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Hazlehurst J, Khoo B, Lobato CB, Ilesanmi I, Abbott S, Chan T, Pillai S, Maslin K, Purkayastha S, McGowan B, Andrews R, Nicholson E, McCullough K, Albon L, Batterham R, Dimitriadis GK, Forbes S, Bewick G, Tan TMM. Society for Endocrinology guidelines for the diagnosis and management of post-bariatric hypoglycaemia. Endocr Connect 2024; 13:EC-23-0285. [PMID: 38451861 PMCID: PMC11046333 DOI: 10.1530/ec-23-0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/07/2024] [Indexed: 03/09/2024]
Abstract
Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres. AIM to improve and standardise clinical practice in the diagnosis and management of PBH. OBJECTIVES (1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition. METHOD A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders. OUTCOME We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.
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Affiliation(s)
- Jonathan Hazlehurst
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bernard Khoo
- Endocrinology, Division of Medicine, University College London, London, UK
| | - Carolina Brito Lobato
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Copenhagen University Hospital – Amager and Hvidovre, Hvidovre, Denmark
| | - Ibiyemi Ilesanmi
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Sally Abbott
- Department of Dietetics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tin Chan
- Faculty of Medicine, Chinese University of Hong Kong, Hong Kong
| | - Sanesh Pillai
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Kate Maslin
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - Sanjay Purkayastha
- Brunel University, London, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
| | - Barbara McGowan
- Endocrinology, Guys’ and St Thomas’s NHS Foundation Trust, London, UK
| | - Rob Andrews
- University of Exeter Medical School, Exeter, UK
| | | | | | - Lorraine Albon
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Rachel Batterham
- Endocrinology, Division of Medicine, University College London, London, UK
| | | | - Shareen Forbes
- BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gavin Bewick
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Tricia M-M Tan
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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Rossini G, Risi R, Monte L, Sancetta B, Quadrini M, Ugoccioni M, Masi D, Rossetti R, D'Alessio R, Mazzilli R, Defeudis G, Lubrano C, Gnessi L, Watanabe M, Manfrini S, Tuccinardi D. Postbariatric surgery hypoglycemia: Nutritional, pharmacological and surgical perspectives. Diabetes Metab Res Rev 2024; 40:e3750. [PMID: 38018334 DOI: 10.1002/dmrr.3750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
Post-bariatric hypoglycaemia (PBH) is a metabolic complication of bariatric surgery (BS), consisting of low post-prandial glucose levels in patients having undergone bariatric procedures. While BS is currently the most effective and relatively safe treatment for obesity and its complications, the development of PBH can significantly impact patients' quality of life and mental health. The diagnosis of PBH is still challenging, considering the lack of definitive and reliable diagnostic tools, and the fact that this condition is frequently asymptomatic. However, PBH's prevalence is alarming, involving up to 88% of the post-bariatric population, depending on the diagnostic tool, and this may be underestimated. Given the prevalence of obesity soaring, and an increasing number of bariatric procedures being performed, it is crucial that physicians are skilled to diagnose PBH and promptly treat patients suffering from it. While the milestone of managing this condition is nutritional therapy, growing evidence suggests that old and new pharmacological approaches may be adopted as adjunct therapies for managing this complex condition.
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Affiliation(s)
- Giovanni Rossini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Renata Risi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lavinia Monte
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Biagio Sancetta
- Department of Medicine, Unit of Neurology, Neurophysiology, Neurobiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Maria Quadrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Massimiliano Ugoccioni
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Davide Masi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rebecca Rossetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Rossella Mazzilli
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Defeudis
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Carla Lubrano
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucio Gnessi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Mikiko Watanabe
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Manfrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
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3
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Lui A, Patel RS, Krause-Hauch M, Sparks RP, Patel NA. Regulation of Human Sortilin Alternative Splicing by Glucagon-like Peptide-1 (GLP1) in Adipocytes. Int J Mol Sci 2023; 24:14324. [PMID: 37762628 PMCID: PMC10531797 DOI: 10.3390/ijms241814324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Type 2 diabetes mellitus is a chronic metabolic disease with no cure. Adipose tissue is a major site of systemic insulin resistance. Sortilin is a central component of the glucose transporter -Glut4 storage vesicles (GSV) which translocate to the plasma membrane to uptake glucose from circulation. Here, using human adipocytes we demonstrate the presence of the alternatively spliced, truncated sortilin variant (Sort_T) whose expression is significantly increased in diabetic adipose tissue. Artificial-intelligence-based modeling, molecular dynamics, intrinsically disordered region analysis, and co-immunoprecipitation demonstrated association of Sort_T with Glut4 and decreased glucose uptake in adipocytes. The results show that glucagon-like peptide-1 (GLP1) hormone decreases Sort_T. We deciphered the molecular mechanism underlying GLP1 regulation of alternative splicing of human sortilin. Using splicing minigenes and RNA-immunoprecipitation assays, the results show that GLP1 regulates Sort_T alternative splicing via the splice factor, TRA2B. We demonstrate that targeted antisense oligonucleotide morpholinos reduces Sort_T levels and improves glucose uptake in diabetic adipocytes. Thus, we demonstrate that GLP1 regulates alternative splicing of sortilin in human diabetic adipocytes.
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Affiliation(s)
- Ashley Lui
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA; (A.L.); (M.K.-H.)
| | - Rekha S. Patel
- Research Service, James A. Haley Veterans Hospital, Tampa, FL 33612, USA; (R.S.P.); (R.P.S.)
| | - Meredith Krause-Hauch
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA; (A.L.); (M.K.-H.)
| | - Robert P. Sparks
- Research Service, James A. Haley Veterans Hospital, Tampa, FL 33612, USA; (R.S.P.); (R.P.S.)
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Niketa A. Patel
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA; (A.L.); (M.K.-H.)
- Research Service, James A. Haley Veterans Hospital, Tampa, FL 33612, USA; (R.S.P.); (R.P.S.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ramos-Levi AM, Rubio-Herrera MA, Matía-Martín P, Pérez-Ferre N, Marcuello C, Sánchez-Pernaute A, Torres-García AJ, Calle-Pascual AL. Mixed Meal Tolerance Test Versus Continuous Glucose Monitoring for an Effective Diagnosis of Persistent Post-Bariatric Hypoglycemia. J Clin Med 2023; 12:4295. [PMID: 37445330 DOI: 10.3390/jcm12134295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/31/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Gastric bypass determines an increase in incretin secretion and glucose excursions throughout the day and may sometimes entail the development of severe post-bariatric hypoglycemia (PBH). However, there is no consensus on the gold standard method for its diagnosis. In this study, we evaluated the usefulness of a mixed meal tolerance test (MMTT) and continuous glucose monitoring (CGM) for the diagnosis of PBH, defined as glucose levels <54 mg/dL (3.0 mmol/L). We found that hypoglycemia occurred in 60% of patients after the MMTT and in 75% during CGM, and it was predominantly asymptomatic. The MMTT confirmed the diagnosis of PBH in 88.9%of patients in whom surgery had been performed more than three years ago, in comparison to 36.4% in cases with a shorter postsurgical duration. CGM diagnosed nocturnal asymptomatic hypoglycemia in 70% of patients, and daytime postprandial hypoglycemia in 25% of cases. The mean duration of asymptomatic hypoglycemia was more than 30 min a day. Patients with ≥2% of their CGM readings with hypoglycemia exhibited a higher degree of glucose variability than those with <1% of the time in hypoglycemia. Our results show that the MMTT may be a useful dynamic test to confirm the occurrence of hypoglycemia in a large number of patients with persistent and recurrent PBH during long-term follow-up after gastric bypass. CGM, on its part, helps identify hypoglycemia in the real-world setting, especially nocturnal asymptomatic hypoglycemia, bringing to light that PBH is not always postprandial.
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Affiliation(s)
- Ana M Ramos-Levi
- Departament of Endocrinology and Nutrition, Hospital La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Miguel A Rubio-Herrera
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Pilar Matía-Martín
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Natalia Pérez-Ferre
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Clara Marcuello
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Andrés Sánchez-Pernaute
- Department of Surgery, Hospital Clínico San Carlos, IdISSC, Faculty of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Antonio J Torres-García
- Department of Surgery, Hospital Clínico San Carlos, IdISSC, Faculty of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Alfonso L Calle-Pascual
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28040 Madrid, Spain
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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: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Wong M, Gome JJ, Dreyer R. A Delayed Presentation of Late Dumping Syndrome After Ivor Lewis Procedure. Cureus 2023; 15:e40877. [PMID: 37492839 PMCID: PMC10363652 DOI: 10.7759/cureus.40877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
An accurate and timely diagnosis of dumping syndrome after gastric and oesophageal surgery is often difficult. A delay in making this diagnosis and instituting therapy can result in significant morbidity and avoidable complications. As bariatric surgery becomes more prevalent, the importance of a timely diagnosis of dumping syndrome is increasing. We present a case of a 77-year-old man who was admitted into the intensive care unit with a reduced conscious state secondary to hypoglycemia. The patient was subsequently diagnosed with late dumping syndrome in the context of an Ivor Lewis procedure seven years prior. Despite having a history of recurrent neuroglycopenic symptoms, there was a delay in diagnosis as dumping syndrome had not previously been considered until this admission. After confirmation of the diagnosis, the patient was commenced on dietary adjustments and acarbose, with a resolution of post-prandial hypoglycaemia. The authors discuss dietary and pharmacological therapy to manage hypoglycaemia associated with dumping syndrome.
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Affiliation(s)
- Melanie Wong
- School of Medicine, Deakin University, Geelong, AUS
- General Medicine, Alfred Health, Melbourne, AUS
| | - James J Gome
- School of Medicine, Deakin University, Geelong, AUS
- Medicine, South West Healthcare, Warrnambool, AUS
| | - Reinhardt Dreyer
- School of Medicine, Deakin University, Geelong, AUS
- Medicine, South West Healthcare, Warrnambool, AUS
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Lath D, Cherian KE, Paul TV, Kapoor N. Beyond diabetes remission a step further: Post bariatric surgery hypoglycemia. World J Diabetes 2022; 13:278-281. [PMID: 35432756 PMCID: PMC8984570 DOI: 10.4239/wjd.v13.i3.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/21/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Postbariatric hypoglycemia is a rare but increasingly recognized complication of bariatric surgery, with significant associated morbidity, and many patients often require multimodal treatment. A mixed meal challenge test is often helpful to diagnose this condition. This manuscript highlights the underlying mechanisms that lead to this condition and the novel emerging therapeutic targets that target these mechanisms.
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Affiliation(s)
- Devraj Lath
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India
| | - Kripa Elizabeth Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India
- Non Communicable Disease Unit, Nossal Institute of Global Health, Melbourne 3053, Victoria, Australia
- The Baker Heart and Diabetes Institute, Melbourne 3004, Victoria, Australia
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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. 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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Scarpellini E, Arts J, Karamanolis G, Laurenius A, Siquini W, Suzuki H, Ukleja A, Van Beek A, Vanuytsel T, Bor S, Ceppa E, Di Lorenzo C, Emous M, Hammer H, Hellström P, Laville M, Lundell L, Masclee A, Ritz P, Tack J. International consensus on the diagnosis and management of dumping syndrome. Nat Rev Endocrinol 2020; 16:448-466. [PMID: 32457534 PMCID: PMC7351708 DOI: 10.1038/s41574-020-0357-5] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.
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Affiliation(s)
- Emidio Scarpellini
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Joris Arts
- Gastroenterology Division, St Lucas Hospital, Bruges, Belgium
| | - George Karamanolis
- 2nd Department of Internal Medicine - Propaedeutic, Hepatogastroenterology Unit, Attikon University Hospital, Medical School, Athens University, Athens, Greece
| | - Anna Laurenius
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Walter Siquini
- Politechnic University of Marche, "Madonna del Soccorso" General Hospital, San Benedetto del Tronto, Italy
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Japan
| | - Andrew Ukleja
- Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andre Van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Serhat Bor
- Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Eugene Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marloes Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Heinz Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Per Hellström
- Department of Medical Sciences, Gastroenterology/Hepatology, Uppsala University, Uppsala, Sweden
| | - Martine Laville
- Department of Endocrinology, Claude Bernard University, Lyon, France
| | - Lars Lundell
- Department of Surgery Hospital, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Ad Masclee
- Department of Gastroenterology-Hepatology, University Hospital Leiden, Leiden, Netherlands
| | | | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium.
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Lobato CB, Pereira SS, Guimarães M, Morais T, Oliveira P, de Carvalho JPM, Nora M, Monteiro MP. Use of flash glucose monitoring for post-bariatric hypoglycaemia diagnosis and management. Sci Rep 2020; 10:11061. [PMID: 32632211 PMCID: PMC7338422 DOI: 10.1038/s41598-020-68029-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 06/18/2020] [Indexed: 12/16/2022] Open
Abstract
Our aim was to assess the potential of flash glucose monitoring (FGM) for diagnostic workup of suspected post-bariatric hypoglycaemia (PBH). Patients (N = 13) with suspected PBH underwent a food and symptoms diary (FSD) record along with FGM over 14 days. Targeted data analysis confirmed the occurrence of low glucose events in parallel to meal-triggered symptoms. Glycaemic variability, as assessed by Mean Absolute Glucose change (MAG change), was increased, while a higher risk of glycaemic excursions towards both hyper and hypoglycaemia (ADRRFGMGT) was observed in those with more frequent and severe hypoglycaemia. The herein described hypoglycaemia risk index (LBGIFGMGT) with a cut-off value of 4.6 showed to have 100% sensitivity and 100% specificity for PBH. This pilot proof-of-concept study highlighted that FSD coupled with FGM followed by targeted data analysis, provides relevant insights towards PBH diagnosis and grading in a user-friendly and easy to implement study protocol. Furthermore, LBGIFGMGT demonstrated to be an excellent index for PBH diagnosis. The unexpected improvement of glucose profile noticed along the monitoring time also unravels a possible application for PBH management.
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Affiliation(s)
- Carolina B Lobato
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal
| | - Sofia S Pereira
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal
| | - Marta Guimarães
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of General Surgery, Centro Hospitalar de Entre o Douro e Vouga, 4520-211, Santa Maria da Feira, Portugal
| | - Tiago Morais
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal
| | - Pedro Oliveira
- Department of Population Studies, ICBAS, University of Porto, 4050-313, Porto, Portugal
| | - Jorge P M de Carvalho
- Department of Mathematics, Faculty of Sciences, University of Porto, 4169-007, Porto, Portugal
| | - Mário Nora
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.,Department of General Surgery, Centro Hospitalar de Entre o Douro e Vouga, 4520-211, Santa Maria da Feira, Portugal
| | - Mariana P Monteiro
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal. .,Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Jorge Viterbo Ferreira 228, Ed.1, 3rd Floor, 4050-313, Porto, Portugal.
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17
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Evers SS, Kim KS, Bozadjieva N, Lewis AG, Farris D, Sorensen MJ, Kim Y, Whitesall SE, Kennedy RT, Michele DE, Seeley RJ, Sandoval DA. Continuous glucose monitoring reveals glycemic variability and hypoglycemia after vertical sleeve gastrectomy in rats. Mol Metab 2020; 32:148-159. [PMID: 32029224 PMCID: PMC7005148 DOI: 10.1016/j.molmet.2019.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Post–bariatric surgery hypoglycemia (PBH) is defined as the presence of neuroglycopenic symptoms accompanied by postprandial hypoglycemia in bariatric surgery patients. Recent clinical studies using continuous glucose monitoring (CGM) technology revealed that PBH is more frequently observed in vertical sleeve gastrectomy (VSG) patients than previously recognized. PBH cannot be alleviated by current medication. Therefore, a model system to investigate the mechanism and treatment is required. Methods We used CGM in a rat model of VSG and monitored the occurrence of glycemic variability and hypoglycemia in various meal conditions for 4 weeks after surgery. Another cohort of VSG rats with CGM was used to investigate whether the blockade of glucagon-like peptide-1 receptor (GLP-1R) signaling alleviates these symptoms. A mouse VSG model was used to investigate whether the impaired glucose counterregulatory system causes postprandial hypoglycemia. Results Like in humans, rats have increased glycemic variability and hypoglycemia after VSG. Postprandial hypoglycemia was specifically detected after liquid versus solid meals. Further, the blockade of GLP-1R signaling raises the glucose nadir but does not affect glycemic variability. Conclusions Rat bariatric surgery duplicates many features of human post–bariatric surgery hypoglycemia including postprandial hypoglycemia and glycemic variability, while blockade of GLP-1R signaling prevents hypoglycemia but not the variability. VSG causes glycemic variability during ad lib feeding condition. Single liquid meal ingestion causes post-VSG hypoglycemia. Blockade of GLP-1 receptor prevents post-VSG hypoglycemia.
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Affiliation(s)
- Simon S Evers
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Ki-Suk Kim
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | | | - Alfor G Lewis
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Diana Farris
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Matthew J Sorensen
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Youngsoo Kim
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Steven E Whitesall
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Robert T Kennedy
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Daniel E Michele
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Darleen A Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48105, USA; Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA.
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Vavricka SR, Greuter T. Gastroparesis and Dumping Syndrome: Current Concepts and Management. J Clin Med 2019; 8:jcm8081127. [PMID: 31362413 PMCID: PMC6723467 DOI: 10.3390/jcm8081127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023] Open
Abstract
Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. Although gastroparesis results from delayed gastric emptying and dumping syndrome from accelerated emptying of the stomach, the two entities share several similarities among which are an underestimated prevalence, considerable impairment of quality of life, the need for a multidisciplinary team setting, and a step-up treatment approach. In the following review, we will present an overview of the most important clinical aspects of gastroparesis and dumping syndrome including epidemiology, pathophysiology, presentation, and diagnostics. Finally, we highlight promising therapeutic options that might be available in the future.
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Affiliation(s)
- Stephan R Vavricka
- Center of Gastroenterology and Hepatology, CH-8048 Zurich, Switzerland.
- Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland.
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland
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Abstract
Postprandial symptoms of neuroglycopenia after bariatric surgery may result as a consequence of endogenous hyperinsulinemic hypoglycemia (nesidioblastosis) not dumping syndrome. Pancreatectomy is an acceptable treatment for this condition. We present the video of a case of near-total distal robotic pancreactectomy for the treatment of nesidioblastosis after Roux-en-Y gastric bypass. Robotic pancreatectomy is an alternative to the treatment of nesidioblastosis after Roux-en-Y gastric bypass.
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Affiliation(s)
| | - Jairo Tabacow Hidal
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
| | - Wagner Marcondes
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
| | - Fernando Concilio Mauro
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
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Johnson KW, Neale A, Gordon A, Roessig J, Bezwada P, Vukelich S, Goldfine I, Rubin P. Attenuation of Insulin Action by an Allosteric Insulin Receptor Antibody in Healthy Volunteers. J Clin Endocrinol Metab 2017; 102:3021-3028. [PMID: 28605468 DOI: 10.1210/jc.2017-00822] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND XOMA 358 (X358) is a fully human monoclonal antibody to the insulin receptor that acts as a negative allosteric modulator of insulin signaling. It is being developed as a novel treatment of hyperinsulinemic hypoglycemia. This report describes pharmacokinetic (PK) and pharmacodynamic (PD) data from a first-in-human clinical trial. METHODS A double-blind, placebo-controlled, single-ascending-dose study was performed with 29 healthy adult males randomized to intravenous infusion of placebo or X358 at 0.1-, 0.3-, 1-, 3-, 6-, or 9-mg/kg dose levels. The primary objective was to assess safety and tolerability, and secondary objectives included PK and PD analyses. A short insulin tolerance test (ITT) was implemented in the 3- to 9-mg/kg dose cohorts at baseline and postinfusion. RESULTS There were no deaths, serious adverse events (AEs), or subject discontinuations due to AEs. There were no clinically meaningful safety findings. X358 exhibited dose-proportional PK with a half-life of 21 days. Dose-dependent elevations of circulating insulin levels, likely related to reduced insulin clearance via monoclonal antibody action at receptors, represented a sensitive biomarker of X358 exposure. X358-dependent increases in postprandial glucose levels and fasting homeostatic model assessment of insulin resistance values were observed and persisted for at least 1 week at the higher dose levels. In all the ITT cohorts, the slope for glucose lowering was substantially attenuated after X358 infusion of a similar magnitude, but with increasing duration with rising dose level. CONCLUSION Single X358 infusions were well tolerated and resulted in a dose-dependent reduction in insulin sensitivity. Clinical development of X358 in hyperinsulinemic, hypoglycemic conditions is proceeding.
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Affiliation(s)
- Kirk W Johnson
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Ann Neale
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Allan Gordon
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Julie Roessig
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Padma Bezwada
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Sabine Vukelich
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Ira Goldfine
- Research and Development, XOMA Corporation, Berkeley, California 94710
| | - Paul Rubin
- Research and Development, XOMA Corporation, Berkeley, California 94710
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Suhl E, Anderson-Haynes SE, Mulla C, Patti ME. Medical nutrition therapy for post-bariatric hypoglycemia: practical insights. Surg Obes Relat Dis 2017; 13:888-896. [PMID: 28392017 DOI: 10.1016/j.soard.2017.01.025] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 01/10/2023]
Abstract
Hypoglycemia is increasingly recognized as a complication of bariatric surgery. Although medications are often required, medical nutrition therapy remains the key cornerstone for successful prevention of hypoglycemia in patients with post-bariatric hypoglycemia (PBH). We provide suggested approaches to the dietary management of PBH, incorporating data from both the medical literature and extensive clinical experience in an academic referral center for PBH. The overall goal of medical nutrition therapy for PBH is to reduce postprandial surges in glucose, which often trigger surges in insulin secretion and promote subsequent hypoglycemia. Thus, strategies focus on controlled portions of low glycemic index carbohydrates, avoidance of rapidly-absorbed carbohydrates, adjustment of timing of meals and snacks, and attention to personal and cultural barriers to implementation.
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Affiliation(s)
- Emmy Suhl
- Hypoglycemia Clinic, Joslin Diabetes Center, Boston MA
| | | | - Christopher Mulla
- Hypoglycemia Clinic, Joslin Diabetes Center, Boston MA; Research Division, Joslin Diabetes Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Mary-Elizabeth Patti
- Hypoglycemia Clinic, Joslin Diabetes Center, Boston MA; Research Division, Joslin Diabetes Center, Boston, MA; Harvard Medical School, Boston, MA.
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van Beek AP, Emous M, Laville M, Tack J. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev 2017; 18:68-85. [PMID: 27749997 DOI: 10.1111/obr.12467] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1-3 h after carbohydrate ingestion, caused by an incretin-driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome. METHODS A systematic literature review was performed through February 2016. Evidence-based medicine was used to develop diagnostic and management strategies for dumping syndrome. RESULTS Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom-based questionnaires, glycemia measurements and oral glucose tolerance tests. First-line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re-intervention or continuous enteral feeding may be necessary for treatment-refractory dumping syndrome, but outcomes are variable. CONCLUSIONS Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.
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Affiliation(s)
- A P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - M Laville
- European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France
| | - J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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