Table 1.

Summary table of recommendations. Confidence in guidance recommendations classified using GRADE (7).

1.	Diagnosis	GRADE certainty
1.1	People potentially presenting with PBH should undergo a careful initial evaluation including consideration of alternative causes of hypoglycaemia.	N/A
1.2	PBH should be defined pragmatically in a patient after bariatric surgery as biochemically confirmed hypoglycaemia <3.0 mmol/L (54 mg/dL), with typical hypoglycaemic symptoms, fulfilling Whipple’s triad, after investigation and exclusion of alternative causes of hypoglycaemia.	Moderate
1.3	Hypoglycaemia should preferably be confirmed in a venous plasma sample utilizing an assay that is validated for low glucose concentrations.	High
1.4	Dynamic or provocational testing with OGTT or MMT is not recommended for the diagnosis of PBH.	Moderate
1.5	CGM is not presently recommended for the diagnosis of PBH.	Moderate
1.6	If a venous plasma glucose measurement is not available or practical, capillary blood glucose measurements can also be acceptable for diagnosis if they are taken using a testing system which conforms to ISO 15197 standards, there are multiple confirmatory readings and the history is strongly consistent with PBH.	Low
2.	Behavioural, dietary and lifestyle management
2.1	People with PBH should undergo evaluation for dietary habits, dietary triggers and eating behaviours by a registered dietitian, preferably with a specialist interest in bariatric surgery, to enable individualised guidance on a healthy post-bariatric eating strategy.	Moderate
2.2	People with PBH should also be screened and treated for nutritional deficiencies according to accepted guidance.	High
2.3	Dietary advice for PBH should include eating controlled portions of carbohydrates, together with reinforcement of the post-bariatric eating strategy. Suggested strategies include: - Small and frequent meals (up to 6× per day). - Reduced carbohydrate content (starting at <30 g/meal). - Emphasis on choosing low GI over high GI carbohydrates. - Consideration may be given to lower carbohydrate targets (e.g. 25 g/meal, 20 g/meal and so on) under supervision if the initial 30 g/meal target is not effective.	Moderate
2.4	We do not recommend modifying the type of carbohydrates (e.g. fructose-containing foods), using cornstarch supplements, or using food additives to modify glycaemic index.	Low
2.5	CGM, where available or funded, may be considered as a tool for education, reinforcing and documenting the relationship between dietary changes to the amelioration of PBH, improving the adherence to dietary advice and for early recognition and treatment of hypos.	Low
2.6	People with PBH should be taught procedures to treat emergent hypoglycaemia. A suggested approach is as follows: - They should be advised to always carry fast acting carbohydrates to treat hypoglycaemia. - Upon receiving a warning or confirmation of hypoglycaemia, they should be advised to consume small amounts of fast acting carbohydrates (e.g. 10–15 g of dextrose). - They should be advised to test blood glucose 15 min after consumption to confirm resolution of the hypoglycaemia. If necessary, a further small dose of carbohydrate can be used if the blood glucose is still low. - A follow-on low GI carbohydrate-containing snack may be considered after initial resolution of the hypoglycaemia.	Low
2.7	Sucrose for treatment of hypoglycaemia should be avoided in acarbose-treated PBH.	High
2.8	People should be encouraged to exercise after bariatric surgery. A suggested approach to exercise in PBH is as follows: - They should be advised to take exercise when the risk of PBH is low (e.g. when fasting or at least 3 hr after meals). - They should be advised to avoid carbohydrate loading prior to exercise. - They should be advised to measure their blood glucose when feeling unwell. - They should be advised to carry some fast-acting carbohydrates that can be used to manage any hypoglycaemia. - A follow-on low GI carbohydrate-containing snack may be considered after exercise.	Low
2.9	People with PBH should be encouraged to reduce or cease alcohol intake.	Low
2.10	Modifications to dietary macronutrient content such as increased consumption of protein during meals should be encouraged. Individualised targets for protein consumption should be set. These are minimally 60 g/day but higher targets may be required.	Moderate
2.11	People with PBH should be encouraged to avoid fluids with each meal. Ideally, they should avoid drinking in the 30 min prior to and continuing for 30 min after each meal, and minimally they should avoid drinking with the meal and for at least 30 min after each meal.	Low
2.12	Gastrostomy feeding tube placement into the remnant stomach may be considered in severe PBH which does not respond to dietary nor pharmacological treatment.	Low
3.	Pharmacological management
3.1	Acarbose should be considered as the first-line pharmacological treatment for PBH.	Moderate
3.2	Second-line options, if acarbose is not effective or not tolerated, include short-acting SC pasireotide or octreotide (given three times a day before meals) or long-acting IM pasireotide LAR.	Moderate
3.3	Diazoxide may be considered as a third-line option if somatostatin analogues are not tolerated.	Low
3.4	In people with frequent, severe PBH, consider prescribing glucagon injections (GlucaGen®, Ogluo®) as rescue treatment, with appropriate training for helpers.	Moderate
3.5	Avexitide (exendin 9–39) may be considered as part of investigational trials for PBH, where available.	Moderate
3.6	We do not currently recommend long-term treatment of PBH with other types of long-acting somatostatin analogues such as IM octreotide LAR or lanreotide, SGLT inhibitors, GLP-1 analogues, IL-1beta antagonists, DPP-IV inhibitors and calcium channel antagonists.	Low
4.	Surgical or endoscopic management
4.1	Decisions regarding reversal surgery should be discussed in a multidisciplinary setting, preferably with bariatric surgeons experienced in these techniques, and with full disclosure as to the likelihood of post-operative complications and weight regain.	N/A
4.2	Partial pancreatectomy may be indicated in cases where there is evidence of a coincident insulinoma/pancreatic mass and evidence of localised excess insulin secretion (e.g. from intraarterial calcium stimulation and hepatic vein sampling for insulin). Cases should be referred to experienced hepato-pancreato-biliary multidisciplinary teams.	Low
5.	Driving in people diagnosed with PBH in the UK
5.1	All people diagnosed with PBH should be advised to contact the DVLA for advice.
5.2	They should be advised to stop driving and contact the DVLA if they experience episodes of severe hypoglycaemia (defined as requiring the assistance of another person), or if there is evidence of impaired awareness of hypoglycaemia.
5.3	People with PBH driving Group 1 vehicles (cars, motorcycles) can utilise glucose monitoring sensor systems but must carry back-up capillary blood glucose systems in their vehicles.
5.4	People with PBH driving Group 2 vehicles (trucks, buses) must use back-up capillary blood glucose systems.
6.	Research area recommendations
6.1	The diagnostic performance and cost-effectiveness of CGM and capillary blood glucose in the diagnosis of PBH.
6.2	The relationship of low interstitial glucose readings from CGM to the symptoms of PBH.
6.3	The clinical efficacy and cost-effectiveness of utilising CGM for the management of PBH.
6.4	The optimal method for treatment of hypoglycaemia in people with PBH.
6.5	Controlled trials of potential treatments against the current standard-of-care (e.g. best dietary practice).
6.6	The efficacy and long-term effects of alternative approaches such as endoscopic revision of gastro-jejunal anastomoses (TORe).

CGM, continuous glucose monitoring; GI, glycaemic index; MMT, mixed meal test; OGTT, oral glucose tolerance test; PBH, post-bariatric hypoglycaemia..