Obesity Abstracts

Introduction: Post-bariatric surgery hypoglycaemia (BPH) is a metabolic complication of bariatric surgery, which may develop months or years post-procedure and is encountered increasingly frequently in obesity medicine. We present a case series from our large Tier 4 service, illustrating the challenges posed when diagnosing and managing this condition.

Case 1: 51F with a history of obesity (BMI 55, weight 159kg) and Roux-en-Y gastric bypass (2010), attended for review weighing 72kg (BMI 24.9), troubled by hypoglycaemia (1.9-2.3 mmol/L using flash monitoring). After unsuccessful trials of dietary modification, acarbose and semaglutide (Ozempic®) 0.5mg, symptoms improved on dulaglutide (Trulicity®) 1.5mg.

Case 2: 58F was re-referred by her GP following Roux-en-Y gastric bypass (2014), having lost over 30kg (contemporary BMI 32.3), reporting a postprandial lab glucose of 2.2 mmol/L. A food diary revealed suboptimal protein intake requiring dietetic support. She was unable to tolerate acarbose 50mg TDS due to bloating.

Case 3: 29F underwent a Roux-en-Y gastric bypass in Turkey (2021), attended for review 6 months post-partum reporting ongoing fatigue, weakness, weight loss. Despite troublesome hypoglycaemia during pregnancy, she delivered a healthy, normal weight baby in May 2023. She cannot tolerate acarbose; enhanced nutritional support is ongoing.

Case 4: 26F had a Roux-en-Y gastric bypass (2018), lost 83kg from baseline 152.4kg (contemporary BMI 26.0) and was referred by the dietician with recurrent hypoglycaemia, prompting 5 A&E attendances. A symptom diary led to dietary modification, and a mixed meal test (MMT) will be considered after Freestyle Libre monitoring.

Case 5: 51F with background of throat cancer and Roux-en-Y gastric bypass (2015), developed hypoglycaemia symptoms in 2018 (weight stable at 65kg). MMT confirmed severe hypoglycaemia with blood glucose 1.2 mmol/L at 90mins. Lifestyle interventions provided little benefit and acarbose was associated with flatulence; canagliflozin 100mg OD is being trialled.

Discussion: Diagnosis of PBH can be difficult; symptom severity varies and timely access to capillary blood glucose measurement is often lacking. A multidisciplinary approach is crucial, given limited efficacy/tolerability of alpha-glucosidase inhibitors and somatostatin analogues. Further evidence regarding the roles of gut hormone agonists and SGLT2 inhibitors in managing PBH is needed.