GLP1 analogs as treatment of postprandial hypoglycemia following gastric bypass surgery: a potential new indication?

Abstract

Objective: The number of morbidly obese subjects submitted to bariatric surgery is rising worldwide. In a fraction of patients undergoing gastric bypass (GBP), episodes with late postprandial hypoglycemia (PPHG) develop 1-3 years after surgery. The pathogenesis of this phenomenon is not fully understood; meal-induced rapid and exaggerated increases of circulating incretins and insulin appear to be at least partially responsible. Current treatments include low-carbohydrate diets, inhibition of glucose intestinal uptake, reduction of insulin secretion with calcium channel blockers, somatostatin analogs, or diazoxide, a K ATP channel opener. Even partial pancreatectomy has been advocated. In type 2 diabetes, GLP1 analogs have a well-documented effect of stabilizing glucose levels without causing hypoglycemia. Design: We explored GLP1 analogs as open treatment in five consecutive GBP cases seeking medical attention because of late postprandial hypoglycemic symptoms. Results: Glucose measured in connection with the episodes in four of the cases had been 2.7, 2.5, 1.8, and 1.6 mmol/l respectively. The patients consistently described that the analogs eliminated their symptoms, which relapsed in four of the five patients when treatment was reduced/discontinued. The drug effect was further documented in one case by repeated 24-h continuous glucose measurements.Conclusion: These open, uncontrolled observations suggest that GLP1 analogs might provide a new treatment option in patients with problems of late PPHG.

Evidence-Based Practice Use of Incretin-Based Therapy in the Natural History of Diabetes

“…Incretins are also used in those who develop latepostprandial hypoglycemia after bariatric surgery, reminiscent of the same syndrome seen prior to developing prediabetes or diabetes (restoring first-phase insulin release). 202 Lastly, with the advent of 9 antihyperglycemic agents that do not cause hypoglycemia, patient treatment goals for glycemic control and HbA 1c level have changed. The ADA goal of HbA 1c level , 7%, and even the AACE goal of HbA 1c level # 6.5%, were previously generated to avoid hyperglycemia.…”

A case report

“…[14] In cases of treatment failure, partial or even total pancreatectomy is described as the surgical ultima ratio . [15] To address this treatment failure and the side effects of the drugs used currently, Abrahamsson et al [16] described a novel treatment option for postprandial hypoglycemia following gastric bypass surgery with GLP-1 analogs and reported a protective effect of GLP-1 analogs on pronounced symptoms of postprandial hypoglycemic episodes in 5 patients. Prospective randomized trials to define further the role of GLP-1 analogs in treating postprandial hypoglycemia are lacking but are urgently needed.…”

Hypoglycemia in everyday life after gastric bypass and duodenal switch

“…Glucagon has been tried as infusion but has not been proven to be useful perhaps because of its concomitantly high levels of insulin (31). We have recently reported successful treatment with GLP-1 analogues (32). In the clinical setting, patients with postprandial hypoglycemic episodes after bariatric surgery are becoming more frequent, which is in line with an increase in the number of patients being operated.…”