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Hazlehurst J, Khoo B, Lobato CB, Ilesanmi I, Abbott S, Chan T, Pillai S, Maslin K, Purkayastha S, McGowan B, Andrews R, Nicholson E, McCullough K, Albon L, Batterham R, Dimitriadis GK, Forbes S, Bewick G, Tan TMM. Society for Endocrinology guidelines for the diagnosis and management of post-bariatric hypoglycaemia. Endocr Connect 2024; 13:EC-23-0285. [PMID: 38451861 PMCID: PMC11046333 DOI: 10.1530/ec-23-0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/07/2024] [Indexed: 03/09/2024]
Abstract
Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres. AIM to improve and standardise clinical practice in the diagnosis and management of PBH. OBJECTIVES (1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition. METHOD A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders. OUTCOME We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.
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Affiliation(s)
- Jonathan Hazlehurst
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bernard Khoo
- Endocrinology, Division of Medicine, University College London, London, UK
| | - Carolina Brito Lobato
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Copenhagen University Hospital – Amager and Hvidovre, Hvidovre, Denmark
| | - Ibiyemi Ilesanmi
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Sally Abbott
- Department of Dietetics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tin Chan
- Faculty of Medicine, Chinese University of Hong Kong, Hong Kong
| | - Sanesh Pillai
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Kate Maslin
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - Sanjay Purkayastha
- Brunel University, London, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
| | - Barbara McGowan
- Endocrinology, Guys’ and St Thomas’s NHS Foundation Trust, London, UK
| | - Rob Andrews
- University of Exeter Medical School, Exeter, UK
| | | | | | - Lorraine Albon
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Rachel Batterham
- Endocrinology, Division of Medicine, University College London, London, UK
| | | | - Shareen Forbes
- BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gavin Bewick
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Tricia M-M Tan
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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2
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Nielsen CK, Øhrstrøm CC, Houji IJK, Helsted MM, Krogh LSL, Johansen NJ, Hartmann B, Holst JJ, Vilsbøll T, Knop FK. Dasiglucagon Treatment for Postprandial Hypoglycemia After Gastric Bypass: A Randomized, Double-Blind, Placebo-Controlled Trial. Diabetes Care 2023; 46:2208-2217. [PMID: 37819999 DOI: 10.2337/dc23-1193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Postbariatric hypoglycemia affects >50% of individuals who have undergone Roux-en-Y gastric bypass surgery. Despite the often debilitating nature of this complication, existing treatment options are limited and often inefficient. Dasiglucagon is a stable glucagon analog available in a ready-to-use formulation and was recently shown to mitigate postbariatric hypoglycemia in experimental settings. Here, we aimed to evaluate the hypoglycemic hindering potential of dasiglucagon in an outpatient trial. RESEARCH DESIGN AND METHODS We conducted a randomized, double-blind, placebo-controlled, crossover, proof-of-concept study at the Center for Clinical Metabolic Research at Gentofte Hospital in Denmark. The study included 24 individuals who had undergone Roux-en-Y gastric bypass surgery (n = 23 women) with continuous glucose monitor-verified postbariatric hypoglycemia (≥15 min at <3.9 mmol/L three or more times per week) randomly assigned to two treatment periods of 4 weeks of self-administered subcutaneous dasiglucagon at 120 μg or placebo. The primary and key secondary outcomes were continuous glucose monitor-captured percentage of time in level 1 and 2 hypoglycemia (<3.9 and <3.0 mmol/L), respectively. RESULTS Compared with placebo, treatment with dasiglucagon significantly reduced time in level 1 hypoglycemia by 33% (-1.2 percentage points; 95% CI -2.0 to -0.5; P = 0.002) and time in level 2 hypoglycemia by 54% (-0.4 percentage points; 95% CI -0.6 to -0.2; P < 0.0001). Furthermore, dasiglucagon corrected hypoglycemia within 15 min in 401 of 412 self-administrations, compared with 104 of 357 placebo self-administrations (97.3% vs. 29.1% correction of hypoglycemia rate; P < 0.001). Dasiglucagon was generally well tolerated, with mostly mild to moderate adverse events of nausea. CONCLUSIONS Compared with placebo, 4 weeks of self-administered dasiglucagon effectively reduced clinically relevant hypoglycemia in individuals who had undergone Roux-en-Y gastric bypass surgery.
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Affiliation(s)
- Casper K Nielsen
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Inas J K Houji
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Mads M Helsted
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Liva S L Krogh
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicklas J Johansen
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
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3
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Heo YH, Kim JK, Lee JS, Lee SH, Shin SH, Choi IY, Kim HH. A novel glucagon analog with an extended half-life, HM15136, normalizes glucose levels in rodent models of congenital hyperinsulinism. Sci Rep 2022; 12:16765. [PMID: 36202918 PMCID: PMC9537296 DOI: 10.1038/s41598-022-21251-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a rare genetic condition characterized by uncontrolled insulin secretion, resulting in hypoglycemia. Although glucagon has lately been regarded as a therapeutic option for CHI, its use is severely hampered by its poor solubility and stability at physiological pH, as well as its short duration of action. To address these constraints, we developed HM15136, a novel long-acting glucagon analog composed of a glucagon analog conjugated to the Fc fragment of human immunoglobulin G4 via a polyethylene glycol linker. In this study, we established that HM15136 was more soluble than natural glucagon (≥ 150 mg/mL vs 0.03 mg/mL). Next, we confirmed that HM15136 activated glucagon receptor in vitro and induced glycogenolysis and gluconeogenesis in rat primary hepatocytes. Pharmacokinetics (PK)/Pharmacodynamics (PD) analysis of HM15136 shows that HM15136 has a markedly longer half-life (36 h vs. < 5 min) and increased bioavailability (90%) compared to native glucagon in mice. Further, HM15136 could effectively reverse acute hypoglycemia induced by insulin challenge, and multiple doses of HM15136 could sustain increased blood glucose levels in CHI rats. In conclusion, our findings indicate that HM15136 promotes sustained elevation of blood glucose, demonstrating the potential for development as a once-weekly therapy for CHI.
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Affiliation(s)
- Yong Ho Heo
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea
- Biotherapeutics and Glycomics Laboratory, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea
| | - Jung Kuk Kim
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea
| | - Jong Suk Lee
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea
| | - Sang-Hyun Lee
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea
| | - Seung-Hyun Shin
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea
| | - In Young Choi
- Hanmi Research Center, Hanmi Pharmaceutical Co. Ltd., 550 Dongtangiheung-ro, Hwaseong-si, 18469, Gyeonggi-do, Republic of Korea.
| | - Ha Hyung Kim
- Biotherapeutics and Glycomics Laboratory, College of Pharmacy, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea.
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea.
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5
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Nielsen CK, Øhrstrøm CC, Kielgast UL, Hansen DL, Hartmann B, Holst JJ, Lund A, Vilsbøll T, Knop FK. Dasiglucagon Effectively Mitigates Postbariatric Postprandial Hypoglycemia: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial. Diabetes Care 2022; 45:1476-1481. [PMID: 35320361 DOI: 10.2337/dc21-2252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/23/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of dasiglucagon, a novel stable glucagon analog in a liquid formulation, in Roux-en-Y gastric bypass (RYGB)-operated individuals suffering from postbariatric hypoglycemia (PBH). RESEARCH DESIGN AND METHODS In a randomized, double-blind, placebo-controlled, crossover trial, 10 RYGB-operated participants with continuous glucose monitoring-verified PBH were randomly assigned to 3 trial days, each consisting of a 240-min standardized liquid mixed-meal test with the subcutaneous injection of placebo or 80 μg or 200 μg dasiglucagon. RESULTS Compared with placebo, treatment with both 80 and 200 μg dasiglucagon raised nadir plasma glucose (PG) (placebo: 3.0 ± 0.2 mmol/L [mean ± SEM]; 80 μg dasiglucagon: 3.9 ± 0.3 mmol/L, P = 0.002; 200 μg dasiglucagon: 4.5 ± 0.2 mmol/L, P = 0.0002) and reduced time in hypoglycemia (PG <3.9 mmol/L) by 70.0 min (P = 0.030 and P = 0.008). CONCLUSIONS Single-dose administration of dasiglucagon effectively mitigated postprandial hypoglycemia.
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Affiliation(s)
- Casper K Nielsen
- Center for Clinical Metabolic Research, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Urd L Kielgast
- Steno Diabetes Center Zealand, Zealand University Hospital, Køge, Denmark
| | | | - Bolette Hartmann
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Asger Lund
- Center for Clinical Metabolic Research, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Clinical Metabolic Research, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark.,Steno Diabetes Center Copenhagen, Herlev, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Steno Diabetes Center Copenhagen, Herlev, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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6
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Hu S, Tang H, Wang H, Dong Z, Jiang S, Wang C, Chen X, Yang W. Hyperinsulinemic Hypoglycemia after Bariatric Surgery. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2020; 9:1-6. [PMID: 36686896 PMCID: PMC9847643 DOI: 10.17476/jmbs.2020.9.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 06/13/2023]
Abstract
Postprandial hyperinsulinemic hypoglycemia (PHH) is one of the serious complications after bariatric surgery, it can lead life-threatening neuroglycopenic symptoms, such as seizures, disorientation, impairment of version and loss of consciousness without any premonitory. The presentation, prevalence, diagnosis, pathology and treatment are reviewed in this summary.
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Affiliation(s)
- Songhao Hu
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hanlin Tang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Huaxi Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhiyong Dong
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuwen Jiang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaomei Chen
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
- State Key Laboratory of Pharmaceutical Biotechnology, LKS Faculty of Medicine, The University of Hong Kong, China
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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7
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Laguna Sanz AJ, Mulla CM, Fowler KM, Cloutier E, Goldfine AB, Newswanger B, Cummins M, Deshpande S, Prestrelski SJ, Strange P, Zisser H, Doyle FJ, Dassau E, Patti ME. Design and Clinical Evaluation of a Novel Low-Glucose Prediction Algorithm with Mini-Dose Stable Glucagon Delivery in Post-Bariatric Hypoglycemia. Diabetes Technol Ther 2018; 20:127-139. [PMID: 29355439 PMCID: PMC5771550 DOI: 10.1089/dia.2017.0298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) is a complication of bariatric surgery with limited therapeutic options. We developed an event-based system to predict and detect hypoglycemia based on continuous glucose monitor (CGM) data and recommend delivery of minidose liquid glucagon. METHODS We performed an iterative development clinical study employing a novel glucagon delivery system: a Dexcom CGM connected to a Windows tablet running a hypoglycemia prediction algorithm and an Omnipod pump filled with an investigational stable liquid glucagon formulation. Meal tolerance testing was performed in seven participants with PBH and history of neuroglycopenia. Glucagon was administered when hypoglycemia was predicted. Primary outcome measures included the safety and feasibility of this system to predict and prevent severe hypoglycemia. Secondary outcomes included hypoglycemia prediction by the prediction algorithm, minimization of time below hypoglycemia threshold using glucagon, and prevention of rebound hyperglycemia. RESULTS The hypoglycemia prediction algorithm alerted for impending hypoglycemia in the postmeal state, prompting delivery of glucagon (150 μg). After observations of initial incomplete efficacy to prevent hypoglycemia in the first two participants, system modifications were implemented: addition of PBH-specific detection algorithm, increased glucagon dose (300 μg), and a second glucagon dose if needed. These modifications, together with rescue carbohydrates provided to some participants, contributed to progressive improvements in glucose time above the hypoglycemia threshold (75 mg/dL). CONCLUSIONS Preliminary results indicate that our event-based automatic monitoring algorithm successfully predicted likely hypoglycemia. Minidose glucagon therapy was well tolerated, without prolonged or severe hypoglycemia, and without rebound hyperglycemia.
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Affiliation(s)
- Alejandro J. Laguna Sanz
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | | | - Emilie Cloutier
- Research Division, Joslin Diabetes Center, Boston, Massachusetts
| | | | - Brett Newswanger
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Martin Cummins
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Sunil Deshpande
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | - Poul Strange
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Howard Zisser
- Department of Chemical Engineering, University of California, Santa Barbara, Santa Barbara, California
| | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
- Research Division, Joslin Diabetes Center, Boston, Massachusetts
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8
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Lee CJ, Brown TT, Schweitzer M, Magnuson T, Clark JM. The incidence and risk factors associated with developing symptoms of hypoglycemia after bariatric surgery. Surg Obes Relat Dis 2018; 14:797-802. [PMID: 29678347 DOI: 10.1016/j.soard.2018.01.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 01/12/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hypoglycemia after bariatric surgery is an increasingly recognized metabolic complication associated with exaggerated secretion of insulin and gut hormones. OBJECTIVE We sought to determine the incidence of hypoglycemic symptoms (hypo-sx) after bariatric surgery and characteristics of those affected compared with those unaffected. SETTING University hospital. METHODS We collected retrospective survey data from the patients who underwent bariatric surgery at a single center. Based on number and severity of postprandial hypo-sx in Edinburgh hypoglycemia questionnaire postoperatively, patients without preoperative hypo-sx were grouped into high versus low suspicion for hypoglycemia. We used multivariable logistic regression to examine potential baseline and operative risk factors for the development of hypo-sx after surgery. RESULTS Among the 1119 patients who had undergone bariatric surgery who received the questionnaire, 464 (40.6%) responded. Among the 341 respondents without preexisting hypo-sx, 29% (n = 99) had new-onset hypo-sx, and most were severe cases (n = 92) with neuroglycopenic symptoms. Compared with the low suspicion group, the high suspicion group consisted of more female patients, younger patients, patients without diabetes, and those who underwent Roux-en-Y gastric bypass with a longer time since surgery and more weight loss. In multivariate analysis, factors independently associated with incidence of hypo-sx after bariatric surgery were female sex (P = .003), Roux-en-Y gastric bypass (P = .001), and absence of preexisting diabetes (P = .011). CONCLUSIONS New onset postprandial hypoglycemic symptoms after bariatric surgery are common, affecting up to a third of those who underwent bariatric surgery. Many affected individuals reported neuroglycopenic symptoms and were more likely to be female and nondiabetic and to have undergone Roux-en-Y gastric bypass.
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Affiliation(s)
- Clare J Lee
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland.
| | - Todd T Brown
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Thomas Magnuson
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Jeanne M Clark
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University, Baltimore, Maryland
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9
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Øhrstrøm CC, Worm D, Hansen DL. Postprandial hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass: an update. Surg Obes Relat Dis 2017; 13:345-351. [DOI: 10.1016/j.soard.2016.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/30/2016] [Accepted: 09/23/2016] [Indexed: 12/24/2022]
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10
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Eisenberg D, Azagury DE, Ghiassi S, Grover BT, Kim JJ. ASMBS Position Statement on Postprandial Hyperinsulinemic Hypoglycemia after Bariatric Surgery. Surg Obes Relat Dis 2016; 13:371-378. [PMID: 28110984 DOI: 10.1016/j.soard.2016.12.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Dan Eisenberg
- Department of Surgery, Stanford School of Medicine, Stanford, California; Department of Surgery, Palo Alto VA Health Care System, Palo Alto, California.
| | - Dan E Azagury
- Section of Bariatric and Minimally Invasive Surgery, Stanford University School of Medicine, Stanford, California
| | - Saber Ghiassi
- Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Bridgeport Hospital, Fairfield, Connecticut
| | - Brandon T Grover
- Department of Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Julie J Kim
- Department of General Surgery, Tufts University School of Medicine, Boston, Massachusetts
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Mordes JP, Alonso LC. Evaluation, Medical Therapy, and Course of Adult Persistent Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass Surgery: A Case Series. Endocr Pract 2016; 21:237-46. [PMID: 25100376 DOI: 10.4158/ep14118.or] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evaluation and treatment of hyperinsulinemic hypoglycemia in adults who had undergone gastric bypass surgery. A small number of patients who undergo Roux-en-Y bypass surgery develop postprandial hypoglycemia in the absence of dumping. In some cases, such patients have been treated with pancreatectomy. METHODS We report the demographics, diagnostic results, response to medical therapy, and subsequent course of 6 referral patients with post-Roux-en-Y gastric bypass hypoglycemia. RESULTS Characteristic clinical and metabolic parameters consistent with hyperinsulinemic hypoglycemia were identified. Parameters were similar for both spontaneous and glucose-challenge-induced hypoglycemia. In the context of exclusively postprandial symptoms, simultaneous glucose ≤55 mg/dL, insulin ≥17 μU/mL, C peptide ≥3.0 ng/mL, and insulin to glucose ratio >0.3 were associated with Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia. Five of 6 patients improved on therapy consisting of dietary modification plus either calcium channel blockade, acarbose, or both. Two patients have remained on therapy for 12 to 15 months. The nonresponder was atypical and had had hypoglycemic events for several decades. Three treated patients were subsequently observed to have undergone partial or complete remission from hypoglycemic episodes after 2 to 37 months of therapy. None of the 6 have undergone pancreatectomy, and none have evidence of insulinoma. Invasive diagnostic procedures were of limited utility. CONCLUSION In a subset of patients with post-Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia, medical management can be efficacious and an alternative to partial pancreatectomy. In some cases, the disorder remits spontaneously.
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Affiliation(s)
- John P Mordes
- Department of Medicine, Division of Endocrinology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Laura C Alonso
- Division of Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts
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12
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Shantavasinkul PC, Torquati A, Corsino L. Post-gastric bypass hypoglycaemia: a review. Clin Endocrinol (Oxf) 2016; 85:3-9. [PMID: 26840207 DOI: 10.1111/cen.13033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/27/2015] [Accepted: 01/28/2016] [Indexed: 12/27/2022]
Abstract
Bariatric surgery is a highly effective treatment for severe obesity, resulting in substantial weight loss and normalizing obesity-related comorbidities. However, long-term consequences can occur, such as postbariatric surgery hypoglycaemia. This is a challenging medical problem, and the number of patients presenting with it has been increasing. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it is the surgery most commonly associated with the development of postbariatric surgery hypoglycaemia. To date, the pathogenesis of this condition has not been completely established. However, various factors - particularly increased postprandial glucagon-like peptide (GLP)-1 secretion - have been considered as crucial mediator. The mechanisms responsible for diabetic remission after bariatric surgery may be responsible for the development of hypoglycaemia, which typically occurs 1-3 h after a meal and is concurrent with inappropriate hyperinsulinaemia. Carbohydrate-rich foods usually provoke hypoglycaemic symptoms, which can typically be alleviated by strict dietary modifications, including carbohydrate restriction and avoidance of high glycaemic index foods and simple sugars. Few patients require further medical intervention, such as medications, but some patients have required a pancreatectomy. Because this option is not always successful, it is no longer routinely recommended. Clinical trials are needed to further determine the pathophysiology of this condition as well as the best diagnostic and treatment approaches for these patients.
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Affiliation(s)
- Prapimporn C Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Alfonso Torquati
- Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Leonor Corsino
- Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University, Durham, NC, USA
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Ritz P, Vaurs C, Barigou M, Hanaire H. Hypoglycaemia after gastric bypass: mechanisms and treatment. Diabetes Obes Metab 2016; 18:217-23. [PMID: 26508374 DOI: 10.1111/dom.12592] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/01/2015] [Accepted: 10/17/2015] [Indexed: 01/07/2023]
Abstract
Hypoglycaemia after gastric bypass can be severe, but is uncommon, and is sometimes only revealed through monitoring glucose concentrations. The published literature is limited by the heterogeneity of the criteria used for diagnosis, arguing in favour of the Whipple triad with a glycaemia threshold of 55 mg/dl as the diagnostic reference. Women who lost most of their excess weight after gastric bypass, long after the surgery was performed, and who did not have diabetes before surgery are at the greatest risk. In this context, hypoglycaemia results from hyperinsulinism, which is either generated by pancreas anomalies (nesidioblastosis) and/or caused by an overstimulation of β cells by incretins, mainly glucagon-like peptide-1 (GLP-1). Glucose absorption is both accelerated and increased because of the direct communication between the gastric pouch and the jejunum. This is a post-surgical exaggeration of a natural adaptation that is seen in patients who have not undergone surgery in whom glucose is infused directly into the jejunum. There is not always a correspondence between symptoms and biological traits; however, hyperinsulinism is constant if hypoglycaemia is severe and there are neuroglucopenic symptoms. The treatment relies firstly on changes in eating habits, splitting food intake into five to six daily meals, slowing gastric emptying, reducing the glycaemic load and glycaemic index of foods, using fructose and avoiding stress at meals. Pharmacological treatment with acarbose is efficient, but other drugs still need to be validated in a greater number of subjects (insulin, glucagon, calcium channel blockers, somatostatin analogues and GLP-1 analogues). Lastly, if the surgical option has to be used, the benefits (efficient symptom relief) and the risks (weight regain, diabetes) should be weighed carefully.
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Affiliation(s)
- P Ritz
- Pôle Cardio-vasculaire et métabolique, Centre Intégré de l'obésité, Inserm U1027, CHU de Toulouse, Hôpital Larrey, Toulouse, France
| | - C Vaurs
- Pôle Cardio-vasculaire et métabolique, Centre Intégré de l'obésité, Inserm U1027, CHU de Toulouse, Hôpital Larrey, Toulouse, France
| | - M Barigou
- Pôle Cardio-vasculaire et métabolique, Centre Intégré de l'obésité, Inserm U1027, CHU de Toulouse, Hôpital Larrey, Toulouse, France
| | - H Hanaire
- Pôle Cardio-vasculaire et métabolique, Centre Intégré de l'obésité, Inserm U1027, CHU de Toulouse, Hôpital Larrey, Toulouse, France
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14
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Guimarães M, Rodrigues P, Pereira SS, Nora M, Gonçalves G, Albrechtsen NW, Hartmann B, Holst JJ, Monteiro MP. GLP1 and glucagon co-secreting pancreatic neuroendocrine tumor presenting as hypoglycemia after gastric bypass. Endocrinol Diabetes Metab Case Rep 2015; 2015:150049. [PMID: 26266036 PMCID: PMC4530374 DOI: 10.1530/edm-15-0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/15/2015] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED Post-prandial hypoglycemia is frequently found after bariatric surgery. Although rare, pancreatic neuroendocrine tumors (pNET), which occasionally are mixed hormone secreting, can lead to atypical clinical manifestations, including reactive hypoglycemia. Two years after gastric bypass surgery for the treatment of severe obesity, a 54-year-old female with previous type 2 diabetes, developed post-prandial sweating, fainting and hypoglycemic episodes, which eventually led to the finding by ultrasound of a 1.8-cm solid mass in the pancreatic head. The 72-h fast test and the plasma chromogranin A levels were normal but octreotide scintigraphy showed a single focus of abnormal radiotracer uptake at the site of the nodule. There were no other clinical signs of hormone secreting pNET and gastrointestinal hormone measurements were not performed. The patient underwent surgical enucleation with complete remission of the hypoglycemic episodes. Histopathology revealed a well-differentiated neuroendocrine carcinoma with low-grade malignancy with positive chromogranin A and glucagon immunostaining. An extract of the resected tumor contained a high concentration of glucagon (26.707 pmol/g tissue), in addition to traces of GLP1 (471 pmol/g), insulin (139 pmol/g) and somatostatin (23 pmol/g). This is the first report of a GLP1 and glucagon co-secreting pNET presenting as hypoglycemia after gastric bypass surgery. Although pNET are rare, they should be considered in the differential diagnosis of the clinical approach to the post-bariatric surgery hypoglycemia patient. LEARNING POINTS pNETs can be multihormonal-secreting, leading to atypical clinical manifestations.Reactive hypoglycemic episodes are frequent after gastric bypass.pNETs should be considered in the differential diagnosis of hypoglycemia after bariatric surgery.
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Affiliation(s)
- Marta Guimarães
- Department of General Surgery , Centro Hospitalar de Entre o Douro e Vouga, Rua Doutor Cândido Pinho , 4520-211, Santa Maria da Feira , Portugal
| | - Pedro Rodrigues
- Department of General Surgery , Centro Hospitalar de Entre o Douro e Vouga, Rua Doutor Cândido Pinho , 4520-211, Santa Maria da Feira , Portugal
| | - Sofia S Pereira
- Clinical and Experimental Endocrinology, Department of Anatomy , Multidisciplinary Unit for Biomedical Research (UMIB), Instituto de Ciências Biomédicas Abel Salazar, University of Porto (ICBAS/UP), Rua Jorge Viterbo Ferreira, 228 , 4050-313, Porto , Portugal
| | - Mário Nora
- Department of General Surgery , Centro Hospitalar de Entre o Douro e Vouga, Rua Doutor Cândido Pinho , 4520-211, Santa Maria da Feira , Portugal
| | - Gil Gonçalves
- Department of General Surgery , Centro Hospitalar de Entre o Douro e Vouga, Rua Doutor Cândido Pinho , 4520-211, Santa Maria da Feira , Portugal
| | - Nicolai Wewer Albrechtsen
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Bolette Hartmann
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Jens Juul Holst
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Mariana P Monteiro
- Clinical and Experimental Endocrinology, Department of Anatomy , Multidisciplinary Unit for Biomedical Research (UMIB), Instituto de Ciências Biomédicas Abel Salazar, University of Porto (ICBAS/UP), Rua Jorge Viterbo Ferreira, 228 , 4050-313, Porto , Portugal ; Endocrine Unit , Centro Hospitalar de Entre o Douro e Vouga, Rua Doutor Cândido Pinho , 4520-211, Santa Maria da Feira , Portugal
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15
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Abrahamsson N, Edén Engström B, Sundbom M, Karlsson FA. Hypoglycemia in everyday life after gastric bypass and duodenal switch. Eur J Endocrinol 2015; 173:91-100. [PMID: 25899582 DOI: 10.1530/eje-14-0821] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 04/21/2015] [Indexed: 12/30/2022]
Abstract
DESIGN Gastric bypass (GBP) and duodenal switch (DS) in morbid obesity are accompanied by marked metabolic improvements, particularly in glucose control. In recent years, episodes of severe late postprandial hypoglycemia have been increasingly described in GBP patients; data in DS patients are scarce. We recruited three groups of subjects; 15 GBP, 15 DS, and 15 non-operated overweight controls to examine to what extent hypoglycemia occurs in daily life. METHODS Continuous glucose monitoring (CGM) was used during 3 days of normal activity. The glycemic variability was measured by mean amplitude of glycemic excursion and continuous overall net glycemic action. Fasting blood samples were drawn, and the patients kept a food and symptom log throughout the study. RESULTS The GBP group displayed highly variable CGM curves, and 2.9% of their time was spent in hypoglycemia (<3.3 mmol/l, or 60 mg/dl). The DS group had twice as much time in hypoglycemia (5.9%) and displayed CGM curves with little variation as well as lower HbA1c levels (29.3 vs 35.9 mmol/mol, P<0.05). Out of a total of 72 hypoglycemic episodes registered over the 3-day period, 70 (97%) occurred in the postprandial state and only about one-fifth of the hypoglycemic episodes in the GBP and DS groups were accompanied by symptoms. No hypoglycemias were seen in controls during the 3-day period. CONCLUSION Both types of bariatric surgery induce marked, but different, changes in glucose balance accompanied by frequent, but mainly unnoticed, hypoglycemic episodes. The impact and mechanism of hypoglycemic unawareness after weight-reduction surgery deserves to be clarified.
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Affiliation(s)
- Niclas Abrahamsson
- Departments of Medical SciencesSurgical SciencesUppsala University Hospital, S-751 85 Uppsala, Sweden
| | - Britt Edén Engström
- Departments of Medical SciencesSurgical SciencesUppsala University Hospital, S-751 85 Uppsala, Sweden
| | - Magnus Sundbom
- Departments of Medical SciencesSurgical SciencesUppsala University Hospital, S-751 85 Uppsala, Sweden
| | - F Anders Karlsson
- Departments of Medical SciencesSurgical SciencesUppsala University Hospital, S-751 85 Uppsala, Sweden
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Lee CJ, Clark JM, Schweitzer M, Magnuson T, Steele K, Koerner O, Brown TT. Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring) 2015; 23:1079-84. [PMID: 25866150 PMCID: PMC4414701 DOI: 10.1002/oby.21042] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/06/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients. METHODS A questionnaire including the Edinburgh hypoglycemia scale was mailed to patients who underwent either Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) at a single center. Based on the questionnaire, the patients were categorized as having high or low suspicion for post surgical, postprandial hypoglycemic symptoms. RESULTS Of the 1119 patients with valid addresses, 40.2% (N = 450) responded. Among the respondents, 34.2% had a high suspicion for symptoms of post bariatric surgery hypoglycemia. In multivariate analyses, in addition to female sex (P = 0.001), RYGB (P = 0.004), longer time since surgery (P = 0.013), and lack of diabetes (P = 0.040), the high suspicion group was more likely to report pre-operative symptoms of hypoglycemia (P < 0.001), compared to the low suspicion group. Similar results were observed when the high suspicion group was restricted to those requiring assistance from others, syncope, seizure with severe symptoms, or medically confirmed hypoglycemia (N = 52). CONCLUSIONS One third of patients who underwent RYGB or VSG reported postprandial symptoms concerning for postsurgical hypoglycemia, which was related to the presence of pre-operative hypoglycemic symptoms. Pre-operative screening for hypoglycemic symptoms may identify a group of patients at increased risk of postbariatric surgery hypoglycemia.
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Affiliation(s)
- Clare J. Lee
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeanne M. Clark
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Magnuson
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kimberley Steele
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Todd T. Brown
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA
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17
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Laurenius A, Werling M, Le Roux CW, Fändriks L, Olbers T. More symptoms but similar blood glucose curve after oral carbohydrate provocation in patients with a history of hypoglycemia-like symptoms compared to asymptomatic patients after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2014; 10:1047-54. [PMID: 25205571 DOI: 10.1016/j.soard.2014.04.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/27/2014] [Accepted: 04/09/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for obesity through altering several physiologic mechanisms. Some patients experience symptoms suggestive of hypglycemia after LRYGB, but whether these symptoms always are associated with low blood glucose are unclear. The objective of this study was to investigate the correlation between symptoms suggestive of hypglycemia, plasma glucose levels and gut hormones involved in glycemic control. METHODS Eight LRYGB patients with hypglycemia-like symptoms (SY) and 8 patients with no hypglycemia-like symptoms (ASY) ingested a liquid carbohydrate meal. Insulin, plasma-glucose, glucagon-like peptide 1 (GLP-1) and glucagon were measured intermittently 180 minutes postprandially. In addition, pulse rate, blood pressure and symptoms were assessed. RESULTS Plasma glucose at 120 min was lower in the ASY mean (95% CI) 2.4 (1.6,3.3) mmol/L (43.2 mg/dL) compared to the SY group 3.0 (3.1,4.6) mmol/L (54.6 mg/dL), (P = .050). The ASY group had larger reduction in plasma glucose than the SY group from pre- to 120 min postmeal -2.2 (-2.8,-1.7) mmol/L (-39.6 mg/dL) versus -1.1 (-1.7,-0.4) mmol/L (-19.8 mg/dL), (P = .011). The concentrations of insulin, GLP-1 and glucagon did not differ significantly between groups. Blood pressure was similar between groups, but the AUC for pulse rate was higher in the SY than ASY group 13009 (11148,14870) versus 11569 (10837,12300) beats/180 minutes, (P = .038). The SY group reported more symptoms than the ASY group, AUC for Sigstad scale 60 to 180 minutes was 970 (-274,1667) for SY versus 170 for ASY (-39,379), (P = .028). CONCLUSION Patients with a history of symptoms suggestive of hypglycemia after LRYGB neither demonstrated lower plasma glucose nor greater insulin response compared to asymptomatic patients in response to a liquid carbohydrate meal, but perceived more symptoms.
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Affiliation(s)
- Anna Laurenius
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Malin Werling
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Carel W Le Roux
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden; Diabetes Complications Research Centre, UCD Conway Institute, School of Medicine and Medical Science, University College Dublin, Ireland
| | - Lars Fändriks
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Torsten Olbers
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Sweden
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Abrahamsson N, Engström BE, Sundbom M, Karlsson FA. GLP1 analogs as treatment of postprandial hypoglycemia following gastric bypass surgery: a potential new indication? Eur J Endocrinol 2013; 169:885-9. [PMID: 24086087 DOI: 10.1530/eje-13-0504] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The number of morbidly obese subjects submitted to bariatric surgery is rising worldwide. In a fraction of patients undergoing gastric bypass (GBP), episodes with late postprandial hypoglycemia (PPHG) develop 1-3 years after surgery. The pathogenesis of this phenomenon is not fully understood; meal-induced rapid and exaggerated increases of circulating incretins and insulin appear to be at least partially responsible. Current treatments include low-carbohydrate diets, inhibition of glucose intestinal uptake, reduction of insulin secretion with calcium channel blockers, somatostatin analogs, or diazoxide, a KATP channel opener. Even partial pancreatectomy has been advocated. In type 2 diabetes, GLP1 analogs have a well-documented effect of stabilizing glucose levels without causing hypoglycemia. DESIGN We explored GLP1 analogs as open treatment in five consecutive GBP cases seeking medical attention because of late postprandial hypoglycemic symptoms. RESULTS Glucose measured in connection with the episodes in four of the cases had been 2.7, 2.5, 1.8, and 1.6 mmol/l respectively. The patients consistently described that the analogs eliminated their symptoms, which relapsed in four of the five patients when treatment was reduced/discontinued. The drug effect was further documented in one case by repeated 24-h continuous glucose measurements. CONCLUSION These open, uncontrolled observations suggest that GLP1 analogs might provide a new treatment option in patients with problems of late PPHG.
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Lee CJ, Brown T, Magnuson TH, Egan JM, Carlson O, Elahi D. Hormonal response to a mixed-meal challenge after reversal of gastric bypass for hypoglycemia. J Clin Endocrinol Metab 2013; 98:E1208-12. [PMID: 23666968 PMCID: PMC5393460 DOI: 10.1210/jc.2013-1151] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
CONTEXT Severe hypoglycemia is a rare and challenging complication of Roux-en-Y gastric bypass (RYGB), which is characterized by hypersecretion of insulin and incretin hormones in the postprandial state. OBJECTIVE The objective of the study was to determine the clinical and hormonal responses to a mixed-meal challenge after the reversal of RYGB in 2 patients with post-RYGB hypoglycemia. We hypothesized that the reversal of RYGB would lead to clinical improvement in hypoglycemia through the attenuation of incretin hormone secretion. DESIGN/SETTING/SUBJECTS/OUTCOME MEASURES: Two patients with post-RYGB hypoglycemia underwent a standardized meal tolerance test prior to and 8 and 18 months after RYGB reversal, respectively, with the measurement of glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin, and glucose levels. Gastric bypass was reversed by reattaching the small gastric pouch to the bypassed distal stomach and resecting the Roux limb to restore the normal flow of food bolus. RESULTS Both subjects showed persistent evidence of hypoglycemia with marked hyperinsulinemia after the RYGB reversal. GLP-1 levels after the RYGB reversal decreased by 76% and 70%, respectively, from their prereversal levels and to the level of nonhypoglycemic post-RYGB controls. In contrast, GIP levels after the RYGB reversal increased by 3-10 times the level before the reversal and 8-26 times that of the nonhypoglycemic post-RYGB controls. CONCLUSIONS Reversal of RYGB did not alleviate hyperinsulinemic hypoglycemia upon a mixed-meal challenge in our patients, thus suggesting its limited clinical benefit as treatment of post-RYGB hypoglycemia. The marked increase in GIP levels and concurrent decrease in GLP-1 levels in our patients suggest a possible role of GIP in persistent hyperinsulinemic hypoglycemia after the reversal of RYGB.
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Affiliation(s)
- Clare J Lee
- Division of Endocrinology and Metabolism, The Johns Hopkins University, Baltimore, Maryland 21287, USA
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Post-bypass hypoglycaemia: A review of current findings. DIABETES & METABOLISM 2011; 37:274-81. [DOI: 10.1016/j.diabet.2011.04.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 04/18/2011] [Accepted: 04/28/2011] [Indexed: 01/06/2023]
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Ashrafian H, Athanasiou T, Li JV, Bueter M, Ahmed K, Nagpal K, Holmes E, Darzi A, Bloom SR. Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. Obes Rev 2011; 12:e257-72. [PMID: 20880129 DOI: 10.1111/j.1467-789x.2010.00802.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.
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Affiliation(s)
- H Ashrafian
- The Department of Surgery and Cancer, Imperial College London, London, UK.
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