Endocrine Abstracts

Post-bariatric hypoglycaemia (PBH) is a recognised complication of bariatric surgery; it is estimated that between 25% and 75% of individuals could experience PBH of varying severity. First-line management includes dietary modification; pharmacotherapy is reserved for refractory cases. We present a 38-year-old woman who underwent sleeve gastrectomy in 2022. Her BMI before surgery was 42.6 kg/m² and reached a steady BMI of 23 kg/m² after two years. She regained 10 kg by the end of 2024 and started tirzepatide from January to March 2025. Shortly after discontinuing tirzepatide, she collapsed without warning, and ambulance-recorded glucose was 2.8 mmol/l. She required an urgent endocrine appointment due to the severity of her symptoms. History revealed hypoglycaemia occurring particularly 2–4 hours after meals, suggestive of PBH. She did not experience hypoglycaemia while fasting. Baseline biochemical tests, including fasting glucose, gut hormone profile, metadrenalines, urine sulphonylurea, short Synacthen test, and IGF1/IGF2 ratio, showed no abnormality. She was commenced on acarbose alongside dietary interventions. Continuous glucose monitoring (CGM) confirmed ongoing severe hypoglycaemic episodes despite strict dietary measures and acarbose. Undetectable glucose readings were recorded on several occasions on both CGM and capillary, linked to near collapses. She was required to keep a glucagon injection at home. Further consultations discussed other options for pharmacotherapy, including somatostatin analogues and diazoxide. Due to side effects associated with diazoxide, this was deemed not a long-term option. Due to current restrictions requiring funding for somatostatin analogue as a high-cost drug, it was not possible to start this immediately. Reintroduction of tirzepatide at a 2.5 mg dose resulted in dramatic clinical improvement within 12 hours, with 100% resolution of all hypoglycaemic episodes. This case highlights a potential therapeutic role for GLP-1/GIP receptor agonists in PBH and the need for further clinical evaluation in larger cohorts.