ACARBOSE (2020 Valderas JP, Ahuad J, Rubio L, Escalona M, Pollak F, Maiz A. Acarbose improves hypoglycaemia following gastric bypass surgery without increasing glucagon-like peptide 1 levels. Obes Surg. 2012;22:582-6.,2121 Moreira RO, Moreira RBM, Machado NAM, Gonçalves TB, Coutinho WF. Post-prandial hypoglycemia after bariatric surgery: Pharmacological treatment with verapamil and acarbose. Obes Surg. 2008;18:1618-21.) |
• Mechanism of action: delays the absorption of carbohydrates, reducing postprandial glycemic and insulinemic peaks. |
• Dose: 100 to 300 mg/day before main meals. Start with 25 mg/day and increase gradually |
• Side effects: flatulence, diarrhea, abdominal pain. |
SOMATOSTATIN ANALOGS (OCTREOTIDE AND PASIREOTIDE) (2626 Arts J, Caenepeel P, Bisschops R, Dewulf D, Holvoet L, Piessevaux H, et al. Efficacy of the Long-Acting Repeatable Formulation of the Somatostatin Analogue Octreotide in Postoperative Dumping. Clin Gastroenterol Hepatol. 2009;7(4):432-7.,2727 Øhrstrøm CC, Hansen DL, Kielgast UL, Hartmann B, Holst JJ, Worm D. A Low Dose of Pasireotide Prevents Hypoglycemia in Roux-en-Y Gastric Bypass-Operated Individuals. Obes Surg. 2020;30:1605-10.) |
• Mechanism of action: reduces GLP-1 levels and inhibits insulin secretion |
• Dose: octreotide 25 to 50 ug SC before meals; pasireotide SC 75 to 300 mcg/day |
• Side effects: diarrhea, steatorrhea, abdominal pain, gallstones, QT interval prolongation, persistent hyperglycemia |
CANAGLIFLOZIN (2222 Ciudin A, Sánchez M, Hernandez I, Cordero E, Fidilio E, Comas M, et al. Canagliflozin: A New Therapeutic Option in Patients That Present Postprandial Hyperinsulinemic Hypoglycemia after Roux-en-Y Gastric Bypass: A Pilot Study. Obes Facts. 2021;14:291-7.) |
• Mechanism of action: Canagliflozin: reduces carbohydrate absorption by inhibiting intestinal SGLT-1 and thus decreases postprandial insulin spike |
• Dose: 300 mg per day |
• Side effects: genital infections, volume depletion, increased urinary frequency |
AVEXITIDE (currently in phase II of testing) (3030 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(8):1406-16.) |
• Mechanism of action: GLP-1 receptor antagonists, reduce postprandial insulin and GLP-1 secretion and increase glucagon |
• Side effects: Headache, nausea, and subcutaneous injection site reaction. |
MEDICATIONS ALREADY USED, HOWEVER, ONLY CASE REPORTS SHOW EFFECTIVENESS
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CALCIUM CHANNEL BLOCKERS (VERAPAMIL (2121 Moreira RO, Moreira RBM, Machado NAM, Gonçalves TB, Coutinho WF. Post-prandial hypoglycemia after bariatric surgery: Pharmacological treatment with verapamil and acarbose. Obes Surg. 2008;18:1618-21.) AND NIFEDIPINE (2323 Ames A, Lago-Hernandez CA, Grunvald E. Hypoglycemia after gastric bypass successfully treated with calcium channel blockers: Two case reports. J Endocr Soc. 2019;3:1417-22.)) |
• Mechanism of action: reduce postprandial insulin secretion |
• Dose: verapamil: 80 mg twice a day; nifedipine: 30 mg/day |
• Side effects: water retention, hypotension, edema, nausea, headache |
DIAZOXIDE (2424 Chen X, Feng L, Yao H, Yang L, Qin Y. Efficacy and safety of diazoxide for treating hyperinsulinemic hypoglycemia: A systematic review and meta-analysis. PLoS One. 2021;16(2):e0246463.,2525 Gonzalez-Gonzalez A, Delgado M, Fraga-Fuentes MD. Use of diazoxide in management of severe postprandial hypoglycemia in patient after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9(1):e18-9.) |
• Mechanism of action: activates ATP-dependent potassium channels and decreases the opening of calcium channels, reducing insulin release |
• Dose: 50 mg, 2x/day |
• Side effects: fluid retention, hypertrichosis, gastrointestinal disorders, edema and neutropenia |
LIRAGLUTIDE (2828 Abrahamsson N, Engström BE, Sundbom M, Karlsson FA. GLP1 analogs as treatment of postprandial hypoglycemia following gastric bypass surgery: A potential new indication? Eur J Endocrinol. 2013;169:885-9.,2929 Chiappetta S, Stier C. A case report: Liraglutide as a novel treatment option in late dumping syndrome. Medicine (Baltimore). 2017;96(12):e6348.) |
• Mechanism of action: persistent activation at the GLP-1 receptor leading to inhibition of insulin release and increased glucagon release in hypoglycemic conditions |
• Dose: 0.6 mg SC/day initially, progress to 1.2 mg SC |
• Side effects: nausea, headache, stomach pains, constipation, diarrhea |