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Aydin Ö, Meijnikman AS, de Jonge PA, van Stralen K, Börger H, Okur K, Iqbal Z, Warmbrunn MV, Acherman YIZ, Bruin S, Winkelmeijer M, Schimmel AWM, Holst JJ, Poulsen SS, Bäckhed F, Nieuwdorp M, Groen AK, Gerdes VEA. Post-Bariatric Hypoglycemia: an Impaired Metabolic Response to a Meal. Obes Surg 2024:10.1007/s11695-024-07309-y. [PMID: 39153140 DOI: 10.1007/s11695-024-07309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/09/2024] [Accepted: 05/23/2024] [Indexed: 08/19/2024]
Abstract
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 Blood was withdrawn at 0, 10, 20, 30, 60, and 120 min after ingestion of a standardized meal.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.
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Affiliation(s)
- Ömrüm Aydin
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Abraham S Meijnikman
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Patrick A de Jonge
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Karlijn van Stralen
- Department of Scientific Research, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Hanneke Börger
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Kadriye Okur
- Department of Bariatric Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Zainab Iqbal
- Cardiometabolic Research, Vrije Universiteit, Amsterdam, the Netherlands
| | - Moritz V Warmbrunn
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Yair I Z Acherman
- Department of Bariatric Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Sjoerd Bruin
- Department of Bariatric Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Maaike Winkelmeijer
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Alinda W M Schimmel
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
| | - Steen S Poulsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Bäckhed
- Department of Cardiovascular and Metabolic Research, Wallenberg Laboratory, Institute of Medicine, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Physiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Max Nieuwdorp
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Albert K Groen
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands
| | - Victor E A Gerdes
- Department of Vascular Medicine, Amsterdam UMC - AMC, Amsterdam, the Netherlands.
- Department of Bariatric Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands.
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands.
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Younes YR, Cron N, Field BC, Nayyar V, Clark J, Zachariah S, Lakshmipathy K, Isuga JO, Maghsoodi N, Emmanuel J. Proposed treatment strategy for reactive hypoglycaemia. Front Endocrinol (Lausanne) 2024; 15:1332702. [PMID: 38370356 PMCID: PMC10869498 DOI: 10.3389/fendo.2024.1332702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024] Open
Abstract
Background/aim Managing reactive hypoglycaemia (RH) poses challenges due to limited and often ineffective treatment options. We report a case series and draw on this to propose a stepwise treatment approach consisting of lifestyle modifications, metformin, GLP-1 analogues, and the use of flash glucose monitoring technology. Method A retrospective review was conducted to analyse the management of 11 cases presenting with recurrent RH symptoms. Result Two patients experienced successful resolution of symptoms through lifestyle modifications. Metformin alone was effective in treating seven out of nine patients who received pharmacological treatment. Two patients with previous upper gastrointestinal surgery showed a partial response to metformin and benefited further from additional long-acting GLP-1 analogue. Pharmacological intervention led to significant reductions in insulin and C-peptide levels in repeat mixed meal tolerance tests (P-values 0.043 for insulin and 0.006 for C-peptide). Finally, flash glucose monitoring technology was useful in early detection and preventing episodes of hypoglycaemia in one of these patients with persistent symptoms. Conclusion These findings highlight the potential efficacy of escalated treatment strategies for RH, including the use of metformin, GLP-1 analogues, and flash glucose monitoring technology.
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Affiliation(s)
- Younes R. Younes
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Nicholas Cron
- Department of Statistics, London School of Economics, London, United Kingdom
| | - Benjamin C.T. Field
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Vidhu Nayyar
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - James Clark
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Sunil Zachariah
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Kavitha Lakshmipathy
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Jimboy O. Isuga
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
| | - Negar Maghsoodi
- Chemical Pathology Department, University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Julian Emmanuel
- Department of Diabetes & Endocrinology, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom
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3
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Hasebe M, Aizawa-Abe M, Shibue K, Hamasaki A. Successful Treatment of Postprandial Hyperinsulinemic Hypoglycemia After Billroth-II Gastrojejunostomy Using Octreotide. JCEM CASE REPORTS 2023; 1:luad150. [PMID: 38045869 PMCID: PMC10690849 DOI: 10.1210/jcemcr/luad150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Indexed: 12/05/2023]
Abstract
Postprandial hyperinsulinemic hypoglycemia, although rare, is a well-documented complication that can manifest after upper gastrointestinal surgery. Despite its potential for severe morbidity, the underlying pathogenesis and optimal treatment strategies for this condition remain insufficiently understood. This report presents a compelling case of postprandial hypoglycemia following Billroth-II gastrojejunostomy, characterized by a marked increase in postprandial insulin levels, accompanied by the exaggerated response of incretin hormones. The incretin effect in this patient was found to be exceptionally high, measuring at approximately 90%. While nutritional interventions proved ineffective in alleviating the patient's symptoms, the administration of octreotide significantly attenuated the exaggerated postprandial insulin and incretin response, substantially ameliorating both the symptoms and postprandial hypoglycemia. Monthly subcutaneous injections of long-acting repeatable octreotide were initiated, resulting in the complete resolution of symptomatic postprandial hypoglycemia. Although the patient developed acalculous cholecystitis and gallstone cholangitis 2 years after commencing octreotide therapy, she has remained free from symptomatic postprandial hypoglycemia for more than 4 years. Our case underscores the efficacy of somatostatin analogs in the management of postprandial hyperinsulinemia after gastrointestinal surgery, shedding light on the potential involvement of incretin hormones in the pathophysiology of this condition.
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Affiliation(s)
- Masashi Hasebe
- Department of Diabetes and Endocrinology, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Kita-ku, Osaka 530-8480, Japan
| | - Megumi Aizawa-Abe
- Department of Diabetes and Endocrinology, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Kita-ku, Osaka 530-8480, Japan
- Division of Diabetes and Endocrinology, Osaka Saiseikai-Noe Hospital, Osaka 536-0001, Japan
| | - Kimitaka Shibue
- Department of Diabetes and Endocrinology, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Kita-ku, Osaka 530-8480, Japan
| | - Akihiro Hamasaki
- Department of Diabetes and Endocrinology, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Kita-ku, Osaka 530-8480, Japan
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Alkhaled L, Al-Kurd A, Butsch WS, Kashyap SR, Aminian A. Diagnosis and management of post-bariatric surgery hypoglycemia. Expert Rev Endocrinol Metab 2023; 18:459-468. [PMID: 37850227 DOI: 10.1080/17446651.2023.2267136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION While bariatric surgery remains the most effective treatment for obesity that allows substantial weight loss with improvement and possibly remission of obesity-associated comorbidities, some postoperative complications may occur. Managing physicians need to be familiar with the common problems to ensure timely and effective management. Of these complications, postoperative hypoglycemia is an increasingly recognized complication of bariatric surgery that remains underreported and underdiagnosed. AREA COVERED This article highlights the importance of identifying hypoglycemia in patients with a history of bariatric surgery, reviews pathophysiology and addresses available nutritional, pharmacological and surgical management options. Systemic evaluation including careful history taking, confirmation of hypoglycemia and biochemical assessment is essential to establish accurate diagnosis. Understanding the weight-dependent and weight-independent mechanisms of improved postoperative glycemic control can provide better insight into the causes of the exaggerated responses that lead to postoperative hypoglycemia. EXPERT OPINION Management of post-operative hypoglycemia can be challenging and requires a multidisciplinary approach. While dietary modification is the mainstay of treatment for most patients, some patients may benefit from pharmacotherapy (e.g. GLP-1 receptor antagonist); Surgery (e.g. reversal of gastric bypass) is reserved for unresponsive severe cases. Additional research is needed to understand the underlying pathophysiology with a primary aim in optimizing diagnostics and treatment options.
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Affiliation(s)
- Lina Alkhaled
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH USA
| | - Abbas Al-Kurd
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
- Department of General Surgery, Henry Ford Hospital, Detroit, MI USA
| | - W Scott Butsch
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
| | - Sangeeta R Kashyap
- Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medicine, New York, NY USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
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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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de Heide LJM, Wouda SHT, Peters VJT, Oosterwerff-Suiker M, Gerdes VA, Emous M, van Beek AP. Medical and surgical treatment of postbariatric hypoglycaemia: Retrospective data from daily practice. Diabetes Obes Metab 2023; 25:735-747. [PMID: 36377811 DOI: 10.1111/dom.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
AIM To evaluate medical and surgical treatment of postbariatric hypoglycaemia (PBH) in daily practice. MATERIALS AND METHODS Retrospective data were extracted from medical records from four hospitals. PBH was defined by neuroglycopenic symptoms together with a documented glucose <3.0 mmol/L in the postprandial setting after previous bariatric surgery. Data were scored semiquantitatively on efficacy and side effects by two reviewers independently. Duration of efficacy and of use were calculated. RESULTS In total, 120 patients were included with a median follow-up of 27 months with a mean baseline age of 41 years, total weight loss of 33% and glucose nadir 2.3 mmol/L. Pharmacotherapy consisted of acarbose, diazoxide, short- and long-acting octreotide and glucagon-like peptide-1 receptor agonist analogues (liraglutide and semaglutide) with an overall efficacy in 45%-75% of patients. Combination therapy with two drugs was used by 30 (25%) patients. The addition of a second drug was successful in over half of the patients. Long-acting octreotide and the glucagon-like peptide-1 receptor agonist analogues scored best in terms of efficacy and side effects with a median duration of use of 35 months for octreotide. Finally, 23 (19%) patients were referred for surgical intervention. Efficacy of the surgical procedures, pouch banding, G-tube placement in remnant stomach and Roux-en-Y gastric bypass reversal, pooled together, was 79% with a median duration of initial effect of 13 months. CONCLUSIONS In daily practice, pharmacotherapy for PBH was successful in half to three quarters of patients. Combination therapy was often of value. One in five patients finally needed a surgical procedure, with overall good results.
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Affiliation(s)
- Loek J M de Heide
- Centre for Obesity Northern Netherlands, Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Sterre H T Wouda
- Department of Biomedical Science, University of Groningen, Groningen, The Netherlands
| | - Vincent J T Peters
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Department of Management, Tilburg University, Tilburg, The Netherlands
| | | | - Victor A Gerdes
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Marloes Emous
- Centre for Obesity Northern Netherlands, Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Tu K, Zhao LJ, Gu J. Adult focal β-cell nesidioblastosis: A case report. World J Clin Cases 2023; 11:150-156. [PMID: 36687197 PMCID: PMC9846974 DOI: 10.12998/wjcc.v11.i1.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/27/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Nesidioblastosis usually refers to a series of clinical manifestations caused by the proliferation of β-cells in pancreatic islets, and these clinical manifestations are hyperinsulinemia and persistent hypoglycemia. According to the size of the lesion, nesidioblastosis is divided into focal nesidioblastosis, diffuse nesidioblastosis and atypical nesidioblastosis, and its pathogenesis is still unclear. Nesidioblastosis is mainly seen in infants and rarely reported in adults, especially focal nesidioblastosis, which is difficult to distinguish from insulinoma.
CASE SUMMARY We report a case of adult focal β-cell nesidioblastosis in which the preoperative diagnosis was insulinoma. The patient was a 48-year-old male who suffered from repeated morning and fasting palpitations, sweating, and severe disturbance of consciousness for 5 years. His blood glucose was found to be as low as 1.79 mmol/L during an attack. However, abdominal computed tomography showed no abnormalities. Magnetic resonance imaging and endoscopic ultrasonography demonstrated a nodular mass in the head of the pancreas, combined with hyperinsulinemia and high serum C-peptide. The patient was diagnosed with insulinoma and underwent Beger surgery; however, the postoperative pathological results showed nesidioblastosis.
CONCLUSION Although surgical resection is the preferred option for nesidioblastosis, some cases can be treated non-surgically. In order to increase clinicians' understanding of nesidioblastosis, it is necessary to review the pathogenesis, diagnosis and treatment of this disease.
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Affiliation(s)
- Kui Tu
- Department of General Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Li-Jin Zhao
- Department of General Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Jin Gu
- Department of General Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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Llewellyn DC, Logan Ellis H, Aylwin SJB, Oštarijaš E, Green S, Sheridan W, Chew NWS, le Roux CW, Miras AD, Patel AG, Vincent RP, Dimitriadis GK. The efficacy of GLP-1RAs for the management of postprandial hypoglycemia following bariatric surgery: a systematic review. Obesity (Silver Spring) 2023; 31:20-30. [PMID: 36502288 PMCID: PMC10107620 DOI: 10.1002/oby.23600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/06/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Postprandial hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass and gastric sleeve surgery that may detrimentally affect patient quality of life. One likely causal factor is glucagon-like peptide-1 (GLP-1), which has an exaggerated rise following ingestion of carbohydrates after bariatric surgery. This paper sought to assess the role of GLP-1 receptor agonists (GLP-1RAs) in managing postprandial hypoglycemia following bariatric surgery. METHODS MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Scopus were systematically and critically appraised for all peer-reviewed publications that suitably fulfilled the inclusion criteria established a priori. This systematic review was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols (PRISMA-P). It followed methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (International Prospective Register of Systematic Reviews; identifier CRD420212716429). RESULTS AND CONCLUSIONS Postprandial hyperinsulinemic hypoglycemia remains a notoriously difficult to manage metabolic complication of bariatric surgery. This first, to the authors' knowledge, systematic review presents evidence suggesting that use of GLP-1RAs does not lead to an increase of hypoglycemic episodes, and, although this approach may appear counterintuitive, the findings suggest that GLP-1RAs could reduce the number of postprandial hypoglycemic episodes and improve glycemic variability.
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Affiliation(s)
- David C Llewellyn
- Department of Endocrinology, King's College Hospital NHS Foundation Trust, London, UK
| | - Hugh Logan Ellis
- Department of Endocrinology, King's College Hospital NHS Foundation Trust, London, UK
| | - Simon J B Aylwin
- Department of Endocrinology, King's College Hospital NHS Foundation Trust, London, UK
| | - Eduard Oštarijaš
- Institute for Translational Medicine, University of Pécs Medical School, University of Pécs, Pécs, Hungary
| | - Shauna Green
- Department of Acute Medicine, Lewisham and Greenwich NHS Foundation Trust, Queen Elizabeth Hospital, London, UK
| | - William Sheridan
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - Nicholas W S Chew
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Carel W le Roux
- Diabetes Complication Research Centre, School of Medicine and Medical Science, UCD Conway Institute, University College Dublin, Belfield, Ireland
| | - Alexander D Miras
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ameet G Patel
- Department of Minimal Access Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Royce P Vincent
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
- Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
| | - Georgios K Dimitriadis
- Department of Endocrinology, King's College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, School of Cardiovascular Medicine and Sciences, Obesity, Type 2 Diabetes and Immunometabolism Research Group, King's College London, London, UK
- Division of Reproductive Health, Warwick Medical School, University of Warwick, Coventry, UK
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9
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Patience N, Sheehan A, Cummings C, Patti ME. Medical Nutrition Therapy and Other Approaches to Management of Post-bariatric Hypoglycemia: A Team-Based Approach. Curr Obes Rep 2022; 11:277-286. [PMID: 36074258 DOI: 10.1007/s13679-022-00482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management. RECENT FINDINGS As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1-10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH. Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.
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Affiliation(s)
- Nicole Patience
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
| | - Amanda Sheehan
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | | | - Mary Elizabeth Patti
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
- Research Division, Joslin Diabetes Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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10
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Vilarrasa N, Bretón I, Ballesteros-Pomar M, Lecube A, Goday A, Pellitero S, Sánchez R, Zugasti A, Ciudin A, de Hollanda A, Rubio MA. Recommendations for the diagnosis and treatment of hypoglycaemia after bariatric surgery. ENDOCRINOL DIAB NUTR 2022; 69:723-731. [PMID: 36424342 DOI: 10.1016/j.endien.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/12/2021] [Indexed: 06/16/2023]
Abstract
Postprandial hyperinsulinaemic hypoglycaemia is a common complication of bariatric surgery. Although in general its evolution is mild and self-limited, it can lead to neuroglycopaenia and compromise the patient's safety and quality of life. The aim of this document is to offer some recommendations to facilitate the clinical care of these complex patients, reviewing the aetiopathogenesis, its diagnosis and treatment that, sequentially, will include dietary and pharmacological measures and surgery in refractory cases. In the absence of high-quality studies, the diagnostic and therapeutic approach proposed is based on the consensus of experts of the Grupo de Obesidad de la Sociedad Española de Endocrinología y Nutrición [Obesity Group of the Spanish Society of Endocrinology and Nutrition], GOSEEN. Those undergoing bariatric surgery should be informed of the possibility of developing this complication.
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Affiliation(s)
- Nuria Vilarrasa
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Bellvitge-IDIBELL, ĹHospitalet de Llobregat, Barcelona, Spain. CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain).
| | - Irene Bretón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Gregorio Marañón, IiSGM, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - María Ballesteros-Pomar
- Servicio de Endocrinología y Nutrición, Complejo Asistencial Universitario de León, León, Spain
| | - Albert Lecube
- Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova, Lleida, Spain. Obesity, Diabetes and Metabolism Research Group (ODIM), IRBLLeida, Universitat de Lleida, CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain)
| | - Albert Goday
- Servicio de Endocrinología y Nutrició, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Spain. CIBERobn (Centros de Investigación Biomédica en Red-CIBER, Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain)
| | - Silvia Pellitero
- Servicio de Endocrinología y Nutrición, Hospital Universitari Germans Trias i Pujol, IMPPC, Institut d Investigació Germans Trias i Pujol (IGTP), Badalona, Barcelona, Spain
| | - Raquel Sánchez
- Servicio de Cirugía General, Complejo Hospitalario Universitario de Vigo, Instituto de Investigación Galicia Sur, Vigo, Pontevedra, Spain
| | - Ana Zugasti
- Sección Nutrición y Dietética, Complejo Hospitalario de Navarra, Pamplona/Iruña, Spain
| | - Andrea Ciudin
- Servicio de Endocrinología y Nutrición, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain) Endocrinology and Nutrition Department, Hospital Universitari Vall Hebron, Barcelona, Spain
| | - Ana de Hollanda
- Servicio de Endocrinología y Nutrición, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain. CIBERobn (Centros de Investigación Biomédica en Red-CIBER, Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid)
| | - Miguel Angel Rubio
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, IDISSC, Madrid, Spain
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Sheehan A, Goldfine A, Bajwa M, Wolfs D, Kozuka C, Piper J, Fowler K, Patti ME. Pramlintide for post-bariatric hypoglycaemia. Diabetes Obes Metab 2022; 24:1021-1028. [PMID: 35137513 PMCID: PMC9035096 DOI: 10.1111/dom.14665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to examine the hypothesis that pramlintide would reduce hypoglycaemia by slowing gastric emptying and reducing postprandial glucagon secretion, thus limiting postprandial glycaemic excursions and insulin secretion, and thus to determine the efficacy of pramlintide on frequency and severity of hypoglycaemia in post-bariatric hypoglycaemia (PBH). MATERIALS AND METHODS Participants with PBH following gastric bypass were recruited from outpatient clinics at the Joslin Diabetes Center, Boston, Massachusetts for an open-label study of pramlintide efficacy over 8 weeks. Twenty-three participants were assessed for eligibility, 20 participants had at least one pramlintide dose, and 14 completed the study. A mixed-meal tolerance test (MMTT) was performed at baseline and after 8 weeks of subcutaneous pramlintide with a sequential dose increase to a maximum of 120 micrograms (mean 69 ± 32 mcg) three times daily. The primary endpoint was change in glucose excursions during the MMTT. Secondary measures included MMTT insulin response, satiety and dumping score, percentage time with sensor glucose (SG) <3.9 mM, and number of days with minimum SG <3 mM, during masked continuous glucose monitoring. RESULTS There were no differences in MMTT glucose, glucagon or insulin between baseline and post treatment. We observed no significant change in satiety or dumping scores. The overall frequency of low SG values did not change, although there was substantial inter-individual variability. CONCLUSIONS In PBH, pramlintide does not modulate glycaemic or insulin responses, satiety, or dumping scores during an MMTT and does not impact glycaemic excursions or decrease low SG levels in the outpatient setting.
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Affiliation(s)
- Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Allison Goldfine
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammed Bajwa
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Danielle Wolfs
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Chisayo Kozuka
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jacqueline Piper
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Kristen Fowler
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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12
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Recomendaciones para el diagnóstico y tratamiento de las hipoglucemias tras cirugía bariátrica. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Decock A, Verroken C, Van de Velde F, Vilsbøll T, Holst JJ, T'Sjoen G, Lapauw B. In patients with controlled acromegaly, indices of glucose homeostasis correlate with IGF-1 levels rather than with type of treatment. Clin Endocrinol (Oxf) 2021; 95:65-73. [PMID: 33715210 DOI: 10.1111/cen.14461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acromegaly is accompanied by abnormalities in glucose and lipid metabolism which improve upon treatment. Few studies have investigated whether these improvements differ between treatment modalities. This study aimed to compare glucose homeostasis, lipid profiles and postprandial gut hormone response in patients with controlled acromegaly according to actual treatment. DESIGN Cross-sectional study at a tertiary care centre. PATIENTS Twenty-one patients with acromegaly under stable control (ie insulin growth factor 1 [IGF1] levels below sex- and age-specific thresholds and a random growth hormone level <1.0 µg/L) after surgery (n = 5), during treatment with long-acting somatostatin analogues (n = 10) or long-acting somatostatin analogues + pegvisomant (n = 6) were included. MEASUREMENTS Glucose, insulin, total cholesterol and high-density lipoprotein-cholesterol were measured in fasting serum samples. Glucose, insulin, triglycerides, glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 were measured during a mixed meal test. Insulin sensitivity was evaluated by a hyperinsulinaemic-euglycaemic clamp. RESULTS There were no significant differences in glucose tolerance, insulin sensitivity or postprandial gut hormone responses between the three groups. Positive correlations between IGF1 levels and HbA1c, fasting glucose and insulin levels and postprandial area under the curve (AUC) of glucose and insulin and also an inverse association between IGF1 and glucose disposal rate were found in the whole cohort (all p < .05, lowest p = .001 for postprandial AUC glucose with rs = 0.660). CONCLUSION In this cross-sectional study in patients with controlled acromegaly, there were no differences in glucose homeostasis or postprandial substrate metabolism according to treatment modality. However, a lower IGF1 level seems associated with a better metabolic profile.
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Affiliation(s)
- Amelie Decock
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | | | | | - Tina Vilsbøll
- NNF Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Juul Holst
- NNF Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
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Bienvenot R, Sirveaux MA, Nguyen-Thi PL, Brunaud L, Quilliot D. Symptomatic Hypoglycemia After Gastric Bypass: Incidence and Predictive Factors in a Cohort of 1,138 Consecutive Patients. Obesity (Silver Spring) 2021; 29:681-688. [PMID: 33608995 DOI: 10.1002/oby.23118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE After Roux-en-Y gastric bypass (RYGB), postprandial hyperinsulinemic hypoglycemia (PPHH) is particularly critical because of the risk of trauma. The aim of this study was to assess the incidence and identify risk factors for symptomatic PPHH. METHODS Patients with RYGB were classified into moderate PPHH (MH) or severe hypoglycemia (SH), which is defined as patients with neuroglycopenic symptoms. Logistic multivariate linear regressions were performed to identify predictive factors for symptomatic PPHH and more specifically for SH with neuroglycopenic symptoms. Patients with diabetes and those with a follow-up shorter than 2 years were excluded. RESULTS Among the 1,138 patients, 44.2% had at least one episode of hypoglycemia with a mean delay of 25.5 (21.3) months, 32.6% had MH, and 11.6% had SH. The annual incidence rate of SH was 2.5% the first year, 3.7% the second year, and 1.5% the third year. Independent predictive factors for higher risk of SH were: younger age (odds ratio [OR] = 1.01; 95% CI: 1.05-16.69; P = 0.0007), lower BMI after RYGB (OR = 1.61; 95% CI: 1.17-2.22; P = 0.0035), and maximal weight loss (OR = 1.04; 95% CI = 1.39-1.23; P = 0.0106), whereas higher preoperative BMI was protective (OR = 0.78; 95% CI: 0.64-0.95; P = 0.0112). CONCLUSIONS This observational cohort study showed that the incidence of severe PPHH with neuroglycopenic symptoms after RYGB was higher than expected.
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Affiliation(s)
- Rébecca Bienvenot
- Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | - Marie-Aude Sirveaux
- Department of Visceral, Metabolic and Cancer Surgery (CVMC), Multidisciplinary Unit for Obesity Surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, Vandoeuvre-lès-Nancy, France
| | - Phi-Linh Nguyen-Thi
- Medical Evaluation Department, Department of Clinical Research Support PARC, University of Lorraine, CHU Nancy, Nancy, France
| | - Laurent Brunaud
- Department of Visceral, Metabolic and Cancer Surgery (CVMC), Multidisciplinary Unit for Obesity Surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, Vandoeuvre-lès-Nancy, France
- INSERM U1256, Nutrition, Genetics, Environmental Risks, Faculty of Medicine, University of Lorraine, Nancy, France
| | - Didier Quilliot
- Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
- Department of Visceral, Metabolic and Cancer Surgery (CVMC), Multidisciplinary Unit for Obesity Surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, Vandoeuvre-lès-Nancy, France
- INSERM U1256, Nutrition, Genetics, Environmental Risks, Faculty of Medicine, University of Lorraine, Nancy, France
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15
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McManus NM, Margart KM, Offman RP. Hypoglycemia Worsened by Glucose Administration: A Case of Hypoglycemia Years After Gastric Surgery. J Emerg Med 2021; 60:e77-e79. [PMID: 33483201 DOI: 10.1016/j.jemermed.2020.11.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a rare syndrome characterized by postprandial hypoglycemia with neuroglycopenic symptoms occurring 1 to 3 h after a meal. Diagnosis can be elusive, as the vast majority of patients have normal fasting blood glucose levels, and onset of hypoglycemic episodes can be a late complication of gastric surgery. CASE REPORT We report the case of a 45-year-old woman presenting to the Emergency Department (ED) with new-onset seizures and hypoglycemia worsened by glucose administration. Surgical history is pertinent for a Roux-en-Y gastric bypass approximately 10 years prior to presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although rare, it is important for emergency physicians to be vigilant of this disease process as a traditional treatment approach for hypoglycemia may be detrimental. Although cases of NIPHS have been documented in literature, its presence in emergency medicine-specific literature is seemingly nonexistent. Noninvasive imaging techniques will be normal, and diagnosis is dependent on awareness of this disease entity coupled with a detailed history.
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Affiliation(s)
- Nicholas M McManus
- Emergency Department, West Michigan Emergency Medicine Residency Program, Mercy Health - Muskegon, Muskegon, Michigan; Emergency Department, Lake Michigan Emergency Specialists, Muskegon, Michigan; Emergency Department, Mercy Health - Muskegon, Muskegon, Michigan
| | - Kendel M Margart
- Emergency Department, West Michigan Emergency Medicine Residency Program, Mercy Health - Muskegon, Muskegon, Michigan; Emergency Department, Mercy Health - Muskegon, Muskegon, Michigan
| | - Ryan P Offman
- Emergency Department, West Michigan Emergency Medicine Residency Program, Mercy Health - Muskegon, Muskegon, Michigan; Emergency Department, Lake Michigan Emergency Specialists, Muskegon, Michigan; Emergency Department, Mercy Health - Muskegon, Muskegon, Michigan
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16
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Haris B, Saraswathi S, Hussain K. Somatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia. Ther Adv Endocrinol Metab 2020; 11:2042018820965068. [PMID: 33329885 PMCID: PMC7720331 DOI: 10.1177/2042018820965068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a biochemical finding of low blood glucose levels due to the dysregulation of insulin secretion from pancreatic β-cells. Under normal physiological conditions, glucose metabolism is coupled to β-cell insulin secretion so that blood glucose levels are maintained within the physiological range of 3.5-5.5 mmol/L. However, in HH this coupling of glucose metabolism to insulin secretion is perturbed so that insulin secretion becomes unregulated. HH typically occurs in the neonatal, infancy and childhood periods and can be due to many different causes. Adults can also present with HH but the causes in adults tend to be different. Somatostatin (SST) is a peptide hormone that is released by the delta cells (δ-cells) in the pancreas. It binds to G protein-coupled SST receptors to regulate a variety of location-specific and selective functions such as hormone inhibition, neurotransmission and cell proliferation. SST plays a potent role in the regulation of both insulin and glucagon secretion in response to changes in glucose levels by negative feedback mechanism. The half-life of SST is only 1-3 min due to quick degradation by peptidases in plasma and tissues. Thus, a direct continuous intravenous or subcutaneous infusion is required to achieve the therapeutic effect. These limitations prompted the discovery of SST analogues such as octreotide and lanreotide, which have longer half-lives and therefore can be administered as injections. SST analogues are used to treat different forms of HH in children and adults and therapeutic effect is achieved by suppressing insulin secretion from pancreatic β-cells by complex mechanisms. These treatments are associated with several side effects, especially in the newborn period, with necrotizing enterocolitis being the most serious side effect and hence SS analogues should be used with extreme caution in this age group.
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Affiliation(s)
- Basma Haris
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Saras Saraswathi
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Professor of Paediatrics, Weill Cornell Medicine-Qatar, Division Chief – Endocrinology, Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, OPC, C6-340 |PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar
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17
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Zanley E, Shah ND, Craig C, Lau JN, Rivas H, McLaughlin T. Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass. Surg Obes Relat Dis 2020; 17:456-465. [PMID: 33160876 DOI: 10.1016/j.soard.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/29/2020] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. OBJECTIVES To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. SETTING Stanford University Hospital and Clinics. METHODS Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. RESULTS A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. CONCLUSIONS G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.
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Affiliation(s)
- Elizabeth Zanley
- Department of Medicine, Stanford University, Stanford, California
| | - Neha D Shah
- Department of Clinical Nutrition, Stanford Health Care, Stanford, California
| | - Colleen Craig
- Department of Medicine, Stanford University, Stanford, California
| | - James N Lau
- Department of General Surgery, Stanford University, Stanford, California
| | - Homero Rivas
- Department of General Surgery, Stanford University, Stanford, California
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18
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Zhou LY, Deng MQ, Xiao XH. Potential contribution of the gut microbiota to hypoglycemia after gastric bypass surgery. Chin Med J (Engl) 2020; 133:1834-1843. [PMID: 32649508 PMCID: PMC7470015 DOI: 10.1097/cm9.0000000000000932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Obesity has become a global health problem. Lifestyle modification and medical treatment only appear to yield short-term weight loss. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it sustains weight reduction and results in the remission of obesity-associated comorbidities for obese individuals. However, patients who undergo this surgery may develop hypoglycemia. To date, the diagnosis is challenging and the prevalence of post-RYGB hypoglycemia (PRH) is unclear. RYGB alters the anatomy of the upper gastrointestinal tract and has a combined effect of caloric intake restriction and nutrient malabsorption. Nevertheless, the physiologic changes after RYGB are complex. Although hyperinsulinemia, incretin effects, dysfunction of β-cells and α-cells, and some other factors have been widely investigated and are reported to be possible mediators of PRH, the pathogenesis is still not completely understood. In light of the important role of the gut microbiome in metabolism, we hypothesized that the gut microbiome might also be a critical link between RYGB and hypoglycemia. In this review, we mainly highlight the current possible factors predisposing individuals to PRH, particularly related to the gut microbiota, which may yield significant insights into the intestinal regulation of glucose metabolic homeostasis and provide novel clues to improve the treatment of type 2 diabetes mellitus.
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Affiliation(s)
- Li-Yuan Zhou
- Key Laboratory of Endocrinology, Translational Medicine Center, Ministry of Health, Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Tan M, Lamendola C, Luong R, McLaughlin T, Craig C. Safety, efficacy and pharmacokinetics of repeat subcutaneous dosing of avexitide (exendin 9-39) for treatment of post-bariatric hypoglycaemia. Diabetes Obes Metab 2020; 22:1406-1416. [PMID: 32250530 DOI: 10.1111/dom.14048] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
AIM To evaluate the safety, efficacy and pharmacokinetics of repeat dosing of two formulations of subcutaneous (SC) avexitide (exendin 9-39) in patients with post-bariatric hypoglycaemia (PBH). METHODS In this phase 2, multiple-ascending-dose study conducted at Stanford University, 19 women with PBH underwent a baseline oral glucose tolerance test (OGTT), with metabolic and symptomatic assessments. Fourteen were then sequentially assigned to receive one of four ascending-dose levels of twice-daily lyophilized (Lyo) avexitide by SC injection for 3 days. On the basis of safety, efficacy and tolerability, five additional participants then received a novel liquid formulation (Liq) of avexitide by SC injection at a fixed dose of 30 mg twice daily for 3 days. All 19 participants underwent a repeat OGTT on day 3 of dosing to quantify metabolic, symptomatic and pharmacokinetic responses. RESULTS Treatment with Lyo avexitide reduced the magnitude of symptomatic hyperinsulinaemic hypoglycaemia at all dose levels, with dose-dependent improvements in glucose nadir, insulin peak and symptom score; doses ≥20 mg twice daily did not require glycaemic rescue (administered at glucose <2.8 mmol/L). Participants receiving Liq avexitide 30 mg twice daily did not require any glycaemic rescue, and on average achieved a 47% increase in glucose nadir, a 67% reduction in peak insulin, and a 47% reduction in overall symptom score. Equivalent doses of Liq versus Lyo avexitide yielded higher and more sustained plasma concentrations. Both formulations were well tolerated. CONCLUSIONS In patients with PBH, twice-daily administration of SC avexitide effectively raised the glucose nadir and prevented severe hypoglycaemia requiring rescue intervention. Avexitide may represent a viable therapy for PBH.
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Affiliation(s)
- Marilyn Tan
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, California, USA
| | - Cynthia Lamendola
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Roger Luong
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | | | - Colleen Craig
- Eiger BioPharmaceuticals, Consultant, Palo Alto, California, USA
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Abstract
As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed.
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Affiliation(s)
- Maria L Collazo-Clavell
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Meera Shah
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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21
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Alawami F, Al Hajjaj A. Post Prandial Hyperinsulnemic Hypoglycemia Thirteen Years after Gastric Bypass Surgery. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sheehan A, Patti ME. Hypoglycemia After Upper Gastrointestinal Surgery: Clinical Approach to Assessment, Diagnosis, and Treatment. Diabetes Metab Syndr Obes 2020; 13:4469-4482. [PMID: 33239898 PMCID: PMC7682607 DOI: 10.2147/dmso.s233078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Post-bariatric hypoglycemia (PBH) is an increasingly encountered complication of upper gastrointestinal surgery; the prevalence of this condition is anticipated to rise given yearly increases in bariatric surgical procedures. While PBH is incompletely understood, there is a growing body of research describing the associated factors, mechanisms, and treatment approaches for this condition. EVIDENCE ACQUISITION Data are integrated and summarized from studies of individuals affected by PBH and hypoglycemia following upper gastrointestinal surgery obtained from PubMed searches (1990-2020). EVIDENCE SYNTHESIS Information addressing etiology, incidence/prevalence, clinical characteristics, assessment, and treatment were reviewed and synthesized for the practicing physician. Literature reports were supplemented by clinical experience as indicated, when published data were not available. CONCLUSION PBH can be life-altering and severe for a subset of individuals. Given the chronic nature of this condition, and sequelae of both acute and recurrent episodes, increasing provider awareness of both the condition and associated risk factors is critical for assessment, prompt diagnosis, treatment, and preoperative identification of individuals at risk.
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Affiliation(s)
- Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Correspondence: Mary Elizabeth Patti Research Division, Joslin Diabetes Center, 1 Joslin Place, Boston, MA02215, USATel +1 617-309-1966Fax +1 617-309-2593 Email
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Øhrstrøm CC, Worm D, Højager A, Andersen D, Holst JJ, Kielgast UL, Hansen DL. Postprandial hypoglycaemia after Roux-en-Y gastric bypass and the effects of acarbose, sitagliptin, verapamil, liraglutide and pasireotide. Diabetes Obes Metab 2019; 21:2142-2151. [PMID: 31144430 DOI: 10.1111/dom.13796] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/17/2019] [Accepted: 05/28/2019] [Indexed: 12/19/2022]
Abstract
AIM To investigate the effects of acarbose, sitagliptin, verapamil, liraglutide and pasireotide on post-bariatric hypoglycaemia (PBH) after Roux-en-Y gastric bypass. MATERIALS AND METHODS In a randomized crossover study, 11 women who had undergone Roux-en-Y gastric bypass and had documented hypoglycaemia were each evaluated during a baseline period without treatment and during five treatment periods with the following interventions: acarbose 50 mg for 1 week, sitagliptin 100 mg for 1 week, verapamil 120 mg for 1 week, liraglutide 1.2 mg for 3 weeks and pasireotide 300 μg as a single dose. Treatment effects were evaluated by a mixed-meal tolerance test (MMTT) and, for all treatment periods except pasireotide, by 6 days of continuous glucose monitoring (CGM). RESULTS Treatment with acarbose and treatment with pasireotide both significantly lifted nadir glucose levels (mean ± SEM 3.9 ± 0.2 and 7.9 ± 0.4 vs 3.4 ± 0.2; P < .03) and reduced time in hypoglycaemia during the MMTTs. Acarbose reduced peak glucose levels and time in hyperglycaemia, whereas pasireotide greatly increased both variables. Acarbose and pasireotide reduced insulin and C-peptide levels, and pasireotide also diminished glucagon-like peptide-1 levels. Sitagliptin lowered nadir glucose values, while verapamil and liraglutide had no effect on hypoglycaemia. During the CGM periods, the treatments had no impact on hypoglycaemia, whereas acarbose and liraglutide reduced hyperglycaemia and glycaemic variability. CONCLUSIONS In an experimental setting, treatment with acarbose and pasireotide reduced PBH. Acarbose appears to have an overall glucose-stabilizing effect, whereas pasireotide leads to increased and sustained hyperglycaemia.
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Affiliation(s)
| | - Dorte Worm
- Department of Medicine, Amager Hospital, Amager, Denmark
| | - Anna Højager
- Department of Medicine, Zealand University Hospital, Køge, Denmark
| | - Ditte Andersen
- Department of Medicine, Zealand University Hospital, Køge, Denmark
| | - Jens Juul Holst
- Department of Biomedical Sciences and Novo Nordisk Foundation Centre for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
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Mejia-Otero JD, Grishman EK, Patni N. Diazoxide for the Treatment of Hypoglycemia Resulting From Dumping Syndrome in a Child. J Endocr Soc 2019; 3:1357-1360. [PMID: 31286099 PMCID: PMC6608547 DOI: 10.1210/js.2019-00120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/30/2019] [Indexed: 01/18/2023] Open
Abstract
Dumping syndrome-associated hypoglycemia is caused by an exaggerated hyperinsulinemic response to glucose absorption in the small intestine. Diazoxide acts on the ATP-sensitive potassium channels and prevents insulin secretion and, thus, should be beneficial for the treatment of hypoglycemia secondary to dumping syndrome. We report on the efficacy of diazoxide in a pediatric patient with dumping syndrome. A 6-year-old girl born at 32 weeks' gestation age with resultant short gut syndrome and liver failure, who had undergone liver, small bowel, and pancreas transplantation at 1 year of age, developed late dumping-like symptoms with postprandial hypoglycemia, headaches, tremors, and irritability. She experienced relief of symptoms with oral intake. An oral glucose tolerance test showed a fasting and 2-hour blood glucose of 3.9 and 2.8 mmol/L, respectively. A gastric emptying study confirmed the diagnosis of dumping. A diet with 2 g of fiber and cornstarch and antimotility medications failed to improve the dumping symptoms. Diazoxide was started orally at a dose of 3 mg/kg/d and was increased to 5 mg/kg/d, divided every 8 hours, after 1 month, with improvement of postprandial blood glucose values (3.6 to 5.0 mmol/L). No hypertrichosis, fluid retention, respiratory concerns, or other side effects were noted. Several duodenal dilations were performed, with resultant improvement of gastric emptying. She was eventually weaned from diazoxide, and no further episodes of substantial hypoglycemia occurred. In conclusion, diazoxide was efficacious and safe for the treatment of hypoglycemia secondary to dumping syndrome in children. It could be of particular use as a bridging therapy for children awaiting more definitive surgical interventions.
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Affiliation(s)
- Juan D Mejia-Otero
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ellen K Grishman
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nivedita Patni
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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25
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Ames A, Lago-Hernandez CA, Grunvald E. Hypoglycemia After Gastric Bypass Successfully Treated With Calcium Channel Blockers: Two Case Reports. J Endocr Soc 2019; 3:1417-1422. [PMID: 31286108 PMCID: PMC6608552 DOI: 10.1210/js.2019-00097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Postprandial hyperinsulinemic hypoglycemia is an uncommon yet well-established complication of Roux-en-Y gastric bypass (RYGB) that can result in serious morbidity and adversely affect quality of life. It is often unrecognized and may be difficult to diagnose. Management is challenging. As the number of bariatric procedures increases in parallel with the obesity epidemic, clinicians will be tasked to offer effective medical therapies for this complication. Two patients presented several years after RYGB with severe postprandial hypoglycemia. In one of the patients, we were able to document simultaneous postprandial hypoglycemia and hyperinsulinemia. Conventional treatment approaches, including medical nutrition therapy, acarbose, diazoxide, and octreotide, were either ineffective or limited by poor tolerance. Nifedipine and verapamil were used adjunctively with dietary modification, resulting in resolution of symptomatic hypoglycemic episodes. These agents are therapeutic options that can be used for some patients refractory to more traditional treatments. They should be tried before surgical procedures are considered for affected patients. These two cases demonstrate that calcium channel blockers may be efficacious and appropriate for select patients refractory to dietary interventions alone.
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Affiliation(s)
- Angharad Ames
- School of Medicine, University of California, San Diego, California.,Department of Psychiatry, University of California, Riverside, California
| | | | - Eduardo Grunvald
- School of Medicine, University of California, San Diego, California.,Bariatric and Metabolic Institute, Division of Minimally Invasive Surgery, Department of Surgery, University of California, San Diego, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Diego, California
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26
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Elliott JA, Docherty NG, Murphy CF, Eckhardt HG, Doyle SL, Guinan EM, Ravi N, Reynolds JV, le Roux CW. Changes in gut hormones, glycaemic response and symptoms after oesophagectomy. Br J Surg 2019; 106:735-746. [PMID: 30883706 DOI: 10.1002/bjs.11118] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/21/2018] [Accepted: 12/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Oesophagectomy is associated with reduced appetite, weight loss and postprandial hypoglycaemia, the pathophysiological basis of which remains largely unexplored. This study aimed to investigate changes in enteroendocrine function after oesophagectomy. METHODS In this prospective study, 12 consecutive patients undergoing oesophagectomy were studied before and 10 days, 6, 12 and 52 weeks after surgery. Serial plasma total fasting ghrelin, and glucagon-like peptide 1 (GLP-1), insulin and glucose release following a standard 400-kcal mixed-meal stimulus were determined. CT body composition and anthropometry were assessed, and symptom scores calculated using European Organisation for Research and Treatment of Cancer (EORTC) questionnaires. RESULTS At 1 year, two of the 12 patients exhibited postprandial hypoglycaemia, with reductions in bodyweight (mean(s.e.m.) 17·1(3·2) per cent, P < 0·001), fat mass (21.5(2.5) kg versus 25.5(2.4) kg before surgery; P = 0·014), lean body mass (51.5(2.2) versus 54.0(1.8) kg respectively; P = 0·003) and insulin resistance (HOMA-IR: 0.84(0.17) versus 1.16(0.20); P = 0·022). Mean(s.e.m.) fasting ghrelin levels decreased from postoperative day 10, but had recovered by 1 year (preoperative: 621·5(71·7) pg/ml; 10 days: 415·1(59·80) pg/ml; 6 weeks: 309·0(42·0) pg/ml; 12 weeks: 415·8(52·1) pg/ml; 52 weeks: 547·4(83·2) pg/ml; P < 0·001) and did not predict weight loss (P = 0·198). Postprandial insulin increased progressively at 10 days, 6, 12 and 52 weeks (mean(s.e.m.) insulin AUC0-30 min : fold change 1·7(0·4), 2·0(0·4), 3·5(0·7) and 4·0(0·8) respectively; P = 0·001). Postprandial GLP-1 concentration increased from day 10 after surgery (P < 0·001), with a 3·3(1·8)-fold increase at 1 year (P < 0·001). Peak GLP-1 level was inversely associated with the postprandial glucose nadir (P = 0·041) and symptomatic neuroglycopenia (Sigstad score, P = 0·017, R2 = 0·45). GLP-1 AUC predicted loss of weight (P = 0·008, R2 = 0·52) and fat mass (P = 0·010, R2 = 0·64) at 1 year. CONCLUSION Altered enteroendocrine physiology is associated with early satiety, weight loss and postprandial hypoglycaemia after oesophagectomy.
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Affiliation(s)
- J A Elliott
- Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, University College Dublin, Dublin, Ireland.,National Oesophageal and Gastric Centre, Trinity Centre for Health Sciences, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - N G Docherty
- Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, University College Dublin, Dublin, Ireland.,Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - C F Murphy
- Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, University College Dublin, Dublin, Ireland.,National Oesophageal and Gastric Centre, Trinity Centre for Health Sciences, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - H-G Eckhardt
- Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, University College Dublin, Dublin, Ireland
| | - S L Doyle
- School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - E M Guinan
- National Oesophageal and Gastric Centre, Trinity Centre for Health Sciences, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - N Ravi
- National Oesophageal and Gastric Centre, Trinity Centre for Health Sciences, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - J V Reynolds
- National Oesophageal and Gastric Centre, Trinity Centre for Health Sciences, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - C W le Roux
- Diabetes Complications Research Centre, Conway Institute of Biomedical and Biomolecular Research, University College Dublin, Dublin, Ireland.,Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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27
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Salehi M, Vella A, McLaughlin T, Patti ME. Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies. J Clin Endocrinol Metab 2018; 103:2815-2826. [PMID: 30101281 PMCID: PMC6692713 DOI: 10.1210/jc.2018-00528] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia, occurring after bariatric and other forms of upper gastrointestinal surgery, is increasingly encountered by clinical endocrinologists. The true frequency of this condition remains uncertain, due, in part, to differences in the diagnostic criteria and in the affected populations, as well as relative lack of patient and physician awareness and understanding of this condition. Postbariatric hypoglycemia can be severe and disabling for some patients, with neuroglycopenia (altered cognition, seizures, and loss of consciousness) leading to falls, motor vehicle accidents, and job and income loss. Moreover, repeated episodes of hypoglycemia can result in hypoglycemia unawareness, further impairing safety and requiring the assistance of others to treat hypoglycemia. OBJECTIVE In this review, we summarize and integrate data from studies of patients affected by hypoglycemia after Roux-en-Y gastric bypass (RYGB) surgery, obtained from PubMed searches (1990 to 2017) and reference searches of relevant retrieved articles. Whereas hypoglycemia can also be observed after sleeve gastrectomy and fundoplication, this review is focused on post-RYGB, given the greater body of published clinical studies at present. OUTCOME MEASURES Data addressing specific aspects of diagnosis, pathophysiology, and treatment were reviewed by the authors; when not available, the authors have provided opinions based on clinical experience with this challenging condition. CONCLUSIONS Hypoglycemia, occurring after gastric bypass surgery, is challenging for patients and physicians alike. This review provides a systematic approach to diagnosis and treatment based on the underlying pathophysiology.
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Affiliation(s)
- Marzieh Salehi
- Diabetes Division, University of Texas Health at San Antonio, San Antonio, Texas
| | | | | | - Mary-Elizabeth Patti
- Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, 1 Joslin Place, Boston, Massachusetts 02215. E-mail:
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28
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Davis DB, Khoraki J, Ziemelis M, Sirinvaravong S, Han JY, Campos GM. Roux en Y gastric bypass hypoglycemia resolves with gastric feeding or reversal: Confirming a non-pancreatic etiology. Mol Metab 2018; 9:15-27. [PMID: 29449181 PMCID: PMC5869737 DOI: 10.1016/j.molmet.2017.12.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postprandial hypoglycemia is an infrequent but disabling complication of Roux-en-Y gastric bypass (RYGB) surgery. Controversy still exists as to whether the postprandial hyperinsulinemia observed is due to inherent changes in pancreatic β-cell mass or function or to reversible alterations caused by RYGB anatomy. We aimed to determine if gastric feeding or reversal of RYGB would normalize postprandial glucose and hormone excursions in patients with symptomatic hypoglycemia. METHODS We completed a prospective study of six patients with severe symptomatic RYGB hypoglycemia who underwent RYGB reversal. An additional subject without hypoglycemia who underwent RYGB reversal was also studied prospectively. Mixed meal tolerance testing (MTT) was done orally (RYGB anatomy), via gastrostomy tube in the excluded stomach in the setting of RYGB, and several months after RYGB reversal. RESULTS All subjects reported symptomatic improvement of hypoglycemia after reversal of RYGB. Weight gain after reversal was moderate and variable. Postprandial glucose, insulin, and GLP-1 excursions were significantly diminished with gastric feeding and after reversal. Insulin secretion changed proportional to glucose levels and insulin clearance increased after reversal. Glucagon/insulin ratios were similar throughout study. We further compared the impact of modified sleeve gastrectomy reversal surgery to those with restoration of complete stomach and found no significant differences in weight regain or in postprandial glucose or hormone levels. CONCLUSIONS Reversal of RYGB is an effective treatment option for severe postprandial hypoglycemia. The pathophysiology of this disorder is primarily due to RYGB anatomy resulting in altered glucose, gut, and pancreatic hormone levels and decreased insulin clearance, rather than inherent β-cell hyperplasia or hyperfunction.
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Affiliation(s)
- Dawn Belt Davis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705, USA.
| | - Jad Khoraki
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA
| | - Martynas Ziemelis
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA
| | - Sirinart Sirinvaravong
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Jee Young Han
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Guilherme M Campos
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA.
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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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Yaqub A, Smith EP, Salehi M. Hyperinsulinemic hypoglycemia after gastric bypass surgery: what's up and what's down? Int J Obes (Lond) 2017; 42:ijo2017257. [PMID: 29087389 PMCID: PMC6599543 DOI: 10.1038/ijo.2017.257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/17/2017] [Accepted: 09/24/2017] [Indexed: 12/18/2022]
Abstract
Obesity is a global public health problem and attempts to treat this condition using life style with and without pharmacological interventions have not been successful in majority of obese individuals. To date, the most effective treatment for obesity is weight loss surgery. One of the most widely used procedures to treat obesity worldwide, Roux-en-Y gastric bypass surgery (RYGB), has shown to induce diabetes remission in addition to significant and sustainable weight loss. As the number of this procedure performed over the last two decades increased, it has become clear that a subgroup of individuals develop postprandial hypoglycemia several years after surgery. This debilitating late complication of RYGB is often associated with loss of consciousness or seizures, and in severe cases, it is only partially responsive to diet modification or other available therapeutic options. The diagnosis is often a challenge resulting in delays in receiving care in the affected individuals. Although the underlying mechanisms are under current investigations, growing evidence suggest that a combination of exaggerated meal-derived nutrient appearance to systemic circulation and altered islet and gut hormone response after eating have a role in pathogenesis of this condition. The goal of this review is to highlight new perspectives regarding this life-threatening complication of RYGB. The etiology, diagnosis, recommendation on how to distinguish from classic dumping and current available treatment based on literature review will be discussed. In addition, physiologic changes after gastric bypass predisposing to hypoglycemia syndrome will be highlighted.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.257.
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Affiliation(s)
- A Yaqub
- Division of Endocrinology, Department of Medicine, Diabetes and Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - EP Smith
- Division of Endocrinology, Department of Medicine, Diabetes and Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - M Salehi
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Incidence and Predictive Factors of Postprandial Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: A Five year Longitudinal Study. Ann Surg 2017; 264:878-885. [PMID: 27560624 DOI: 10.1097/sla.0000000000001915] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postprandial hyperinsulinemic hypoglycemia (PHH) is often reported after Roux-en-Y gastric bypass (RYGB). In the absence of a prospective study, the clinical and biological determinants of PHH remain unclear. OBJECTIVE To determine the incidence and predictive factors of PHH after RYGB. METHODS Participants were 957 RYGB patients enrolled in an ongoing longitudinal cohort study. We analyzed the results of an oral glucose tolerance test (OGTT) routinely performed before surgery and 1 and/or 5 years after. PHH was defined as blood glucose < 50 mg/dL AND plasma insulin > 3 mU/L at 120 minutes post glucose challenge. Validated indices of insulin sensitivity (Matsuda index), beta-cell function (Insulinogenic index), and beta-cell mass (fasting C-peptide: glucose ratio) were calculated, from glucose, insulin, and c-peptide values measured during OGTT. RESULTS OGTT results were available in all patients at baseline, in 85.6% at 12 months and 52.8% at 60 months. The incidence of PHH was 0.5% at baseline, 9.1% * and 7.9%* at 12 months and 60 months following RYGB (*: P < 0.001). In multivariate logistic regression analysis, PHH after RYGB was independently associated with lower age (P = 0.005), greater weight loss (P = 0.031), as well as higher beta-cell function (P = 0.002) and insulin sensitivity (P < 0.001), but not with beta-cell mass (P = 0.381). A preoperative elevated beta-cell function was an independent predictor of PHH after RYGB (receiver operating characteristics curve area under the curve 0.68, P = 0.04). CONCLUSIONS: The incidence of PHH significantly increased after RYGB but remained stable between 1 and 5 years. The estimation of beta-cell function with an OGTT before surgery can identify patients at risk for developing PHH after RYGB.
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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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Kassem MAM, Durda MA, Stoicea N, Cavus O, Sahin L, Rogers B. The Impact of Bariatric Surgery on Type 2 Diabetes Mellitus and the Management of Hypoglycemic Events. Front Endocrinol (Lausanne) 2017; 8:37. [PMID: 28298900 PMCID: PMC5331470 DOI: 10.3389/fendo.2017.00037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/14/2017] [Indexed: 01/10/2023] Open
Abstract
Recent studies discussed the benefit of bariatric surgery on obese patients diagnosed with type 2 diabetes mellitus (T2DM). Several factors play an essential role in predicting the impact of bariatric surgery on T2DM, such as ABCD score (age, BMI, C-peptide, and duration of the disease), HbA1c, and fasting blood glucose, incretins [glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP)]. DiaRem score known to include factors such as age, HbA1c, medication, and insulin usage used to predict the remission of T2DM, but it has some limitations. An extensive literature search was conducted on PubMed and Google Scholar using keywords such as gastric bypass, T2DM, bariatric surgery, GLP-1, GIP, and post bariatric hypoglycemia. Restrictive-malabsorptive procedures are most effective in treating T2DM patients based on changes induced in appetite through regulation of gastrointestinal hormones, with decreased hunger and increased satiation. We provide a review of bariatric surgery influence on T2DM and management of post-intervention hypoglycemic events. Post-bariatric surgery hypoglycemia is a serious complication especially when patients develop life-threatening neuroglycopenia with loss of consciousness and seizure. The avoidance of this adverse event may be achieved by strict dietary modification including a restriction on carbohydrates as well as foods with high glycemic index. Further research will provide more information on post-bariatric surgery hyperinsulinemic hypoglycemia pathophysiology and management.
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Affiliation(s)
- Mahmoud Attia Mohamed Kassem
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- *Correspondence: Mahmoud Attia Mohamed Kassem,
| | - Michael Andrew Durda
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Omer Cavus
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Levent Sahin
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Barbara Rogers
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Abstract
Bariatric surgery is most commonly carried out in women of childbearing age. Whilst fertility rates are improved, pregnancy following bariatric surgery poses several challenges. Whilst rates of many adverse maternal and foetal outcomes in obese women are reduced after bariatric surgery, pregnancy is best avoided for 12-24 months to reduce the potential risk of intrauterine growth retardation. Dumping syndromes are common after bariatric surgery and can present diagnostic and therapeutic challenges in pregnancy. Early dumping occurs due to osmotic fluid shifts resulting from rapid gastrointestinal food transit, whilst late dumping is characterized by a hyperinsulinemic response to rapid absorption of simple carbohydrates. Dietary measures are the mainstay of management of dumping syndromes but pharmacotherapy may sometimes become necessary. Acarbose is the least hazardous pharmacological option for the management of postprandial hypoglycemia in pregnancy. Nutrient deficiencies may vary depending on the type of surgery; it is important to optimize the nutritional status of women prior to and during pregnancy. Dietary management should include adequate protein and calorie intake and supplementation of vitamins and micronutrients. A high clinical index of suspicion is required for early diagnosis of surgical complications of prior weight loss procedures during pregnancy, including small bowel obstruction, internal hernias, gastric band erosion or migration and cholelithiasis.
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Affiliation(s)
- Ram Prakash Narayanan
- Department of Obesity Medicine and Endocrinology, Salford Royal NHS Foundation Trust and University Teaching Hospital, Salford, UK
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
- Diabetes Centre, St Helens Hospital, Marshalls Cross Road, St Helens, WA9 3DA UK
| | - Akheel A. Syed
- Department of Obesity Medicine and Endocrinology, Salford Royal NHS Foundation Trust and University Teaching Hospital, Salford, UK
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
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35
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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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Synchronous Nesidioblastosis, Endocrine Microadenoma, and Intraductal Papillary Mucinous Neoplasia in a Man Presenting With Hyperinsulinemic Hypoglycemia. Pancreas 2016; 45:154-9. [PMID: 26658039 DOI: 10.1097/mpa.0000000000000430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Herein, we report the first case of concomitant nesidioblastosis, pancreatic neuroendocrine tumor, and intraductal papillary mucinous neoplasia. The combination is significant as each of these pathological entities is independently very rare. The patient was a 33-year-old man who presented with symptomatic hyperinsulinemic hypoglycemia and no risk factors for pancreatic disease. Abdominal imaging showed an isolated 12 mm pancreatic lesion, whilst selective arterial calcium stimulation testing demonstrated multiple territories of insulin excess. He proceeded to subtotal pancreatectomy. Histopathology revealed an endocrine microadenoma, α and β cell nesidioblastosis, and multifocal intraductal papillary mucinous neoplasia. The endocrine microadenoma and nesidioblastosis stained for insulin, suggesting both likely contributed to hypoglycemia. Glucagon immunohistochemistry was also positive, though there were no clinical features of glucagon excess. Hypoglycemia resolved postoperatively. This case and other evidence from the literature suggest that hyperplasia and neoplasia may occur sequentially in the pancreas, and that endocrine and exocrine tumorigenesis may be linked in some individuals. Further study is required to identify a unifying mechanism, and to elucidate potential ramifications in the management of patients with pancreatic neoplasms.
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Vilarrasa N, Goday A, Rubio MA, Caixàs A, Pellitero S, Ciudin A, Calañas A, Botella JI, Bretón I, Morales MJ, Díaz-Fernández MJ, García-Luna PP, Lecube A. Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry. Obes Facts 2016; 9:41-51. [PMID: 26901345 PMCID: PMC5644871 DOI: 10.1159/000442764] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Severe postprandial hypoglycemia after bariatric surgery is a rare but invalidating complication. Our aim was to describe the different tests performed for its diagnosis and their outcomes as well as the response to the prescribed pharmacological and surgical treatments. METHODS Multicenter, retrospective systematic review of cases with recurrent severe postprandial hypoglycemia. RESULTS Over 11 years of follow-up, 22 patients were identified. The test most used to provoke hypoglycemia was the oral glucose load test followed by the mixed meal test which was the least standardized test. With pharmacological treatment, 3 patients were symptom-free (with octreotide) and in 12 patients hypoglycemic episodes were attenuated. Seven patients had persistent hypoglycemic episodes and underwent surgery. Partial pancreatectomy was performed in 3 patients who had positive selective arterial calcium stimulation, and nesidioblastosis was confirmed in 2 patients. Reconversion to normal anatomy was performed in 3 patients, and 1 patient underwent a resection of the 'candy cane' roux limb, with resolution of hypoglycemia in all cases. CONCLUSIONS There is high heterogeneity in the evaluation and treatment options for postoperative hypoglycemia. In patients that do not respond to pharmacological treatment, reconstruction of gastrojejunal continuity may be the safest and most successful procedure.
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Affiliation(s)
- Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Hospital Universitario de Bellvitge-IDIBELL, Lx00B4;Hospitalet de Llobregat, Barcelona, Spain
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Malik S, Mitchell JE, Steffen K, Engel S, Wiisanen R, Garcia L, Malik SA. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract 2015; 10:1-14. [PMID: 26522879 DOI: 10.1016/j.orcp.2015.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/17/2015] [Accepted: 07/06/2015] [Indexed: 02/06/2023]
Abstract
Hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass (RYGB) due to the changes in gut hormonal milieu. Physicians should be aware of this complication to ensure timely and effective treatment of post-RYGB patients, who present to them with hypoglycemic symptoms. Possible causes of hypoglycemia in these patients include late dumping syndrome, nesidioblastosis and rarely insulinoma. Systematic evaluation including history, biochemical analysis, and diagnostic testing might help in distinguishing among these diagnoses. Continuous glucose monitoring is also a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success. Treatment should begin with strict low carbohydrate diet, followed by medication therapy. Therapy with diazoxide, acarbose, calcium channel blockers and octreotide have been proven to be beneficial, but the response apparently is highly variable. When other treatment options fail, surgical options can be considered.
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Affiliation(s)
- Sarah Malik
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | - James E Mitchell
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States.
| | - Kristine Steffen
- Neuropsychiatric Research Institute, Fargo, ND, United States; North Dakota State University, United States
| | - Scott Engel
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | | | | | - Shahbaz Ali Malik
- University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
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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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41
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Pucci A, Cheung WH, Jones J, Manning S, Kingett H, Adamo M, Elkalaawy M, Jenkinson A, Finer N, Doyle J, Hashemi M, Batterham RL. A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy. Endocrinol Diabetes Metab Case Rep 2015; 2015:150020. [PMID: 26664728 PMCID: PMC4674657 DOI: 10.1530/edm-15-0020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 05/18/2015] [Indexed: 12/13/2022] Open
Abstract
Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m2). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m2, weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m2), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m2 after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting.
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Affiliation(s)
- Andrea Pucci
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Wui Hang Cheung
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Jenny Jones
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK
| | - Sean Manning
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; National Institute of Health Research, Biomedical Research Centre, University College London Hospitals , London, W1T 7DN , UK
| | - Helen Kingett
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Marco Adamo
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Mohamed Elkalaawy
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; Clinical and Experimental Surgery Department , Medical Research Institute, University of Alexandria , Hadara, Alexandria, 21561 , Egypt
| | - Andrew Jenkinson
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Nicholas Finer
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Jacqueline Doyle
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Majid Hashemi
- UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK
| | - Rachel L Batterham
- Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; National Institute of Health Research, Biomedical Research Centre, University College London Hospitals , London, W1T 7DN , UK
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42
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Total pancreatectomy for the management of refractory post-gastric bypass hypoglycemia. Dig Dis Sci 2015; 60:1505-9. [PMID: 25344909 DOI: 10.1007/s10620-014-3408-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/15/2014] [Indexed: 12/19/2022]
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Sarwar H, Chapman WH, Pender JR, Ivanescu A, Drake AJ, Pories WJ, Dar MS. Hypoglycemia after Roux-en-Y gastric bypass: the BOLD experience. Obes Surg 2015; 24:1120-4. [PMID: 24737312 DOI: 10.1007/s11695-014-1260-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Hafiz Sarwar
- Department of Internal Medicine, Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA,
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Shi Y, Avatapalle HB, Skae MS, Padidela R, Newbould M, Rigby L, Flanagan SE, Ellard S, Rahier J, Clayton PE, Dunne MJ, Banerjee I, Cosgrove KE. Increased plasma incretin concentrations identifies a subset of patients with persistent congenital hyperinsulinism without KATP channel gene defects. J Pediatr 2015; 166:191-4. [PMID: 25444530 DOI: 10.1016/j.jpeds.2014.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/30/2014] [Accepted: 09/09/2014] [Indexed: 11/26/2022]
Abstract
Congenital hyperinsulinism causes profound hypoglycemia, which may persist or resolve spontaneously. Among 13 children with congenital hyperinsulinism, elevated incretin hormone concentrations were detected in 2 with atypical, persistent disease. We suggest that incretin biomarkers may identify these patients, and that elevated hormone levels may contribute to their pathophysiology.
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Affiliation(s)
- Yanqin Shi
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom
| | - Hima B Avatapalle
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Mars S Skae
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Raja Padidela
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Melanie Newbould
- Department of Pediatric Histopathology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Lindsey Rigby
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, United Kingdom
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, United Kingdom
| | - Jacques Rahier
- Department of Pathology, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Peter E Clayton
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Manchester Academic Health Science Centre, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Mark J Dunne
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Karen E Cosgrove
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom.
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Kefurt R, Langer FB, Schindler K, Shakeri-Leidenmühler S, Ludvik B, Prager G. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test. Surg Obes Relat Dis 2014; 11:564-9. [PMID: 25737101 DOI: 10.1016/j.soard.2014.11.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM). SETTING University Hospital, Austria. METHODS To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test. RESULTS CGM detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while MMT indicated hypoglycemia in 29% of the patients. CGM also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM. CONCLUSIONS Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB.
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Affiliation(s)
- Ronald Kefurt
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix B Langer
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Karin Schindler
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Bernhard Ludvik
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria.
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46
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Redford C, Smith J. Use of a somatostatin analogue in treating severe hypoglycaemia and neuroglycopaenia, in association with hyperinsulinaemia, post bariatric surgery. PRACTICAL DIABETES 2014. [DOI: 10.1002/pdi.1865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Christopher Redford
- Department of Diabetes and Endocrinology; Torbay Hospital, South Devon Healthcare Trust; Torquay UK
| | - Jamie Smith
- Department of Diabetes and Endocrinology; Torbay Hospital, South Devon Healthcare Trust; Torquay UK
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47
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Treatment of severe postRYGB hyperinsulinemic hypoglycemia with pasireotide: A comparison with octreotide on insulin, glucagon, and GLP-1. Surg Obes Relat Dis 2014; 10:e31-3. [DOI: 10.1016/j.soard.2013.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 11/09/2013] [Accepted: 11/12/2013] [Indexed: 11/23/2022]
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48
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Affiliation(s)
- Mary-Elizabeth Patti
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts.
| | - Allison B Goldfine
- Research Division, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
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49
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Abstract
The peptide hormone somatostatin (SST) is produced in the brain, the gut, and in δ-cells in pancreatic islets of Langerhans. SST secretion from δ-cells is stimulated by glucose, amino acids, and glucagon-like peptide-1. Exogenous SST strongly inhibits the secretion of the blood glucose-regulating hormones insulin and glucagon from pancreatic β-cells and α-cells, respectively. Endogenous SST secreted from δ-cells is a paracrine regulator of insulin and glucagon secretion, although the exact physiological significance of this regulation is unclear. Secreted SST binds to specific receptors (SSTRs), which are coupled to Gi/o proteins. In both β- and α-cells, activation of SSTRs suppresses hormone secretion by reducing cAMP levels, inhibiting electrical activity, decreasing Ca²⁺ influx through voltage-gated Ca²⁺ channels and directly reducing exocytosis in a Ca²⁺ and cAMP-independent manner. In rodents, β-cells express predominantly SSTR5, whereas α-cells express SSTR2. In human islets, SSTR2 is the dominant receptor in both β- and α-cells, but other isoforms also contribute to the SST effects. Evidence from rodent models suggests that SST secretion from δ-cells is dysregulated in diabetes mellitus, which may contribute to the metabolic disturbances in this disease. SST analogues are currently used for the treatment of hyperinsulinism and other endocrine disorders, including acromegaly and Cushing's syndrome.
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Affiliation(s)
- Matthias Braun
- Alberta Diabetes Institute, Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Shirakawa J, Murohashi Y, Okazaki N, Yamazaki S, Tamura T, Okuyama T, Togashi Y, Terauchi Y. Using miglitol at 30 min before meal is effective in hyperinsulinemic hypoglycemia after a total gastrectomy. Endocr J 2014; 61:1115-23. [PMID: 25142087 DOI: 10.1507/endocrj.ej14-0290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 45-year-old woman who had undergone total gastrectomy for gastric cancer presented with a history of postprandial hypoglycemic episodes with loss of consciousness after meals. Laboratory findings revealed marked hyperinsulinemia and hypoglycemia after a meal. We first treated the patient with octreotide; however, she was unable to continue the treatment because of adverse effects of the drug, such as nausea and headache. Diazoxide was used next for preventing hyperinsulinemia; however, this was not effective for suppressing the postprandial insulin secretion. Since hypoglycemia following gastrectomy is thought to be caused by rapid delivery of nutrients into the duodenum, we performed a meal tolerance test while varying the timing of administration of miglitol in relation to the meal. Miglitol was administered 30 min before, just before, or both 30 min and just before a meal. In the case of administration just before a meal, insulin secretion was suppressed, although hypoglycemia was not prevented. Administration of the drug 30 min before a meal prevented postprandial hypoglycemia by slowing the increase of the blood glucose and serum insulin levels following the meal to a greater degree than administration just before a meal. Miglitol administration both 30 min and just before a meal caused an even smoother increase in blood glucose and serum insulin levels following the meal. In this report, we propose a new therapeutic approach for reactive hypoglycemia after gastrectomy, namely, administration of miglitol 30 min before meals.
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Affiliation(s)
- Jun Shirakawa
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama-City University, Yokohama 236-0004, Japan
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