Abstract
Background: Hypoglycemia is a significant complication of post-bariatric surgery. Case history: A 46 year old woman was referred for further management. She had had a Roux-en-Y gastric bypass surgery in 2012. She lost over 20 kilograms of weight. Pre-opertaively, a single HbA1c was borderline at 48 mmol/mol (6.5%) which improved to 41-44 mmol/mol. In November 2013, she started to experience symptoms suggestive of hypoglycemia. Dietary adjustments were advised and a trial of metformin and saxagliptin was given on basis of wide fluctuation of blood glucose with a remarkable early postprandial hyperglycemia followed by hypoglycemia. She stopped both medications due to gastrointestinal side effects. Renal and liver disease and hypoadrenalism were all excluded. We started her on increasing doses of Acarbose (an alpha glucosidase inhibitor) up to 100 mgs with each meal but she experienced minimal improvement in hypoglycemia. A a trial of Dapagliflozin, a sodiumglucose co-transporter 2 (SGLT 2) inhibitor, in a standard daily dose of 10 mgs in addition to Acarbose was offered to the patient (from 6th October 2015). The theoretical basis were explained to her and she consented verbally to this. Within 2 weeks, she experienced remarkable symptomatic improvement associated with reduction of both hyperglycemia and hypoglycemia documented on self-monitoring of blood glucose. The patient reduced Acarbose progressively to a complete cessation on her own accord. She remained well controlled solely on Dapagliflozin 10 mgs daily. The improvement is sustained for 12 months. The effect was further confirmed by 1 week off and one week on Dapagliflozin using flash glucose monitoring. Conclusions: This is the first report of a beneficial use of SGLT2 inhibition primarily for post-bariatric hypoglycemia. SGLT2 inhibitors may have a role in managing gastric bypass hypoglycemia.
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