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Insulin

In patients failing to respond adequately to insulin sensitizers or insulin secretogogues, treatment with insulin becomes important. In the immediate post-operative setting, this could be in the form of sliding scale short acting insulin or fixed dose long acting insulin. It has also been shown that a protocol based individualized insulin titration in combination with OHA s could offer better glycemic control [6].

GLP-1 Analogues/DPP4 Inhibitors

With increasing understanding on the role of incretins in T2DM remission following bariatric surgery, research has been focused in developing drugs mimicking the actions of these incretins. The most commonly studied incretin is the GLP-1 secreted in the L cells of the ileum, which is trophic to the beta cells and also improving insulin sensitivity. Native GLP-1 has a very short plasma half-life and novel methods have been developed to augment its half-life, so that its anti-hyperglycemic effects can be exploited. They analogues can be broadly classified as exendin-based therapies (exenatide, DPP-4-resistant analogues (lixisenatide, albiglutide), and analogues of human GLP-1 (liraglutide, taspoglutide) [19].

Research on obese rate models with T2DM has suggested that the use of these agents improves surgically induced weight loss [20]. Also a recent meta-analysis has demonstrated excellent glycemic control in T2DM patients [21]. Considering its role in both weight management and glycemic control, these drugs could find potential use in the post bariatric patient with inadequate remission or relapse of diabetes.

 
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