BACKGROUND AND OBJECTIVES: Idiopathic intracranial hypertension (IIH) is strongly associated with obesity with weight reduction as a central component to management. The relative effectiveness of bariatric surgery (BS) vs glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy remains uncertain. This study aimed to assess the short-term and long-term effectiveness of GLP-1RA therapy vs BS for symptom control in patients with IIH.
METHODS: This multicenter retrospective cohort study used the TriNetX Research Network. Adults aged 18 years or older with IIH and body mass index (BMI) ≥40 who underwent BS or initiated GLP-1RA therapy were included. Propensity score-matched cohorts were created to balance demographics, comorbidities, symptoms, and medication use. The primary outcomes were persistence or recurrence of IIH-related symptoms (headache, papilledema, visual deficits). Secondary outcomes included BMI change, nausea/vomiting, lumbar punctures, cerebrospinal fluid shunting, venous sinus stenting, and use of carbonic anhydrase inhibitors (CAIs) or topiramate. Outcomes were assessed at 3 to 18 months and >18 months postintervention.
RESULTS: Among 3185 eligible patients (1982 GLP-1RA; 1203 BS), 946 matched pairs had 3 to 18 months of follow-up and 963 matched pairs had >18 months. At 3 to 18 months, BS achieved greater BMI reduction (mean 35.6 vs 40.5, P < .01) and lower rates of papilledema (hazard ratio [HR]: 4.65 [1.89, 11.43], P < .01), CAI use (HR: 2.86 [1.37, 5.99], P < .01), and topiramate use (HR: 1.71 [1.06, 2.77], P = .02). However, other outcomes were comparable. At >18 months of follow-up, the 2 arms were comparable in time-to-event analyses, although GLP-1RA patients had higher hazards of nausea/vomiting (HR: 1.78 [1.15, 2.77], P = .01) and CAI use (HR: 2.37 [1.09, 5.16], P = .03).
CONCLUSION: BS achieved greater early weight loss and symptom improvement, while GLP-1RA therapy provided comparable outcomes in long-term. BS remains the most effective intervention for rapid benefit, but GLP-1RAs may represent a durable nonsurgical alternative, supporting individualized treatment selection based on comorbidities, preferences, cost, and surgical candidacy.
