Manejo da hipoglicemia pós-prandial após a cirurgia bariátrica: empagliflozina, uma nova opção terapêutica?
Data
2022-06-27
Autores
Carpentieri, Giovanna Braganholo 
Orientadores
Zanella, Maria Teresa
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A cirurgia bariátrica é uma opção de tratamento para a obesidade grave, porém algumas complicações podem ocorrer após a cirurgia. A hipoglicemia pós prandial (HPP) após a cirurgia bariátrica é uma complicação frequente que pode acontecer a partir de 6 meses após o procedimento. A fisiopatologia é complexa e multifatorial e alguns pacientes podem apresentar sintomas debilitantes, enquanto outros são assintomáticos. As opções terapêuticas disponíveis são limitadas e nem sempre apresentam bons resultados, sendo muitas vezes associadas a efeitos colaterais indesejados. Objetivo: Entender o mecanismo de ação das diferentes opções terapêuticas para o tratamento da HPP após a cirurgia bariátrica e avaliar o efeito da droga empagliflozina em reduzir a ocorrência de hipoglicemia nestes pacientes. Métodos: Uma revisão bibliográfica sobre o tratamento atual da HPP após a cirurgia bariátrica foi realizada e um ensaio clínico foi conduzido com pacientes submetidos à cirurgia bariátrica no Ambulatório de Obesidade da Universidade Federal de São Paulo. Os pacientes foram submetidos ao teste oral da refeição líquida e foi feita a avaliação das curvas de glicemia e insulina em jejum e a cada 30 minutos após a ingestão da refeição líquida, por 120 minutos, antes e após a administração de empagliflozina (Jardiance 25mg), um inibidor do cotransportador 2 de sódio e glicose (iSGLT2) no túbulo proximal renal, por três dias consecutivos. Os pacientes foram comparados entre os que apresentavam sintomas sugestivos de hipoglicemia versus pacientes assintomáticos. Resultados: Foram elaborados dois artigos científicos relacionados ao tema. O primeiro artigo elucidou as diferentes opções terapêuticas testadas para o manejo da HPP após a cirurgia bariátrica. O segundo artigo evidenciou uma melhora significativa nos níveis glicêmicos após o tratamento com empagliflozina nos pacientes com hipoglicemia após a cirurgia bariátrica provavelmente por aumento da produção hepática de glicose. Conclusão: O tratamento da HPP após a cirurgia bariátrica é desafiador e as opções terapêuticas disponíveis agem por diferentes mecanismos, atuando na complexa fisiopatologia desta complicação. A empagliflozina foi testada para este fim em nosso estudo e apresentou resultados promissores. No entanto, são necessários ensaios clínicos randomizados de longo prazo com um número maior de pacientes para testar o efeito da administração de empagliflozina nesta condição.
Introduction: Bariatric surgery is an option for severe obesity treatment, but some complications may occur after surgery. Postprandial hypoglycemia (PPH) after bariatric surgery is a frequent late complication that may occur at least 6 months after the procedure. The pathophysiology is complex and multifactorial, and some patients may experience debilitating symptoms, while others are asymptomatic. The therapeutic options available are limited and do not always present good results, being often associated with adverse side effects. Objective: To describe the mechanisms of action of the different therapeutic options for the treatment of PPH after bariatric surgery and to evaluate the effect of empagliflozin in reducing the episodes of hypoglycemia in these patients. Methods: A review of the literature on the current treatment of PPH after bariatric surgery was performed and a clinical trial was conducted with patients undergoing bariatric surgery at the Obesity Outpatient Clinic of the Federal University of São Paulo. Patients were submitted to an oral liquid meal tolerance test, and blood glucose and serum insulin levels were measured in fasting and every 30 minutes after ingestion of the liquid meal, for 120 minutes, before and after the administration of empagliflozin (Jardiance 25mg), a renal sodium-glucose cotransporter 2 inhibitor (iSGLT2), for three consecutive days. Patients were compared between those with symptoms suggestive of hypoglycemia versus asymptomatic patients. Results: Two scientific articles related to the topic were prepared. The first article describes the different therapeutic options tested for the management of PPH after bariatric surgery. The second article showed a significant improvement in glycemic levels after treatment with empagliflozin in patients with hypoglycemia after bariatric surgery, probably due to increased hepatic glucose production. Conclusion: Treating PPH after bariatric surgery is challenging and the available therapeutic options act through different mechanisms, acting on the complex pathophysiology of this complication. Empagliflozin was tested for this purpose in our study and showed promising results. However randomized long-term clinical trials with a larger number of patients are needed to test the long-term effect of empagliflozin administration in this condition.
Introduction: Bariatric surgery is an option for severe obesity treatment, but some complications may occur after surgery. Postprandial hypoglycemia (PPH) after bariatric surgery is a frequent late complication that may occur at least 6 months after the procedure. The pathophysiology is complex and multifactorial, and some patients may experience debilitating symptoms, while others are asymptomatic. The therapeutic options available are limited and do not always present good results, being often associated with adverse side effects. Objective: To describe the mechanisms of action of the different therapeutic options for the treatment of PPH after bariatric surgery and to evaluate the effect of empagliflozin in reducing the episodes of hypoglycemia in these patients. Methods: A review of the literature on the current treatment of PPH after bariatric surgery was performed and a clinical trial was conducted with patients undergoing bariatric surgery at the Obesity Outpatient Clinic of the Federal University of São Paulo. Patients were submitted to an oral liquid meal tolerance test, and blood glucose and serum insulin levels were measured in fasting and every 30 minutes after ingestion of the liquid meal, for 120 minutes, before and after the administration of empagliflozin (Jardiance 25mg), a renal sodium-glucose cotransporter 2 inhibitor (iSGLT2), for three consecutive days. Patients were compared between those with symptoms suggestive of hypoglycemia versus asymptomatic patients. Results: Two scientific articles related to the topic were prepared. The first article describes the different therapeutic options tested for the management of PPH after bariatric surgery. The second article showed a significant improvement in glycemic levels after treatment with empagliflozin in patients with hypoglycemia after bariatric surgery, probably due to increased hepatic glucose production. Conclusion: Treating PPH after bariatric surgery is challenging and the available therapeutic options act through different mechanisms, acting on the complex pathophysiology of this complication. Empagliflozin was tested for this purpose in our study and showed promising results. However randomized long-term clinical trials with a larger number of patients are needed to test the long-term effect of empagliflozin administration in this condition.