title: Critical role for GLP-1 in symptomatic post-bariatric hypoglycaemia.
abstract: Post-bariatric hypoglycaemia (PBH) is a rare, but severe, metabolic disorder arising months to years after bariatric surgery. It is characterised by symptomatic postprandial hypoglycaemia, with inappropriately elevated insulin concentrations. The relative contribution of exaggerated incretin hormone signalling to dysregulated insulin secretion and symptomatic hypoglycaemia is a subject of ongoing inquiry. This study was designed to test the hypothesis that PBH and associated symptoms are primarily mediated by glucagon-like peptide-1 (GLP-1).
  
  
  
  We conducted a double-blinded crossover study wherein eight participants with confirmed PBH were assigned in random order to intravenous infusion of the GLP-1 receptor (GLP-1r) antagonist. Exendin (9-39) (Ex-9), or placebo during an OGTT on two separate days at the Stanford University Clinical and Translational Research Unit. Metabolic, symptomatic and pharmacokinetic variables were evaluated. Results were compared with a cohort of BMI- and glucose-matched non-surgical controls (NSCs).
  
  
  
  Infusion of Ex-9 decreased the time to peak glucose and rate of glucose decline during OGTT, and raised the postprandial nadir by over 70%, normalising it relative to NSCs and preventing hypoglycaemia in all PBH participants. Insulin AUC and secretion rate decreased by 57% and 71% respectively, and peak postprandial insulin was normalised relative to NSCs. Autonomic and neuroglycopenic symptoms were significantly reduced during Ex-9 infusion.
  
  
  
  GLP-1r blockade prevented hypoglycaemia in 100% of individuals, normalised beta cell function and reversed neuroglycopenic symptoms, supporting the conclusion that GLP-1 plays a primary role in mediating hyperinsulinaemic hypoglycaemia in PBH. Competitive antagonism at the GLP-1r merits consideration as a therapeutic strategy.
  
  
  
  ClinicalTrials.gov NCT02550145.
authors.affiliation: Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA. cmcraig@stanford.edu.
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Craig
authors.affiliation: Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA.
authors.forename: Li-Fen
authors.initials: LF
authors.lastname: Liu
authors.affiliation: Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Carolyn F
authors.initials: CF
authors.lastname: Deacon
authors.affiliation: Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jens J
authors.initials: JJ
authors.lastname: Holst
authors.affiliation: Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA.
authors.forename: Tracey L
authors.initials: TL
authors.lastname: McLaughlin
mesh_terms: D000328:Adult; D018592:Cross-Over Studies; D004311:Double-Blind Method; D005260:Female; D015390:Gastric Bypass; D005749:Gastric Inhibitory Polypeptide / Q000378:metabolism; D005934:Glucagon / Q000378:metabolism; D052216:Glucagon-Like Peptide 1 / Q000378:metabolism*; D000067757:Glucagon-Like Peptide-1 Receptor / Q000037:antagonists & inhibitors / Q000378:metabolism; D005947:Glucose / Q000378:metabolism; D005951:Glucose Tolerance Test; D006801:Humans; D007003:Hypoglycemia / Q000378:metabolism*; D007328:Insulin / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000494:pharmacology; D011795:Surveys and Questionnaires
chemical_list: D000067757:Glucagon-Like Peptide-1 Receptor; D007328:Insulin; D010446:Peptide Fragments; C083773:exendin (9-39); D005749:Gastric Inhibitory Polypeptide; D052216:Glucagon-Like Peptide 1; D005934:Glucagon; D005947:Glucose
keywords: Bariatric complication; GLP-1; Hyperinsulinaemic hypoglycaemia; Hypoglycaemia; Late dumping syndrome; NIPHS; Nesidioblastosis; Neuroglycopenia; Noninsulinoma pancreatogenous hypoglycaemia syndrome; Post-bariatric hypoglycaemia; RYGB; Roux-en-Y gastric bypass