TABLE 2

Medications for managing post–bariatric surgery hypoglycemia: Dosages and side effects

MedicationDosageSide effectsNotes
Acarbose8,23,25,2625 mg with 1 meal per day, slowly titrate up to 100 mg at every meal dailyBloating, abdominal cramping, diarrheaUsed as first line because it’s affordable and available
Not recommended in significant renal impairment
If hypoglycemia occurs, correct with simple carbohydrates (glucose, dextrose, honey)—complex carbohydrates (table sugar, juice, soft drink, candy) will not be effective
Diazoxide262850–100 mg twice daily to startFluid retention, edema, nausea, hypotension, hirsutism, headacheConsider dose reduction with renal impairment
Typically used for hypoglycemia from insulinomas
Affordability and insurance coverage are barriers
Octreotide, pasireotide25,26,29Octreotide 25–100 μg SC before meals
Octreotide long-acting repeatable 20-mg intramuscular injection monthly
Pasireotide 50–300 μg
SC before meals or 300 μg
SC daily
Diarrhea, steatorrhea, cholelithiasis, hyperglycemia (more with pasireotide), QT prolongationSafe to use in renal impairment
Expensive
Screening abdominal ultrasonography and electrocardiogram required
Pasireotide is longer acting than octreotide and is available for compassionate use in severe PBH
Oral octreotide is available but has not been used for this indication
Nifedipine or verapamil25,30Verapamil 40 mg 3 times daily
Nifedipine 30–60 mg daily
Hypotension, edemaSafe to use in renal impairment
GLP-1 analogs25,26,31Liraglutide 0.6 mg titrated to 1.2 mg SC daily, up to 1.8 mg dailyNausea, constipationContraindicated in patients with family or personal history of medullary thyroid carcinoma
Use with caution in patients with history of pancreatitis
Safe to use in renal impairment but avoid dehydration
Expensive
Dipeptidyl peptidase 4 inhibitors25,26Sitagliptin 100 mg once dailyNausea, constipationInconclusive results—not recommended
GLP-1 antagonist3234Avexitide 30 mg SC twice dailyHeadache, nausea, injection-site reactionRecently granted breakthrough therapy designation by the US
Food and Drug Administration for treating PBH and congenital hyperinsulinism, currently in phase 3 trial
SGLT-2 inhibitors35,36Canagliflozin 100 or 300 mg daily
Empagliflozin 10–25 mg daily
Dehydration, urinary tract and genital mycotic infections, euglycemic diabetic ketoacidosisDosage adjustment required in renal impairment
Canagliflozin and empagliflozin shown to improve glycemic response to oral glucose tolerance and mixed meal tolerance tests, respectively, in patients with PBH
Interleukin 1 beta antagonist37Anakinra 100 mg SC dailyAnakinra and SGLT-2 inhibitor empagliflozin reduced the number of hypoglycemic events during a liquid mixed meal test
Glucagon38,39Dasiglucagon 80 or 120 μg
SC injection as needed for hypoglycemia
Nausea, vomiting, hyperglycemia, reduced appetiteStill under clinical investigation, use of glucagon in an insulin pump has shown satisfactory results
May be used for treatment of acute severe hypoglycemia
Insulin receptor antibody40,41XOMA 358
3–9 mg/kg daily
Headache, hyperhidrosisResults from phase 2 trial not announced yet
  • GLP = glucagon-like peptide; SC = subcutaneous; PBH = post–bariatric surgery hypoglycemia; SGLT = sodium-glucose cotransporter