ECE2021 Joint Sessions ESE/EASO Joint Session: Endocrine lab findings in people with obesity and their therapeutic consequences (4 abstracts)
Department of Bariatric and Metabolic surgery, CON, Medical Center Leeuwarden, The Netherlands
Stimulation of insulin release by increased gut hormone levels after gastric bypass surgery, especially glucagonlike polypeptide-1(GLP-1), is considered to be the most important mechanism of action in diabetes remission. However, these beneficial effects can come at a price, namely the development of postprandial hyperinsulinaemic hypoglycaemia, more often called post bariatric hypoglycaemie (PBH). The exact pathophysiology of PBH is not known but GLP-1 plays an important role as blocking the receptor with exendin 9-39 can abolish the occurrence of hypoglycaemia. Altered betacel response, insulin sensitivity, FGF-19, bile acids and the gut microbioma probably also play a role. There is no established definition of PBH as it is probably part of a sliding scale of postprandial glucose values. Consequently, none of the diagnostic tools, self-measured blood glucose, provoking tests like OGTT and MMT, or CGM have established cut-off values. Most authors agree with the diagnosis of PBH in the combination of neuroglycopenic symptoms, a blood glucose level < 2.8 mmol/l with resolution of symptoms with correction of the hypoglycaemia (Whipples triad). Treatment of PBH is not supported by well designed studies but relies mainly on clinical experience and case reports. A diet low in carbohydrates is the first step, lowering glucose excursions and thereby diminishing insulin release. Off-label medical treatment is a matter of trial and error and consists of acarbose, reducing postprandial glucose rise, somatostatin analogues, reducing GLP-1 and insulin release, diazoxide, inhibiting insulin secretion or liraglutide, a GLP-1 agonist, the mechanism of action is currently not known. Avexitide, exendin 9-39, a GLP-1r antagonist and colesevelam are promising new medications. Surgical options for PBH, resistant to medication are banding the pouch, placing a feeding tube in the native stomache, an undo operation or even pancreatectomy, all with limited success.