FRI612 Tirzepatide For The Treatment Of Post-bariatric Surgery Hypoglycemia And Early Dumping Syndrome

Abstract

Abstract Disclosure: E.F. Stortz: None. H.M. Lawler: Research Investigator; Self; VogenX. Background: Post-bariatric hypoglycemia (PBH) is a challenging condition with limited treatment options. Glucagon-like peptide 1 (GLP-1) receptor agonists have been used with mixed success. To our knowledge, there have been no reported cases of PBH treatment with dual incretin agonist medications. We describe a case in which tirzepatide was successfully used to improve both post-bariatric surgery hypoglycemia as well as symptoms of early dumping syndrome. Clinical Case: A 46-year-old woman with prediabetes presented with labile blood sugars, post-prandial hypoglycemia, and intermittent severe bloating with diarrhea shortly after eating meals. She had a past medical history of gastric banding 16 years ago, resulting in a 70 pound weight loss. Her post-operative course was complicated by post-meal retching and vomiting for many years. She subsequently had gastric band reversal with concurrent sleeve gastrectomy 2 years ago. While her vomiting improved, she experienced intermittent post-meal bloating and diarrhea. About 8 months after this surgery, she developed symptoms of hypoglycemia after meals, with glucometer readings of 30-49 mg/dL. Continuous glucose monitoring (CGM) for 1 week prior to therapy revealed a time in range (70-180 mg/dL) of 90%, 3-4% time above 180 mg/dL, and 6-7% time below 70 mg/dL. Dietary changes did not help improve hypoglycemic episodes or her dumping symptoms. She initially started tirzepatide 2.5mg weekly and noticed improvement in both symptoms. Her dose increased to 5mg weekly, and she had near complete resolution in her post-prandial hypoglycemia. Upon review of 1 week of CGM data, her time in range improved to 96% with 2% time above 180 mg/dL and 0% time below 70 mg/dL. Her glucose peak was 224 with a nadir of 72. Her early dumping symptoms also improved, occurring only with very high-carb meals. Conclusion: Many pharmacotherapies have sought to improve post-bariatric surgery hypoglycemia with limited success often significant side effects. The post-prandial peak of GLP-1 levels tends to be higher in patients after bariatric surgery compared to obese controls, possibly playing a role in the condition’s pathophysiology. Studies of glucose-dependent insulinotropic peptide (GIP) in patients after bariatric surgery exhibit mixed trends. Numerous case reports have shown successful treatment of PBH with GLP-1 receptor agonists, while other have shown no clear benefit. It is possible that dual incretin therapy may attenuate more of the post-prandial hyperinsulinemic-hypoglycemic response in ways that are incompletely understood and requires further investigation. Interestingly, this case showed that tirzepatide administration not only resulted near-resolution of post-prandial hypoglycemia, but it also improved this patients’ early dumping syndrome symptoms. Presentation: Friday, June 16, 2023