Challenges in the treatment of a patient with type 1 diabetes mellitus (T1DM) after Roux-en-Y gastric bypass (RYBG)

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 660-676-Clinical Obesity Treatment
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-672
Lucie Favre*1, Luc Tappy2, Luc Portmann3 and Vittorio Giusti4
1Univ Hosp CHUV, Lausanne, Vaud, Switzerland, 2université lausanne, Switzerland, 3Univ Hosp CHUV, Lausanne, Switzerland, 4Univ Hosp CHUV
Background/Introduction

Roux -en-Y Gastric Bypass (RYGB) is presently considered a first-line treatment for obese T2DM patients. Its consequences in patients with T1DM are however largely unknown. Several authors documented a significant improvement in blood glucose control and an increase in the insulin sensitivity in morbidly obese patients with T1DM after RYBG1,2. Since RYGB is associated with alterations in glucose kinetics and glucoregulatory hormone secretion, it can be postulated that the usual treatment of T1DM should be modified accordingly.

Clinical case

A 28 year-old obese women (initial BMI 51 kg/m2), developed an autoimmune diabetes with strongly positive anti-GAD antibodies (1’390’800 IU/ml, N<10) 5 years after RYGB which has led to a 50 kg weight loss. Basal-bolus insulin treatment was introduced.  As the patient frequently experienced premature satiety conducting to early termination of meal intake,  short-acting insulin boluses  initially administered 15 mn after the beginning of meals. With this treatment, blood glucose control was unsatisfactory with recurrent post-prandial hyperglycemia > 400 mg/dl. To better determine the optimal timing for prandial insulin administration, 4-days continuous glucose monitoring (iPro2 Medtronic) were performed. The average peaks post-prandial glycemia were 342, 288 and 212 mg/dl when short-acting insulin was injected 15 min before, at the beginning, or 15 mn after the meal respectively. Minimal post-prandial glycemia when short-acting insulin was injected 15 min after the meal was 100 mg/dl indicating that post-meal injection improved blood glucose control without hypoglycaemia. The HbA1c subsequently decreased from 8.9% to 7.4% within 10 weeks after switching insulin injections to 15 mn before meals.   

Conclusion

We report a case of T1DM onset 5 years after RYGB. This does not support the idea that an early RYGB in T1DM may preserve the B-cell mass by improving HbA1c and thus glycemic control as stated by Hussain and Al3. Blood glucose control was difficult with standard basal-bolus timing, most likely due to the early absorption of exogenous glucose after RYGB. Administration of post-meal short-acting insulin markedly improved glycemic control, most likely due to a better match between peak blood insulin and peak exogenous glucose absorption.

1 Czupryniak, L. Wiszniewski, M.  Szymanski, D. Pawlowski, M. Loba, J. Strzelczyk, J. Long-term results of gastric bypass surgery in morbidly obese type 1 diabetes patients. Obes Surg. 2010;20:506-508   2 Mendez, C. Tanenberg, R. Pories, W. Outcomes of Roux-en-Y gastric bypass surgery for severely obese patients with type I diabetes: a case series report. Diabetes Metab Synd Obses. 2010; 3:281-283   3Hussain,  A. Mahmood, H. El-Hasani, S. Can Roux-en-Y gastric bypass provide a lifelong solution for diabetes mellitus? Can J Surg. 2009; 52

Nothing to Disclose: LF, LT, LP, VG

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