (BMI ≥35 kg/m2) with comorbidities
• Type 2 diabetes
• Hypertension
• Sleep apnea
• High-risk cardiovascular disease

Who Is Running the Clinical Trial?

Boston Medical Center

Lead Sponsor

Trials

410

Recruited

890,000+

Published Research Related to This Trial

Duodenal switch (DS) surgery can be effective for weight loss in super obese patients, but it carries significant risks, including complications like duodenal stump blowout, which can lead to severe postoperative issues such as bleeding and abdominal pain.

Early diagnosis and appropriate management of duodenal stump leaks are crucial, involving stabilization of the patient and surgical repair, to prevent serious complications following the DS procedure.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Duodenal stump leak following a duodenal switch: A case report. Nelson, L., Moon, RC., Teixeira, AF., et al.[2020]

Bariatric surgery is the most effective long-term solution for significant weight loss and improving obesity-related health issues, with benefits including enhanced quality of life and reduced mortality rates.

The mechanisms of action for bariatric surgery include restricting food intake, causing malabsorption, increasing metabolic rate, and altering hunger and satiety hormones, making it a multifaceted approach to weight management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Current State of Bariatric Surgery: Procedures, Data, and Patient Management. Rogers, AM.[2020]

Bariatric surgery is more effective for weight loss than lifestyle changes or medications alone, with expected weight loss ranging from 37% to 79% of excess weight within 2 years, depending on the type of surgery performed.

Candidates for surgery typically have a body mass index (BMI) of 40 or higher, or a BMI of 35 with obesity-related health issues, and must commit to lifelong dietary monitoring to prevent nutritional deficiencies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Obesity: surgical management. Vesely, JM., DeMattia, LG.[2019]

In a study of 617 patients who underwent Roux-en-Y gastric bypass, Medicare beneficiaries experienced similar long-term weight loss and comorbidity resolution as non-Medicare patients after 10 years, indicating the procedure's effectiveness across different insurance statuses.

Despite Medicare patients being older and having a higher preoperative body mass index, their outcomes were equivalent to those of non-Medicare patients, supporting the case for continued Medicare coverage of bariatric surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ten-year outcomes of Roux-en-Y gastric bypass are equivalent in patients with Medicare disability and non-Medicare patients. Michaels, AD., Mehaffey, JH., Hawkins, RB., et al.[2019]

Surgical methods, particularly vertical banded gastroplasty and Roux-Y gastric bypass, are currently the most effective treatments for severe obesity, as nonsurgical methods often fail to achieve significant long-term weight loss.

The success of these surgeries relies more on patient motivation and behavior than on the technical aspects of the procedures, suggesting that psychological support and lifestyle changes are crucial for achieving and maintaining weight loss.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Overview of surgical techniques for treating obesity. Kral, JG.[2018]

Bariatric surgery is increasingly recognized as an effective treatment for morbid obesity, leading to sustained weight loss and improved health outcomes, including decreased morbidity and reversal of related health conditions.

The abstract highlights specific surgical procedures like Roux-en-Y gastric bypass, biliopancreatic diversion, and gastric sleeve, which are associated with distinct imaging appearances and potential complications, emphasizing the need for careful monitoring post-surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Imaging following bariatric procedures: Roux-en-Y gastric bypass, gastric sleeve, and biliopancreatic diversion. Carucci, LR., Turner, MA.[2016]

Laparoscopic conversion from Roux-en-Y gastric bypass (RYGB) to sleeve gastrectomy (SG) is a feasible and safe procedure for patients experiencing insufficient weight loss or weight regain, with no conversions to open surgery and no mortality reported among the four patients studied.

After an average follow-up of 11 months, patients showed significant weight loss improvements, with a mean weight reduction of 20.7 kg and a % excess weight loss of 59.3%, indicating that this conversion can effectively enhance weight loss outcomes before proceeding to the next step of duodenal switch.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Laparoscopic conversion of Roux-en-Y gastric bypass to sleeve gastrectomy as first step of duodenal switch: technique and preliminary outcomes. Dapri, G., Cadière, GB., Himpens, J.[2021]

Combining bariatric surgery with orthopedic interventions, like joint arthroplasty, is shown to be beneficial for patients with severe obesity and osteoarthritis, providing a safe and effective treatment pathway.

This two-step approach not only facilitates successful joint surgery but also encourages lifestyle changes that help patients maintain their weight loss after the procedures.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Obesity Disease Pandemic on Joint Disease and Longevity. Milla, C., Lo Menzo, E., Morton, J., et al.[2020]

Biliopancreatic diversion with duodenal switch (BPD/DS) leads to significant long-term weight loss, with an average excess BMI loss of around 78% maintained over 14 years, and a high remission rate of type 2 diabetes in 92.8% of patients.

Despite its effectiveness, BPD/DS is associated with notable long-term side effects, including a 29.3% reoperation rate due to complications like malnutrition and insufficient weight loss, highlighting the need for regular follow-up care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Long-term outcome after biliopancreatic diversion with duodenal switch: a single-center experience with up to 20 years follow-up. Süsstrunk, J., Schneider, R., Peterli, R., et al.[2023]

Bariatric surgery, such as Roux-en-Y gastric bypass and biliopancreatic diversion, is effective for long-term weight loss and reducing health risks in morbidly obese individuals, but it can lead to serious nutritional complications that may require revisional surgery.

In a study of four patients who underwent revisional surgery due to complications, one patient died, highlighting that while revision surgery is rare, it carries increased risks and can involve different surgical approaches depending on the patient's condition.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Revisional surgery in severe nutritional complications after bariatric surgical procedures: report of four cases from a single institution and review of the literature. Braga, JGR., Concon, MM., Lima, AP., et al.[2021]

In a study of 3,378 primary and 487 revisional biliopancreatic diversion/duodenal switch (BPD/DS) patients, revisional procedures were found to have a higher rate of major complications compared to primary procedures, indicating a safety concern for revisional surgeries.

Despite the higher complexity and longer operative times for revisional BPD/DS, both types of surgeries showed similar rates of 30-day readmissions, reoperations, and mortality, suggesting that while revisional surgeries carry more risk, they do not necessarily lead to worse short-term outcomes in terms of these specific metrics.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database. Wang, A., Wang, H., Abdurakhmanov, A., et al.[2022]

Both Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) resulted in significant weight loss after one year, with RYGBP patients losing an average of 48.6% of their excess weight and SG patients losing 57.6%.

Despite the weight loss, a high prevalence of vitamin deficiencies was observed post-surgery, with 65% of patients still deficient in vitamin D after one year, and significant decreases in oral hydration were noted, particularly in RYGBP patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Oral Hydration, Food Intake, and Nutritional Status Before and After Bariatric Surgery. Vinolas, H., Barnetche, T., Ferrandi, G., et al.[2020]

Bariatric surgery is currently the most effective and sustainable method for significant weight loss in the US, which is crucial given that about two-thirds of the population is overweight or obese.

In addition to aiding weight loss, bariatric surgery has been successful in reversing severe comorbidities associated with obesity, highlighting its potential health benefits beyond just weight management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perioperative nursing care of the bariatric surgical patient. Ide, P., Farber, ES., Lautz, D.[2019]

Citations

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Effects of bariatric surgery on knee osteoarthritis, knee pain ... In conclusion, we observed that bariatric surgery might be efficacious for improving knee pain, functionality and quality of life in female patients in early ...

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Long-term effectiveness, outcomes and complications of ... This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.

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Association between bariatric surgery with long-term ... To date, several studies have reported bariatric surgery led to the short-term (≤12 months) pain reduction among individuals with knee pain or OA,,, however, ...

5. sciencedirect.com sciencedirect.com/science/article/abs/pii/S1550728921002094

The influence of bariatric surgery on hip and knee joint pain Results of this systematic review suggest that bariatric surgery can positively influence hip and knee joint pain, but conclusive evidence is lacking.

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Comparative Safety of Sleeve Gastrectomy and Gastric ... This cohort study investigates the safety of sleeve gastrectomy vs gastric bypass up to 5 years after surgery in patients with severe obesity.

7. jamanetwork.com jamanetwork.com/journals/jamasurgery/fullarticle/2784823

Safety of Sleeve Gastrectomy and Gastric Bypass After ... Sleeve gastrectomy was associated with a lower risk of mortality, complications, and overall reintervention 5 years after surgery.

8. ahajournals.org ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.052386

Bariatric Surgery and Cardiovascular Outcomes in Patients ... The primary outcome occurred in 11.5% (151/1319) of the surgery group and 19.6% (259/1319) of the controls (adjusted hazard ratio [HR], 0.58 [95 ...

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Studies Weigh in on Safety and Effectiveness of Newer ... This study found sleeve gastrectomy had the lowest complication and reoperation rates of the three procedures.