Table 3.
Pharmacotherapy for Hypoglycemia After Upper GI Surgery
| Route | Dosing Schedule* | Mechanism of Action | Possible Side-Effects/Adverse Events | |
|---|---|---|---|---|
| Acarbose | PO | 20 minutes before each main meal up to 300 mg/day | Delays digestion of carbohydrate via enzymatic inhibition. | Flatulence, diarrhea, abdominal pain. May decrease over time. Less with prescribed MTN. |
| Diazoxide (suspension) | PO | Q 8–12 hours (including hs) | Inhibits insulin release. | Fluid and sodium retention, anorexia, nausea, vomiting, abdominal pain, ileus, diarrhea, hirsutism. |
| Octreotide | SQ | Q 6–8 hours, pre-meal (timing individualized based on response) | Short-acting somatostatin analog which inhibits secretion of insulin and other GI peptides, slows gastric emptying. | Cholelithiasis, sinus bradycardia, conduction abnormalities, arrhythmia, diarrhea, loose stools, nausea and abdominal discomfort, pain on injection, headache, dizziness, hypothyroidism, worsening hypoglycemia.** |
| Sandostatin LAR Depot | IM | Q 3–4 weeks | Long-acting somatostatin analog, inhibits insulin secretion, as well as other GI peptides, slows gastric emptying. | Nausea, headache, abdominal pain, dizziness, myalgia, generalized pain, back pain, fatigue, flatulence, upper respiratory tract infection (URI), pruritis, rash, sinusitis, vomiting.*** Typically cannot be self-injected. |
| Pasireotide57 | IM | Q 4 weeks | Somatostatin analog which inhibits secretion of insulin and other GI peptides, slows gastric emptying. | Diarrhea, abdominal pain, nausea, fatigue, abdominal distention, vomiting, upper abdominal pain, hyperglycemia, hypertension, QT prolongation, sinus bradycardia, cholelithiasis, liver enzyme abnormalities, headache, alopecia, arthralgia, back pain, extremity pain, anemia. |
| If the above are contraindicated, not tolerated, or cannot be used for other reasons consider options below, though reports of efficacy in the literature are inconsistent. | ||||
| Calcium channel blockers (eg, verapamil, nifedipine)70,71 | PO | Daily | Block calcium channels, including in the pancreatic beta cell, decreasing insulin release. | Hypotension, constipation, fatigue, dizziness, dyspnea, nausea, bradycardia, AV block total, headache, edema, 2nd/3rd degree block, rash, congestive heart failure, pulmonary edema, flushing, elevated liver enzymes. |
| Liraglutide71 | SQ | Daily | Slows gastric transport. Case reports indicate may reduce hyperglycemia and glucose variability. | Nausea, diarrhea, headache, nasopharyngitis, vomiting, decreased appetite, dyspepsia, URI, constipation, back pain, worsening hypoglycemia. Warning in place regarding pancreatitis, renal impairment, thyroid C-cell tumors. |
Notes: *Dosing schedule, amount, and titration requires individualization based upon patterns of hypoglycemia, presence of side-effects/tolerability. **Hypoglycemia may occur due to concurrent inhibition of glucagon. ***Frequency and presence vary by dose and indication for Sandostatin LAR depot.