Endocrine Abstracts

Mrs MP was referred to the Weight Management service in 2011, aged 45. She weighed 108 kg, with a BMI of 40 kg/m². She had type 2 diabetes, but no other past medical history and was working in a high profile job. A Roux-en-Y bypass was performed in November 2011, with no immediate complications. She successfully lost 25% of her body weight and by April 2012 weighed 79.2 kg. Towards the end of 2015 she was re-referred with symptoms of severe fatigue, poor concentration and mood changes particularly at work. As a result of this she had been signed of sick by occupational health. Investigations revealed no evidence of anaemia or vitamin deficiency, and a normal cortisol response to Synacthen. Treatment with a course of thiamine and IV Pabrinex initially improved her symptoms but they then returned. Despite denying symptoms of dumping syndrome and hypoglycemia, a decision was made to proceed with Continuous Glucose Monitoring (CGM). This revealed hypoglycaemia 2–3 h after meals. A clinical diagnosis of hyperinsulinaemic hypoglycaemia was made and she was referred to see our dietitian. Changing her diet initially improved her symptoms but they then returned. Acarbose and diltiazem were tried without success. Liraglutide significantly improved her symptoms for a number of months but the effect diminished with time. Commencement of octreotide improved her symptoms but she was still getting 5–6 hypos per week. Due to the persistence of her symptoms a CT-pancreas, 72 h fast and octreotide scan were performed ruling out an insulinoma. In early 2017 we successfully got her back to work on Prednisolone, Sitagliptin, Liragutide and Octreotide, and with a CGM funded through exceptional funding. In the last 3 months her hypos have returned and she has had to take early retirement. Her most recent CGM download shows she spends 19% of her time with a blood glucose below 4 mmol/l and 5% below 3 mmol/l. Various options have now been discussed including trialing a dual insulin and glucagon pump or further surgery. We welcome other peoples’ advice on how to manage this woman’s hypoglycaemia in a bid to improve her quality of life.