Glucose-stimulated insulin secretion in gastric bypass patients with hypoglycemic syndrome: no evidence for inappropriate pancreatic beta-cell function

Post-Bariatric Hypoglycemia: an Impaired Metabolic Response to a Meal

AIMS/HYPOTHESIS

Post-bariatric hypoglycemia (PBH) is caused by postprandial hyperinsulinemia, due to anatomical alterations and changes in post-prandial metabolism after bariatric surgery. The mechanisms underlying the failing regulatory and compensatory systems are unclear. In this study, we investigated the differences in post-prandial hormones and metabolic profiles between patients with and without PBH.

METHODS

We performed a mixed meal test (MMT) in 63 subjects before and 1 year after Roux-en-Y gastric bypass (RYGB) surgery. Blood was withdrawn at 0, 10, 20, 30, 60, and 120 min after ingestion of a standardized meal. Glucose, insulin, GLP-1, FGF-19, and FGF-21 were measured and untargeted metabolomics analysis was performed on blood plasma to analyze which hormonal and metabolic systems were altered between patients with and without PBH.

RESULTS

Out of 63, a total of 21 subjects (33%) subjects developed PBH (glucose < 3.1 mmol/L) after surgery. Decreased glucose and increased insulin excursions during MMT were seen in PBH (p < 0.05). GLP-1, FGF-19, and FGF-21 were elevated after surgery (p < 0.001), but did not differ between PBH and non-PBH groups. We identified 20 metabolites possibly involved in carbohydrate metabolism which differed between the two groups, including increased carnitine and acylcholines in PBH.

CONCLUSION

Overall, 33% of the subjects developed PBH 1 year after RYGB surgery. While GLP-1, FGF-19, and FGF-21 were similar in PBH and non-PBH patients, metabolomics analysis revealed changes in carnitine and acyclcholines that are possibly involved in energy metabolism, which may play a role in the occurrence of PBH.

PREVENT: A Randomized, Placebo-controlled Crossover Trial of Avexitide for Treatment of Postbariatric Hypoglycemia

CONTEXT

Postbariatric hypoglycemia (PBH), characterized by enteroinsular axis overstimulation and hyperinsulinemic hypoglycemia, is a complication of bariatric surgery for which there is no approved therapy.

OBJECTIVE

To evaluate efficacy and safety of avexitide [exendin (9-39)], a glucagon-like peptide-1 antagonist, for treatment of PBH.

METHODS

A multicenter, Phase 2, randomized, placebo-controlled crossover study (PREVENT). Eighteen female patients with PBH were given placebo for 14 days followed by avexitide 30 mg twice daily and 60 mg once daily, each for 14 days in random order. The main outcome measures were glucose nadir and insulin peak during mixed-meal tolerance testing (MMTT) and hypoglycemic events captured by self-monitoring of blood glucose (SMBG), electronic diary, and blinded continuous glucose monitoring (CGM).

RESULTS

Compared with placebo, avexitide 30 mg twice daily and 60 mg once daily raised the glucose nadir by 21% (P = .001) and 26% (P = .0002) and lowered the insulin peak by 23% (P = .029) and 21% (P = .042), corresponding to 50% and 75% fewer participants requiring rescue during MMTT, respectively. Significant reductions in rates of Levels 1 to 3 hypoglycemia were observed, defined, respectively, as SMBG <70 mg/dL, SMBG <54 mg/dL, and a severe event characterized by altered mental and/or physical function requiring assistance. CGM demonstrated reductions in hypoglycemia without induction of clinically relevant hyperglycemia. Avexitide was well tolerated, with no increase in adverse events.

CONCLUSION

Avexitide administered for 28 days was well tolerated and resulted in robust and consistent improvements across multiple clinical and metabolic parameters, reinforcing the targeted therapeutic approach and demonstrating durability of effect. Avexitide may represent a first promising treatment for patients with severe PBH.

Roux-en-Y Gastric Bypass Is Associated With Hyperinsulinemia But Not Increased Maximal β-Cell Function

Context

Roux-en-Y gastric bypass (RYGB) is associated with postprandial hyperinsulinemia.

Objective

This study assessed whether increased blood insulin levels may be due to an increase in maximal β-cell function.

Design, Setting, and Participants

We performed a cross-sectional study at Columbia University Medical Center, New York, New York. Subjects without a history of diabetes were studied after surgery (n = 12) and were compared with nonsurgical controls (n = 10) who were mean matched for body mass index, insulin sensitivity, and hemoglobin A1c and with nonobese controls (n = 8).

Methods

Subjects underwent a mixed-meal tolerance test and on a separate day an intravenous glucose tolerance test followed by a hyperglycemic clamp (450 mg/dL; 25 mM blood glucose) and arginine stimulation. The main outcome measure was maximal insulin secretion quantified after arginine stimulation (AinsRmax).

Results

The RYGB group exhibited greater peak postprandial glucose levels and fourfold greater peak insulin levels than control groups; however, there were no significant differences in insulinogenic index or AinsRmax. Another finding was significantly greater postprandial glucagon levels in the RYGB group compared with controls.

Conclusions

Our results suggest that after RYGB, the increase in postprandial levels of insulin are not due to changes in maximal β-cell function but appear to be an appropriate response to altered nutrient flow and absorption.

Beta-cell sensitivity to glucose is impaired after gastric bypass surgery

AIMS

Patients who have undergone Roux-en-Y gastric bypass surgery (GB) have exaggerated postprandial insulin secretion, which has been attributed to increased meal glucose appearance and enhanced incretin effect. Here, we sought to determine β-cell glucose sensitivity in the absence of meal stimulation and insulinotropic gut factors.

MATERIALS AND METHODS

A total of 12 non-diabetic subjects with prior GB, and 7 matched non-surgical control subjects with normal glucose tolerance were studied. Blood glucose and insulin secretion rates were measured during a graded glucose infusion at increasing and then decreasing rates. Insulin sensitivity (S_I ) and glucose effectiveness (S_G ) were determined by the minimal model.

RESULTS

GB subjects had S_I comparable to that of control subjects. GB subjects had relative hyperglycaemia during the highest dose of glucose infusion associated with significantly reduced β-cell glucose sensitivity throughout both step-up (GB: 34 ± 6, CN: 82 ± 9 pmol min^-1 mM^-1 L, P < .0001) and step-down (GB: 31 ± 6, CN: 74 ± 9 pmol min^-1 mM^-1 L, P < .0001) phases of the glucose infusion. GB subjects also had reduced S_G (GB: 0.04 ± 0.00, CN: 0.07 ± 0.01 min^-1 , P = .004).

CONCLUSION

In the absence of enteric stimuli, β-cell sensitivity to changes in glycaemia is blunted among individuals with GB, indicating a significant shift in a fundamental property of β-cell function several years after surgery.

Critical role for GLP-1 in symptomatic post-bariatric hypoglycaemia

AIMS/HYPOTHESIS

Post-bariatric hypoglycaemia (PBH) is a rare, but severe, metabolic disorder arising months to years after bariatric surgery. It is characterised by symptomatic postprandial hypoglycaemia, with inappropriately elevated insulin concentrations. The relative contribution of exaggerated incretin hormone signalling to dysregulated insulin secretion and symptomatic hypoglycaemia is a subject of ongoing inquiry. This study was designed to test the hypothesis that PBH and associated symptoms are primarily mediated by glucagon-like peptide-1 (GLP-1).

METHODS

We conducted a double-blinded crossover study wherein eight participants with confirmed PBH were assigned in random order to intravenous infusion of the GLP-1 receptor (GLP-1r) antagonist. Exendin (9-39) (Ex-9), or placebo during an OGTT on two separate days at the Stanford University Clinical and Translational Research Unit. Metabolic, symptomatic and pharmacokinetic variables were evaluated. Results were compared with a cohort of BMI- and glucose-matched non-surgical controls (NSCs).

RESULTS

Infusion of Ex-9 decreased the time to peak glucose and rate of glucose decline during OGTT, and raised the postprandial nadir by over 70%, normalising it relative to NSCs and preventing hypoglycaemia in all PBH participants. Insulin AUC and secretion rate decreased by 57% and 71% respectively, and peak postprandial insulin was normalised relative to NSCs. Autonomic and neuroglycopenic symptoms were significantly reduced during Ex-9 infusion.

CONCLUSIONS/INTERPRETATION

GLP-1r blockade prevented hypoglycaemia in 100% of individuals, normalised beta cell function and reversed neuroglycopenic symptoms, supporting the conclusion that GLP-1 plays a primary role in mediating hyperinsulinaemic hypoglycaemia in PBH. Competitive antagonism at the GLP-1r merits consideration as a therapeutic strategy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02550145.

Insulin response to oral stimuli and glucose effectiveness increased in neuroglycopenia following gastric bypass

OBJECTIVE

Hyperinsulinemic hypoglycemia with neuroglycopenia is a rare complication following Roux-en-Y gastric bypass (RYGB) surgery for weight management. Insulin secretion and action in response to oral and intravenous stimuli in persons with and without neuroglycopenia following RYGB are evaluated in this study.

METHODS

Cross-sectional cohort studies were performed at a single academic institution to assess insulin secretion and action during oral mixed meal tolerance test and intravenous glucose tolerance test (IVGTT).

RESULTS

Insulin secretion was increased more following oral mixed meal than intravenous glucose in individuals with neuroglycopenia compared to the asymptomatic group. Reduced insulin clearance did not contribute to higher insulinemia. Glucose effectiveness at zero insulin, estimated during the IVGTT, was also higher in those with neuroglycopenia. Insulin sensitivity did not differ between groups.

CONCLUSIONS

Increased beta-cell response to oral stimuli and insulin-independent glucose disposal may both contribute to severe hypoglycemia after RYGB.

Umbilical cord mesenchymal stem cells: the new gold standard for mesenchymal stem cell-based therapies?

Due to their self-renewal capacity, multilineage differentiation potential, paracrine effects, and immunosuppressive properties, mesenchymal stromal cells (MSCs) are an attractive and promising tool for regenerative medicine. MSCs can be isolated from various tissues but despite their common immunophenotypic characteristics and functional properties, source-dependent differences in MSCs properties have recently emerged and lead to different clinical applications. Considered for a long time as a medical waste, umbilical cord appears these days as a promising source of MSCs. Several reports have shown that umbilical cord-derived MSCs are more primitive, proliferative, and immunosuppressive than their adult counterparts. In this review, we aim at synthesizing the differences between umbilical cord MSCs and MSCs from other sources (bone marrow, adipose tissue, periodontal ligament, dental pulp,…) with regard to their proliferation capacity, proteic and transcriptomic profiles, and their secretome involved in their regenerative, homing, and immunomodulatory capacities. Although umbilical cord MSCs are until now not particularly used as an MSC source in clinical practice, accumulating evidence shows that they may have a therapeutic advantage to treat several diseases, especially autoimmune and neurodegenerative diseases.

Long-term results of laparoscopic Roux-en-Y Gastric bypass: evaluation after 9 years

This retrospective study aimed to evaluate the long-term results of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure performed at our department of bariatric surgery. The 126 consecutive patients treated by LRYGB between January 1, 2001 and December 31, 2002 were analyzed in August 2011. Seventy-seven patients (61.1 %), including 18 who had had previous bariatric surgery, were available for evaluation after 9.4 ± 0.6 years (range, 8.7-10.9 years). Eight patients (10.4 %) suffered from type 2 diabetes mellitus (DMII) at the time of surgery. Initial body mass index (BMI) was 40.3 ± 7.5 kg/m(2) (range, 24.5-66.1 kg/m(2)). There was no postoperative mortality, but two patients died of causes unrelated to the surgery. Some 9 % of the patients suffered from internal herniation, despite the closure of potential hernia sites. With time, the patients had the tendency to experience weight regain: percentage of excess BMI lost was 56.2 ± 29.3 % (range, -78.8 to 117.9 %), down from a maximum of 88.0 ± 29.6 % (range, -19.7 to 197.1 %), that had been obtained after a median of 2.0 years (range, 1-8 years). LRYGB was effective for diabetes control in 85.7 % of the affected patients, but, surprisingly, 27.9 % developed new-onset diabetes. The weight regain in this latter patient group was statistically not different from the nondiabetic group. Conversely, four patients required hospitalization for hypoglycemic syndrome. Two patients underwent reversal of their bypass for problems linked to glucose metabolism (one hypoglycemia, one DMII). Patient quality of life was fair. The patient satisfaction remained good in 76 % of the cases.

Glucose-responsive artificial promoter-mediated insulin gene transfer improves glucose control in diabetic mice

AIM: To investigate the effect of insulin gene therapy using a glucose-responsive synthetic promoter in type 2 diabetic obese mice.

METHODS: We employed a recently developed novel insulin gene therapy strategy using a synthetic promoter that regulates insulin gene expression in the liver in response to blood glucose level changes. We intravenously administered a recombinant adenovirus expressing furin-cleavable rat insulin under the control of the synthetic promoter (rAd-SP-rINSfur) into diabetic Lepr^db/db mice. A recombinant adenovirus expressing β-galactosidase under the cytomegalovirus promoter was used as a control (rAd-CMV-βgal). Blood glucose levels and body weights were monitored for 50 d. Glucose and insulin tolerance tests were performed. Immunohistochemical staining was performed to investigate islet morphology and insulin content.

RESULTS: Administration of rAd-SP-rINSfur lowered blood glucose levels and normoglycemia was maintained for 50 d, whereas the rAd-CMV-βgal control virus-injected mice remained hyperglycemic. Glucose tolerance tests showed that rAd-SP-rINSfur-treated mice cleared exogenous glucose from the blood more efficiently than control virus-injected mice at 4 wk [area under the curve (AUC): 21  508.80 ± 2248.18 vs 62  640.00 ± 5014.28, P < 0.01] and at 6 wk (AUC: 29  956.60 ± 1757.33 vs 60  016.60 ± 3794.47, P < 0.01). In addition, insulin sensitivity was also significantly improved in mice treated with rAd-SP-rINSfur compared with rAd-CMV-βgal-treated mice (AUC: 9150.17 ± 1007.78 vs 11  994.20 ± 474.40, P < 0.05). The islets from rAd-SP-rINSfur-injected mice appeared to be smaller and to contain a higher concentration of insulin than those from rAd-CMV-βgal-injected mice.

CONCLUSION: Based on these results, we suggest that insulin gene therapy might be one therapeutic option for remission of type 2 diabetes.

Insulin resistance and bariatric surgery

The objective of this article is to systematically review the changes in insulin resistance after various types of bariatric surgical procedures. A Pubmed and EMBASE search for studies measuring insulin resistance before and after bariatric surgery was done and all original research articles from 1980 to present (2011) were included. Only the currently widely performed bariatric procedures were included. A meta-analysis of change in HOMA-IR was conducted, grouping studies with similar duration of follow-up. The percentage decrease in HOMA-IR at <=2 weeks, 1 month, 3 months, 6 months, 12 months and >16-18 months was found to be (mean ± standard error) -33.48 ± 5.78, -46.43 ± 6.99, -38.79 ± 9.64, -58.62 ± 7.38, -44.91 ± 7.98 and -67.04 ± 10.78%, respectively. RYGB (gastric bypass) and BPD (biliopancreatic diversion) produced a significant decrease in insulin resistance at 2 weeks after surgery, while LSG (sleeve gastrectomy) was strongly trending. LSG produced an earlier decrease in insulin resistance when compared to LAGB (gastric banding). RYGB, BPD and LSG produce an early decrease in insulin resistance through yet unknown mechanisms.

Post-prandial reactive hypoglycaemia and diarrhea caused by idiopathic accelerated gastric emptying: a case report

Introduction

The majority of cases of post-prandial reactive hypoglycemia are considered idiopathic. Abnormalities of B-cell function and glucose regulation by insulin and glucagon have been postulated as causes but associated gastrointestinal dysfunction has not been reported. We report the first case of accelerated gastric emptying associated with post-prandial reactive hypoglycemia, abdominal bloating and diarrhea. We consider that gastric dysmotility is an important cause of this condition as treatment of the underlying abnormal gastric emptying allows effective control of symptoms.

Case presentation

A 20-year-old Caucasian woman presented with post-prandial fatigue, sweating, nausea, faintness and intermittent confusion, which had led to pre-syncope and syncope on occasions. She also experienced marked abdominal bloating and diarrhea over the same period. These episodes responded to oral administration of sweet drinks. Her symptoms were ameliorated by modification of her diet.

Conclusion

This is an original case report of the association of idiopathic accelerated gastric emptying with post-prandial reactive hypoglycemia and diarrhea. Family physicians, endocrinologists and gastroenterologists often consult patients with a constellation of post-prandial symptoms, which are considered to be idiopathic in most cases. This case indicates that gastric dysmotility might be the primary cause of these symptoms in some patients and, if found, offers a therapeutic target which in our case was successful.