Italian guidelines for the management of adult individuals with overweight and obesity and metabolic comorbidities that are resistant to behavioral treatment
Aim This guideline (GL) is aimed at providing a clinical practice reference for the management of adult patients with overweight
or obesity associated with metabolic complications who are resistant to lifestyle modification.
Methods Surgeons, endocrinologists, gastroenterologists, psychologists, pharmacologists, a general practitioner, a nutritionist,
a nurse and a patients’ representative acted as multi-disciplinary panel. This GL has been developed following the
Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A systematic review and
network meta-analysis was performed by a methodologic group. For each question, the panel identified potentially relevant
outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as “critical” and “important”
were considered in the systematic review of evidence. Those classified as “critical” were considered for clinical practice
recommendations. Consensus on the direction (for or against) and strength (strong or conditional) of recommendations was
reached through a majority vote.
Results The present GL provides recommendations about the role of both pharmacological and surgical treatment for the
clinical management of the adult patient population with BMI > 27 kg/m2 and < 40 kg/m2 associated with weight-related metabolic
comorbidities, resistant to lifestyle changes. The panel: suggests the timely implementation of therapeutic interventions
in addition to diet and physical activity; recommends the use of semaglutide 2.4 mg/week and suggests liraglutide 3 mg/day
in patients with obesity or overweight also affected by diabetes or pre-diabetes; recommends semaglutide 2.4 mg/week in
patients with obesity or overweight also affected by non-alcoholic fatty liver disease; recommends semaglutide 2.4 mg/week
as first-line drug in patients with obesity or overweight that require a larger weight loss to reduce comorbidities; suggests
the use of orlistat in patients with obesity or overweight also affected by hypertriglyceridemia that assume high-calorie and
high-fat diet; suggests the use of naltrexone/bupropion combination in patients with obesity or overweight, with emotional
eating; recommends surgical intervention (sleeve gastrectomy, Roux-en-Y gastric bypass, or metabolic gastric bypass/gastric
bypass with single anastomosis/gastric mini bypass in patients with BMI ≥ 35 kg/m2 who are suitable for metabolic surgery;
and suggests gastric banding as a possible, though less effective, surgical alternative.
Conclusion The present GL is directed to all physicians addressing people with obesity—working in hospitals, territorial
services or private practice—and to general practitioners and patients. The recommendations should also consider the
patient’s preferences and the available resources and expertise
