Gastric Bypass and Sleeve Gastrectomy for Hypoglycemia

Recruiting at 1 trial location

Overseen By Marzieh Salehi, MD, MS

Age: 18+

Sex: Any

Trial Phase: Phase < 1

Sponsor: The University of Texas Health Science Center at San Antonio

Must not be taking: Atropine interactors

Disqualifiers: Heart, lung, liver, kidney, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

Duration: 8-12 weeks

200 Participants Needed

Trial Summary

What is the purpose of this trial?

The purpose of this study is learn the effect of gastric bypass surgery and sleeve gastrectomy on glucose metabolism mediated by neural and hormonal factors initiated after eating.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop taking your current medications, but if you are taking any medication that might interact with atropine and cannot be stopped, you will be excluded from the study.

What data supports the effectiveness of this treatment for hypoglycemia?

The research indicates that Roux-en-Y gastric bypass (RYGB) surgery can improve glucose control in patients with type 2 diabetes, but it may also lead to hypoglycemia in some cases. Sleeve gastrectomy (SG) is less frequently associated with hypoglycemia compared to RYGB. ^{1 2 3 4 5}

Is gastric bypass or sleeve gastrectomy generally safe for humans?

Both gastric bypass and sleeve gastrectomy are generally safe, but they can lead to hypoglycemia (low blood sugar) in some patients, especially after gastric bypass. This condition can cause symptoms like feeling very unwell and can affect quality of life. ^{1 4 6 7 8}

How is gastric bypass and sleeve gastrectomy treatment different for hypoglycemia?

Gastric bypass and sleeve gastrectomy are unique surgical treatments for hypoglycemia because they alter the digestive system to improve glucose control, but they can also lead to increased risk of hypoglycemia due to changes in insulin secretion. Unlike other treatments, these surgeries are primarily used for weight loss and can have the side effect of causing hypoglycemia, especially in patients without diabetes. ^{1 2 4 6 9}

Research Team

Marzieh Salehi, MD, MS

Principal Investigator

The University of Texas Health Science Center at San Antonio

Eligibility Criteria

This trial is for individuals who've had bariatric surgery and are asymptomatic, can visit Cedars-Sinai Medical Center, and don't have a personal history of diabetes. It's not for those with enlarged prostates, pregnant women, anyone unable to consent, diabetics, or people with certain medical conditions like uncontrolled hypertension or serious organ diseases.

Inclusion Criteria

I can travel to Cedars-Sinai Medical Center for the study.

I have had weight loss surgery and feel no symptoms.

I am healthy, have never had surgery, and do not have diabetes.

Exclusion Criteria

I am not on medications that interact with atropine or can stop them if needed.

I have a history of glaucoma.

I am unable to understand and agree to the study's procedures and risks.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo gastric bypass surgery or sleeve gastrectomy to study effects on glucose metabolism

8-12 weeks

Follow-up

Participants are monitored for safety and effectiveness after surgery, focusing on glucose metabolism and insulin secretion

12 weeks

Treatment Details

Interventions

• Atropine
• Exendin-(9-39)
• Gastric Bypass Surgery
• Sleeve Gastrectomy

Trial Overview The study investigates how gastric bypass and sleeve gastrectomy affect blood sugar control after eating by looking at neural and hormonal responses. Participants will be given Exendin-(9-39) or Atropine to see the effects on glucose metabolism.

Participant Groups

Group I: Exendin-(9-39) Experimental Treatment 1 Intervention

To evaluate the role of GLP-1 on glucose metabolism and insulin secretin after glucose and protein ingestion.

Group II: Atropine Experimental Treatment 1 Intervention

to evaluate the effect of neural activation on insulin secretion and glucose metabolism

Gastric Bypass Surgery is already approved in United States, European Union, Canada for the following indications:

Approved in United States as Roux-en-Y Gastric Bypass for:

• Severe obesity with BMI ≥35 kg/m²
• Type 2 diabetes with BMI ≥30 kg/m²
• Obesity-related comorbidities such as hypertension, hyperlipidemia, obstructive sleep apnea, and GERD

Approved in European Union as Roux-en-Y Gastric Bypass for:

• Severe obesity with BMI ≥35 kg/m²
• Type 2 diabetes with BMI ≥30 kg/m²
• Obesity-related comorbidities such as hypertension, hyperlipidemia, obstructive sleep apnea, and GERD

Approved in Canada as Roux-en-Y Gastric Bypass for:

• Severe obesity with BMI ≥35 kg/m²
• Type 2 diabetes with BMI ≥30 kg/m²
• Obesity-related comorbidities such as hypertension, hyperlipidemia, obstructive sleep apnea, and GERD

Who Is Running the Clinical Trial?

The University of Texas Health Science Center at San Antonio

Lead Sponsor

Trials

486

Recruited

92,500+

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Collaborator

Trials

2,513

Recruited

4,366,000+

Findings from Research

In a study of 120 patients who underwent either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), reactive hypoglycemia occurred in 29% of RYGB patients compared to 14% of SG patients, indicating a higher risk associated with RYGB.

RYGB was linked to more severe hypoglycemic episodes and a decrease in dynamic β-cell glucose sensitivity, suggesting that it may lead to inappropriate insulin secretion in response to glucose changes, while both procedures improved overall insulin sensitivity.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Incidence of Hypoglycemia After Gastric Bypass vs Sleeve Gastrectomy: A Randomized Trial. Capristo, E., Panunzi, S., De Gaetano, A., et al.[2018]

Roux-en-Y gastric bypass surgery (RYGB) significantly improves glucose control in most patients with type 2 diabetes, but can lead to a serious complication known as hyperinsulinemic hypoglycemia in a minority of individuals.

This condition arises due to rapid nutrient emptying and increased insulin and GLP-1 secretion after meals, resulting in higher glucose levels and exaggerated insulin responses, making diagnosis and treatment challenging.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Postprandial hypoglycemia after gastric bypass surgery: from pathogenesis to diagnosis and treatment. Honka, H., Salehi, M.[2020]

Reversing Roux-en-Y gastric bypass (RYGB) in two patients with post-RYGB hypoglycemia did not improve their condition, as both continued to experience hyperinsulinemic hypoglycemia after a mixed-meal challenge.

After the reversal, GLP-1 levels significantly decreased, while GIP levels increased dramatically, indicating that GIP may play a role in the persistence of hypoglycemia despite the surgical reversal.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Hormonal response to a mixed-meal challenge after reversal of gastric bypass for hypoglycemia. Lee, CJ., Brown, T., Magnuson, TH., et al.[2021]

The study aims to compare the incidence of reactive hypoglycaemia between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) over a 1-year period, as reactive hypoglycaemia is a common complication in about 72% of RYGB patients.

A secondary goal is to evaluate how each surgical procedure affects insulin sensitivity, which is important for understanding their impact on obesity-related cardiometabolic issues.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Protocol for a randomised clinical study comparing the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on reactive hypoglycaemia in morbidly obese subjects. Mingrone, G., Panunzi, S., De Gaetano, A., et al.[2021]

In two pilot studies involving 69 obese patients with type 2 diabetes, intensive glucose management before and after Roux-en-Y gastric bypass (RYGB) surgery did not lead to significantly better glycemic control one year post-surgery compared to conservative management.

The results suggest that while RYGB surgery itself has a strong positive impact on glucose control, additional intensive glucose-lowering interventions before or shortly after the surgery do not provide extra clinical benefits.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of perioperative management of glycemia in severely obese diabetic patients undergoing gastric bypass surgery. Chuah, LL., Miras, AD., Papamargaritis, D., et al.[2022]

Patients who experienced hypoglycemic syndrome after Roux-en-Y gastric bypass surgery (RYGB) showed insulin secretion rates similar to those of insulin-sensitive individuals, indicating that their insulin response is appropriate despite their condition.

The study found that RYGB patients had lower pancreatic beta-cell sensitivity to glucose compared to other groups, suggesting that the hypoglycemic syndrome is not due to excessive insulin secretion but rather a specific response to glucose.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Glucose-stimulated insulin secretion in gastric bypass patients with hypoglycemic syndrome: no evidence for inappropriate pancreatic beta-cell function. Kim, SH., Abbasi, F., Lamendola, C., et al.[2022]

In a study of 46 patients after Roux-en-Y gastric bypass (RYGB), those experiencing hypoglycemia (HYPO group) showed higher early insulin secretion rates but lower late insulin secretion rates compared to those without hypoglycemia (NONHYPO group) during an oral glucose tolerance test.

Continuous glucose monitoring revealed that HYPO patients spent more time with glucose levels below 3.3 mmol/L in real life, indicating a need for careful monitoring of this patient group post-surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Post-prandial hypoglycemia results from a non-glucose-dependent inappropriate insulin secretion in Roux-en-Y gastric bypassed patients. Vaurs, C., Brun, JF., Bertrand, M., et al.[2018]

A carbohydrate-restricted diet (CRD) significantly reduced the frequency of hypoglycemic events in 41 patients who had undergone Roux-en-Y gastric bypass surgery, decreasing events from an average of 17.1 to 2.5 per month, which is an 85% reduction.

The CRD also improved the lowest blood glucose levels during hypoglycemic events, indicating better overall glucose control, although about 34% of patients still required additional insulin therapy for adequate management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Evaluation of carbohydrate restriction as primary treatment for post-gastric bypass hypoglycemia. van Meijeren, J., Timmer, I., Brandts, H., et al.[2019]

In a study of 47 females without diabetes undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), both surgeries resulted in lower fasting glucose levels but increased glycemic variability (GV) after 6 and 12 months.

56% of RYGB and 75% of SG patients experienced interstitial glucose concentrations below 3.9 mmol/L after 12 months, with about 70% of these patients reporting hypoglycemic symptoms, indicating a potential risk for hypoglycemia post-surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Glycemic variability and hypoglycemia before and after Roux-en-Y Gastric Bypass and Sleeve Gastrectomy - A cohort study of females without diabetes. Nilsen, I., Sundbom, M., Osterberg, J., et al.[2023]

References

1. United States pubmed.ncbi.nlm.nih.gov

Incidence of Hypoglycemia After Gastric Bypass vs Sleeve Gastrectomy: A Randomized Trial. [2018]

2. England pubmed.ncbi.nlm.nih.gov

Postprandial hypoglycemia after gastric bypass surgery: from pathogenesis to diagnosis and treatment. [2020]

3. United States pubmed.ncbi.nlm.nih.gov

Hormonal response to a mixed-meal challenge after reversal of gastric bypass for hypoglycemia. [2021]

4. England pubmed.ncbi.nlm.nih.gov

Protocol for a randomised clinical study comparing the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on reactive hypoglycaemia in morbidly obese subjects. [2021]

5. United States pubmed.ncbi.nlm.nih.gov

Impact of perioperative management of glycemia in severely obese diabetic patients undergoing gastric bypass surgery. [2022]

6. United States pubmed.ncbi.nlm.nih.gov

Glucose-stimulated insulin secretion in gastric bypass patients with hypoglycemic syndrome: no evidence for inappropriate pancreatic beta-cell function. [2022]

7. United States pubmed.ncbi.nlm.nih.gov

Post-prandial hypoglycemia results from a non-glucose-dependent inappropriate insulin secretion in Roux-en-Y gastric bypassed patients. [2018]

8. United States pubmed.ncbi.nlm.nih.gov

Evaluation of carbohydrate restriction as primary treatment for post-gastric bypass hypoglycemia. [2019]

9. United States pubmed.ncbi.nlm.nih.gov

Glycemic variability and hypoglycemia before and after Roux-en-Y Gastric Bypass and Sleeve Gastrectomy - A cohort study of females without diabetes. [2023]