Review of multimodal treatment for type 2 diabetes: combining metabolic surgery and pharmacotherapy

Treating type 2 diabetes mellitus (T2DM) in patients with obesity remains a challenge for physicians, endocrinologists and surgeons, a fact supported by uncontroverted evidence from studies looking at mortality and associated morbidity. Metabolic surgery remains the most effective treatment for obesity and T2DM with evidence demonstrating an improvement or resolution of symptoms of T2DM and a reduction in a mortality and rates of cardiovascular events compared with pharmacotherapy alone. While these results are promising, two important limitations must be recognized and addressed. With regards to long-term remission of T2DM, the metabolic benefits of bariatric surgery appear to fatigue with time and a proportion of patients will not maintain normoglycaemia without pharmacotherapy. Second, there has been noteworthy progress in the development of several classes of medications for the treatment of T2DM which were unavailable when the original studies comparing the effects of bariatric surgery with pharmacotherapy were conducted. Recognizing the need for further treatment following metabolic surgery for long-term disease control in conjunction with the availability of newer medications offering more effective, nonsurgical treatment presents a critical turning point in treatment treating obesity. While the traditional approach would be to determine the superiority (or non-inferiority) of these agents compared with surgery, clinicians and surgeons must acknowledge the limitations of this attitude towards treatment given evidence from fields such as cancer, where a combinational approach is the gold standard. Recent advances in pharmacotherapy, present not only a novel approach to medical therapy but a renewed impetus to investigate what can be achieved through multimodal care.