Medications for managing post–bariatric surgery hypoglycemia: Dosages and side effects
| Medication | Dosage | Side effects | Notes |
|---|---|---|---|
| Acarbose8,23,25,26 | 25 mg with 1 meal per day, slowly titrate up to 100 mg at every meal daily | Bloating, abdominal cramping, diarrhea | Used 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 |
| Diazoxide26–28 | 50–100 mg twice daily to start | Fluid retention, edema, nausea, hypotension, hirsutism, headache | Consider dose reduction with renal impairment Typically used for hypoglycemia from insulinomas Affordability and insurance coverage are barriers |
| Octreotide, pasireotide25,26,29 | Octreotide 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 prolongation | Safe 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 verapamil25,30 | Verapamil 40 mg 3 times daily Nifedipine 30–60 mg daily | Hypotension, edema | Safe to use in renal impairment |
| GLP-1 analogs25,26,31 | Liraglutide 0.6 mg titrated to 1.2 mg SC daily, up to 1.8 mg daily | Nausea, constipation | Contraindicated 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 inhibitors25,26 | Sitagliptin 100 mg once daily | Nausea, constipation | Inconclusive results—not recommended |
| GLP-1 antagonist32–34 | Avexitide 30 mg SC twice daily | Headache, nausea, injection-site reaction | Recently granted breakthrough therapy designation by the US Food and Drug Administration for treating PBH and congenital hyperinsulinism, currently in phase 3 trial |
| SGLT-2 inhibitors35,36 | Canagliflozin 100 or 300 mg daily Empagliflozin 10–25 mg daily | Dehydration, urinary tract and genital mycotic infections, euglycemic diabetic ketoacidosis | Dosage 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 antagonist37 | Anakinra 100 mg SC daily | Anakinra and SGLT-2 inhibitor empagliflozin reduced the number of hypoglycemic events during a liquid mixed meal test | |
| Glucagon38,39 | Dasiglucagon 80 or 120 μg SC injection as needed for hypoglycemia | Nausea, vomiting, hyperglycemia, reduced appetite | Still 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 antibody40,41 | XOMA 358 3–9 mg/kg daily | Headache, hyperhidrosis | Results from phase 2 trial not announced yet |
GLP = glucagon-like peptide; SC = subcutaneous; PBH = post–bariatric surgery hypoglycemia; SGLT = sodium-glucose cotransporter