Obesity Surgery. 14. 802-805
Topiramate after Adjustable Gastric Banding in Patients with Binge Eating and Difficulty Losing Weight Bruno Zilberstein, MD, PhD; Denis Pajecki, MD; Alex Cleiton Garcia de Brito, MD; Samuel Terra Gallafrio; Rony Eshkenazy, MD; Carla Granja Andrade, MD Gastromed – Instituto Zilberstein, Bariatric Surgery Department, São Paulo, Brazil Background: About 15% of patients who undergo adjustable gastric banding (AGB) have difficulty losing weight due to, among other factors, the development or maintenance of binge eating disorder. Topiramate is an anticonvulsive drug with proven good results in controlling binge eating episodes.The objective of this study was to analyze the effect of topiramate in patients with AGB. Methods: 16 patients with binge eating and inadequate weight loss after AGB were analyzed prospectively for 3 months while receiving topiramate in doses varying from 12.5 to 50 mg per day. Results: There was a mean increase in excess weight loss from 20.4% to 34.1% without the need for band readjustment. 2 patients had intolerance to topiramate and were changed to fluoxetine 40 mg per day. Conclusion: Topiramate may be a useful adjuvant for patients with AGB and binge eating disorder. Key words: Morbid obesity, bariatric surgery, laparoscopic gastric banding, binge eating disorder, topiramate
Introduction Laparoscopic adjustable gastric banding (AGB) has been a common bariatric operation in Europe and Australia, and in the last 5 years has been performed frequently in Brazil. Despite the demonstrated effectiveness of AGB in the first 2 years postoperatively in achieving 50% excess weight loss (EWL)1,2 Reprint requests to:Bruno Zilberstein, Av 9 de julho 4440, CEP: 01406-100, São Paulo, SP, Brazil.E-mail: [email protected]
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and the favorable long-term results published by some authors,3-5 about 15% of the patients have difficulties in achieving these goals.6.7 The analysis of this latter group of patients shows that among them are those who do not return for band adjustments as requested, those who develop a sweet eating habit, and those with recurrent episodes of binge eating, which is not well diagnosed preoperatively. Binge eating disorder is a syndrome characterized by anxiety in which individuals eat much more quickly than usual during binge episodes, eat until so full that they are uncomfortable, and eat large amounts of food even when they are not really hungry. Difficulty in losing weight leads to more band filling, and, in the long term, high volumes in the inflatable band may lead to esophageal motility disorders8 and to a high incidence of band erosion.9 Topiramate (Topamax®) is an antiepileptic drug which is associated with weight loss. Its best effect has been observed in patients with binge eating disorder.10,11 We analyzed the effect of topiramate in patients with the AGB and recurrent binge eating episodes who are not losing the expected weight.
Methods From September 1999 to September 2003, 253 patients were operated with the Swedish adjustable gastric band (SAGB ®, Ethicon Endo-Surgery). Age varied from 15 to 60 years (mean 36.4), weight from 84 to 194 kg (mean 120.37), and BMI from 33.2 to © FD-Communications Inc.
Topiramate for Binge Eating after Banding
65.6 kg/m2 (mean 43.5). In follow-up, 16 patients (6.3%) were identified among those who did not have acceptable weight loss, who had binge-eating episodes. Two were male and 14 female. In this group, age varied from 20 to 44 years, and the BMI before surgery varied from 36.0 to 54.6 kg/m2. All these patients were losing weight very slowly or had stopped losing. The mean %EWL after surgery was 20.9% (4.6 to 40%). The mean volume of liquid in the band was 5.6 ml (4.5 to 8.0). All 16 patients underwent psychological re-evaluation before receiving topiramate, and binge eating episodes or disorder was diagnosed. Initially, a low dose of 12.5 mg of topiramate was taken in the morning and increased to 25 mg after 10 days if the patient tolerated the drug well. After 30 days, topiramate was increased to 50 mg in two patients.
Results After 90 days, we found a mean increase in the excess weight loss from 20.9% to 34.1% without the need for band readjustment (Table 1). Two patients
had intolerance to topiramate and it was changed to fluoxetine (Prozac®) 40 mg per day.
Discussion In the past few years, bariatric surgery has increased rapidly in Brazil, and now most patients are not directly referred but come on their own to bariatric surgery centers seeking treatment. The profile analysis of these patients in the last 12 months shows that at least half of these patients are young people 55
Figure 3. BMI of patients coming for surgical evaluation.
Our results with the AGB are similar to those published by many authors, with mean of 60.2% EWL at a mean of 18 months after surgery.12,13 However, 15% of the patients have difficulties in achieving this weight loss, mainly those with difficulties in following a hypocaloric diet, those with binge eating episodes or those who do not return for band adjustment. In the psychological evaluation before surgery, binge eating disorder was not identified in any patient. If this had happened, gastric banding would not have been perfomed. However, in the re804
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evaluation, 10 of the 16 patients now admitted that they had had binge eating episodes before the operation. The maintenance or the development of a sweet eating habit postoperatively may be another factor. but Hudson et al14 found that there is no difference in long-term weight loss of these patients. Psychotherapeutic support may have an impact on patients’ quality of life and weight loss,15,16 but although provided in our institution, it is not paid for by most of the health insurance companies and many patients give up this treatment for economic reasons. Regarding complications, port infection occurred in 2% (treated without band removal), band slippage in 2% with band removal in one case, and band erosion in 3.9% (10 patients). This last complication resulted in band removal and in four cases the performance of a horizontal gastric bypass. To reduce the rate of weight loss failure and of erosion, we have started using topiramate in patients with binge eating disorder with the objective of bringing them back to the weight loss curve without the need for extreme band inflation. This treatment was based on the good results published regarding use of topiramate in obese patients with binge eating disorder.17 We started with a very low dose (12.5 mg) because we were concerned about possible side-effects, but also because the idea was to use the drug as an adjuvant therapy to the gastric banding. In clinical trials, the dose ranged from 50 to 600 mg per day and was relatively well-tolerated in shortterm treatment. In those trials, the most common reasons for discontinuing topir amate were headache, paresthesia, fatigue and somnolence. In our patients, two complained of somnolence and the drug was discontinued. We found that after starting medication, patients could follow the diet more easily, and this is the main factor for the improvement in the excess weight loss. The association of anti-obesity drugs in patients with AGB is not novel. Zoss et al18 have used orlistat (Zenical ®) with dietary counseling after AGB in patients who had stopped losing weight, with good results when compared with dietary counseling alone. In conclusion, topiramate may be a useful adjuvant therapy for patients with AGB and binge eating disorder. However, some points must be clarified
Topiramate for Binge Eating after Banding
before its routine use is established: 1) improving methods for routinely identifying binge eating disorder before surgery; 2) determining the right moment to start medication; and 3) defining the ideal dose of the medication.
References 1. Victorzon M, Tolonen P. Intermediate results following laparoscopic adjustable gastric banding for morbid obesity. Dig Surg 2002; 19: 354-7; discussion 358. 2. Zinzindohoue F, Chevallier JM, Douard R et al. Laparoscopic gastric banding: a minimally invasive surgical treatment for morbid obesity: propospective study of 500 consecutive patients. Ann Surg 2003; 237: 1-9. 3. Steffen R, Biertho L, Ricklin T et al. Laparoscopic Swedish adjustable gastric banding: a five-year prospective study. Obes Surg 2003; 13: 404-11. 4. Mittermair RP, Weiss H, Nehoda H et al. Laparoscopic Swedish adjustable gastric banding: 6year follow-up and comparison to other laparoscopic bariatric procedures. Obes Surg 2003; 13: 412-7. 5. Weiner R, Blanco-Engert R, Weiner S et al. Outcome after laparoscopic adjustable gastric banding – 8 years experience. Obes Surg 2003; 13: 427-34. 6. Hotter A, Mangweth B, Kemmler G et al. Therapeutic outcome of adjustable gastric banding in morbid obese patients. Eat Weight Disord 2003; 218-24. 7. Biertho L, Steffen R, Ricklin T et al. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1,200 cases. J Am Coll Surg 2003; 197: 536-44; discussion 544-5. 8. Weiss HG, Nehoda H, Labeck B et al. Adjustable gastric and esophagogastric banding: a randomized clini-
cal trial. Obes Surg 2002; 12: 573-8. 9. Weiss HG, Kichmayr W, Klaus A et al. Surgical revision after failure of laparoscopic adjustable gastric banding. Br J Surg 2004; 235-41. 10.Shapira NA, Goldsmith TD, McElroy SL. Treatment of binge-eating disorder with topiramate: a clinical case series. J Clin Psychiatry 2000; 61: 368-72. 11.McElroy SL, Arnold LM, Shapira NA et al. Topiramate in the treatment of binge eating disorder associated with obesity: a randomized. placebo-controlled trial. Am J Psychiatry 2003; 160: 255-61. 12.Coskun H, Bozbora A, Ogunc G et al. Adjustable gastric banding in a multicenter study in Turkey. Obes Surg 2003; 13: 294-6. 13.Dolan K, Greighton L, Hopkins G et al. Laparoscopic gastric banding in morbidly obese adolescents. Obes Surg 2003; 13: 101-4. 14.Hudson SM, Dixon JB, O’Brien PE. Sweet eating is not a predictor of outcome after Lap-Band® placement. Can we finally bury the myth? Obes Surg 2002; 12: 789-94. 15.Nicolai A, Ippoliti C, Petrelli MD. Laparoscopic adjustable gastric banding: essential role of psychological support. Obes Surg 2002; 12: 857-63. 16.Kinzl JF, Trefalt E, Fiala M et al. Psychotherapeutic treatment of morbidly obese patients after gastric banding. Obes Surg 2002; 12: 292-4. 17.Appolinario JC, Fontenelle LF, Papelbaum M et al. Topiramate use in obese patients with binge eating disorder: open study. Can J Psychiatry 2002; 47: 2713. 18.Zoss I, Piec G, Horber FF. Impact of orlistat therapy on weight reduction in morbidly obese patients after implantarion of Swedish adjustable gastric band. Obes Surg 2002; 12: 113-7. ( R e c e ived Marcy 24, 2004; accepted June 20, 2 0 0 4 )
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