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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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Cossu L, Cappon G, Streicher O, Herzig D, Bally L, Facchinetti A. Design and Usability Assessment of a User-Centered, Modular Platform for Real-World Data Acquisition in Clinical Trials involving Post-bariatric Surgery Patients. J Diabetes Sci Technol 2023:19322968231220061. [PMID: 38142364 DOI: 10.1177/19322968231220061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
BACKGROUND Clinical trials often face challenges in efficient data collection and participant monitoring. To address these issues, we developed the IMPACT platform, comprising a real-time mobile application for data collection and a web-based dashboard for remote monitoring and management. METHODS This article presents the design, development, and usability assessment of the IMPACT platform customized for patients with post-bariatric surgery hypoglycemia (PBH). We focus on adapting key IMPACT components, including continuous glucose monitoring (CGM), symptom tracking, and meal logging, as crucial elements for user-friendly and efficient PBH monitoring. RESULTS The adapted IMPACT platform demonstrated effectiveness in data collection and remote participant monitoring. The mobile application allowed patients to easily track their data, while the clinician dashboard provided a comprehensive overview of enrolled patients, featuring filtering options and alert mechanisms for identifying data collection issues. The platform incorporated various visual representations, including time plots and category-based visualizations, which greatly facilitated data interpretation and analysis. The System Usability Scale questionnaire results indicated a high level of usability for the web dashboard, with an average score of 86.3 out of 100. The active involvement of clinicians throughout the development process ensured that the platform allowed for the collection and visualization of clinically meaningful data. CONCLUSIONS By leveraging IMPACT's existing features and infrastructure, the adapted version streamlined data collection, analysis, and trial customization for PBH research. The platform's high usability underscores its alignment with the requirements for conducting research using continuous real-world data in PBH patients and other populations of interest.
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Affiliation(s)
- Luca Cossu
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Olivia Streicher
- Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - David Herzig
- Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Lia Bally
- Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
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Tripyla A, Ferreira A, Schönenberger KA, Näf NH, Inderbitzin LE, Prendin F, Cossu L, Cappon G, Facchinetti A, Herzig D, Bally L. Relationship Between Symptom Perception and Postprandial Glycemic Profiles in Patients With Postbariatric Hypoglycemia After Roux-en-Y Gastric Bypass Surgery. Diabetes Care 2023; 46:1792-1798. [PMID: 37499048 DOI: 10.2337/dc23-0454] [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: 03/14/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Post-bariatric surgery hypoglycemia (PBH) is a metabolic complication of Roux-en-Y gastric bypass (RYGB). Since symptoms are a key component of the Whipple's triad to diagnose nondiabetic hypoglycemia, we evaluated the relationship between self-reported symptoms and postprandial sensor glucose profiles. RESEARCH DESIGN AND METHODS Thirty patients with PBH after RYGB (age: 50.1 [41.6-60.6] years, 86.7% female, BMI: 26.5 [23.5-31.2] kg/m2; median [interquartile range]) wore a blinded Dexcom G6 sensor while recording autonomic, neuroglycopenic, and gastrointestinal symptoms over 50 days. Symptoms (overall and each type) were categorized into those occurring in postprandial periods (PPPs) without hypoglycemia, or in the preceding dynamic or hypoglycemic phase of PPPs with hypoglycemia (nadir sensor glucose <3.9 mmol/L). We further explored the relationship between symptoms and the maximum negative rate of sensor glucose change and nadir sensor glucose levels. RESULTS In 5,851 PPPs, 775 symptoms were reported, of which 30.6 (0.0-59.9)% were perceived in PPPs without hypoglycemia, 16.7 (0.0-30.1)% in the preceding dynamic phase and 45.0 (13.7-84.7)% in the hypoglycemic phase of PPPs with hypoglycemia. Per symptom type, 53.6 (23.8-100.0)% of the autonomic, 30.0 (5.6-80.0)% of the neuroglycopenic, and 10.4 (0.0-50.0)% of the gastrointestinal symptoms occurred in the hypoglycemic phase of PPPs with hypoglycemia. Both faster glucose dynamics and lower nadir sensor glucose levels were related with symptom perception. CONCLUSIONS The relationship between symptom perception and PBH is complex, challenging clinical judgement and decision-making in this population.
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Affiliation(s)
- Afroditi Tripyla
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Ferreira
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katja A Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Noah H Näf
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas E Inderbitzin
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Francesco Prendin
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Luca Cossu
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Al-Jafari M, Alrosan S, Alkhawaldeh IM, Zein Eddin S, Abu-Jeyyab M, Zuaiter SN. Dumping Syndrome in Children: A Narrative Review. Cureus 2023; 15:e41407. [PMID: 37546099 PMCID: PMC10402847 DOI: 10.7759/cureus.41407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Dumping syndrome (DS) is a typical side effect of stomach surgery, which includes cancer, non-cancer esophageal and gastric surgery, and bariatric surgery. It is marked by the fast evacuation of undigested food from the stomach into the small intestine, which causes a variety of symptoms. Early dumping symptoms include gastrointestinal symptoms such as stomach discomfort, diarrhea, and nausea, as well as vasomotor symptoms such as drowsiness and face flushing, and occur within the first hour following a meal. Late dumping symptoms appear one to three hours after a meal and are related to reactive hypoglycemia, resulting in hypoglycemia, sweating, palpitations, and confusion. Early dumping pathophysiology involves abnormalities in stomach structure and function, which result in rapid transit of stomach contents to the duodenum, insufficient digestion, and fluid transfers from the vascular compartment to the intestine. Late dumping occurs as a result of hyperinsulinemia caused by the fast passage of undigested foods to the gut. Symptom-based questionnaires and diagnostic testing such as plasma glucose measurement and stomach emptying studies can be used to confirm a diagnosis of DS. The primary approach to managing DS is dietary modifications, including eating smaller, more frequent meals and avoiding high glycemic index carbohydrates. Dietary supplements and medications may be used to slow down gastric emptying or control blood glucose levels. Pharmacological options include alpha-glycosidase inhibitors, somatostatin analogs, glucagon-like peptide-1 analogs, and sodium-glucose cotransporter inhibitors. In severe cases, refractory to conservative measures, surgical interventions may be considered. DS can arise in children following gastric surgery for obesity or corrective surgery for congenital abnormalities. It is frequently misdiagnosed and can have serious implications, such as hypoglycemia-related cognition deficits. Screening and early identification using glucose tolerance testing and continuous glucose monitoring (CGM) are critical in at-risk youngsters. Children's treatment techniques are similar to those used in adults, with dietary changes and medication therapies serving as the cornerstone of care. Overall, DS is a complex condition that requires a multidisciplinary approach to diagnosis and management. Further research is needed to improve understanding of its pathophysiology and optimize treatment strategies, particularly in children. This review aims to provide a well-rounded informative summary of the most recent literature on the under-recognized clinical and scientific aspects of DS among the children age group. It incorporates the quality of life, pathophysiology, diagnosis, prevalence, and treatment.
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Affiliation(s)
| | - Sallam Alrosan
- Internal Medicine, Saint Luke's Health System, Kansas, USA
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