Early Re-Initiation of Semaglutide After Metabolic and Bariatric Surgery in Youth: A Randomized Clinical Trial
openNIDDK - National Institute of Diabetes and Digestive and Kidney Diseases
Youth with severe obesity are less likely to reach, and maintain, body mass index (BMI) reduction with lifestyle
modification and obesity pharmacotherapy alone.1–5 Metabolic and bariatric surgery (MBS) remains the most
effective intervention for managing severe pediatric obesity.6 Up to one in four youth do not respond to MBS,
whereas others experience weight regain.7 Until recently, few alternative options existed for these young people
other than another technique of MBS.4,5 Recent research highlights that lower post-surgical levels of glucagon-
like peptide-1 (GLP-1) and increased reward-based eating behaviors contribute to suboptimal early weight loss
and weight gain reoccurence.8–11 A multi-pronged approach, immediately postoperatively, that adds GLP-1
receptor agonists (GLP-1RA), like semaglutide, to lifestyle modification may improve weight trajectories by
targeting appetite and satiety mechanisms early in the postoperative course, yet this has never been tested in
youth.2,12,13 To date, there are no standard of care guidelines for how to incorporate obesity pharmacotherapy
after MBS in youth. Accordingly, this study aims to address this gap in evidence-based guidelines involving early
re-initiation of semaglutide in youth, who have undergone MBS. Based on novel data from our pediatric MBS
program14, we have designed a 24-month randomized controlled trial involving 80 youth, ages 12-18 years, with
class III obesity, who have been on semaglutide preoperatively and are undergoing MBS. Youth will be randomly
assigned to (1) early reintroduction of semaglutide (MBS + semaglutide) two-weeks postoperatively or (2) MBS
alone with no semaglutide. All participants will receive intensive lifestyle modification counseling per standard
of care guidelines throughout the trial period.15,16 Assessments will be conducted over a 24-month period to
capture changes in anthropometric, cardiometabolic, and food intake outcomes. Aim 1: Evaluate the efficacy of
early re-initiation of semaglutide immediately after MBS on weight reduction and body composition. H1: We
hypothesize that early semaglutide re-initiation is associated with significantly greater weight loss and reduction
in fat mass compared to MBS alone. Aim 2: Examine the efficacy of early semaglutide re-initiation immediately
after MBS on GLP-1 and glucose profiles following a frequently sampled oral glucose tolerance test. H2: We
hypothesize that early semaglutide re-initiation will increase modified percent time in glucose range, captured
with continuous glucose monitoring and increase stimulated GLP-1 levels compared to MBS alone. Aim 3:
Assess the effect of early semaglutide re-initiation after MBS on objective measures of ad libitum food intake
and food reinforcement using validated, experimental procedures (Eating in the Absence of Hunger, palatable
buffet meal, and relative reinforcing value of food task). H3: Compared to MBS alone, youth who receive early
semaglutide re-initiation will decrease ad libitum food intake and decrease food motivation. This study will
generate the first RCT evidence to inform early, phenotype-driven GLP-1RA use after adolescent MBS—
advancing urgently needed, evidence-based protocols with direct implications for clinical practice.
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