Dasiglucagon Effectively Mitigates Postbariatric Postprandial Hypoglycemia: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial

Roux-en-Y gastric bypass (RYGB) is a frequently performed bariatric procedure causing massive body weight loss and beneficial metabolic effects resulting in remission of type 2 diabetes and increased lifetime expectancy (1–3). RYGB is, however, associated with postbariatric hypoglycemia (PBH), a complication with frequent postprandial hypoglycemic episodes, occurring in up to 75% of individuals who have undergone RYGB surgery (4). PBH is a consequence of the anatomical reconfiguration of the gastrointestinal tract that leads to accelerated glucose absorption, massively elevated glucagon-like peptide 1 (GLP-1) levels, hyperinsulinemia, and, subsequently, hypoglycemia. Despite the debilitating nature of PBH, including impaired quality of life and increased risk of accidental death (5), treatment options of PBH are sparse and often have limited efficiency (6–12).

Glucagon administration is vital for managing severe hypoglycemic events (requiring assistance from a third party) (13). Like the native glucagon molecule, dasiglucagon is a 29–amino acid peptide, albeit substituted at 7 amino acid positions, hence solving the issue of unstable glucagon formulation and thus enabling ready-to-use administration (14). Until now, the use of dasiglucagon in treating PBH has not been studied.

In this proof-of-concept study, we evaluated the efficacy and safety of 80 and 200 µg of dasiglucagon versus placebo in RYGB-operated individuals suffering from PBH.

This was a clinical single-center (Center for Clinical Metabolic Research, Copenhagen University Hospital – Herlev and Gentofte, Hellerup, Denmark) double-blind, placebo-controlled, randomized, crossover study in which 10 RYGB-operated individuals with PBH were subjected to 3 separate trial days, each involving a liquid mixed-meal test (MMT) and either single-dose subcutaneous administration of dasiglucagon (Zealand Pharma A/S, Søborg, Denmark) (80 or 200 µg) or placebo. The Danish Medicine Agency (reg. no. 2019063248) and the Scientific-Ethical Committee of the Capital Region of Denmark (reg. no. H-19035146) approved the study. The study was registered at the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT2019–001915–22, https://eudract.ema.europa.eu/) and ClinicalTrials.gov (identifier: NCT03984370) and conducted per the principles of the Helsinki Declaration (seventh revision, 2013). Verbal and written consent was obtained from participants before study inclusion.

Participants fasted overnight prior to the MMTs and were, in addition, instructed to abstain from rigorous excise and alcohol in the days leading up to MMTs. The liquid mixed meal (5.98 kcal/kg body weight) consisted of 50 energy percent (E%) carbohydrates, 35E% fat, and 15E% protein (Nutricia Compact, 300 kcal) mixed with 1.5 g acetaminophen dissolved in 75 mL water (rate of intestinal nutrient entry estimation) was consumed at t = 0 to 10 min. Blood samples for plasma glucose (PG) were collected every 5 min. Blood pressure, heart rate, and collection of blood samples for hormone analysis were performed every 15 min. For further details, please refer to the Supplementary Material.

The 80-µg and 200-µg doses were chosen based on previously demonstrated effects on hypoglycemia, showing obtainment of euglycemia within 6 to 10 min of administration (15). Pharmacokinetic data from this study suggest a peak concentration of 407 and 775 pmol/L ∼30 min after administration of 80 and 200 µg dasiglucagon and with a half-life of 28–33 min.

The trial drug (placebo or dasiglucagon) was administered subcutaneously in the abdomen by the medical personnel. A subject-specific linear regression model was used to guide the time of drug administration, aiming for trial drug injection ∼5–10 min before PG dropped below fasting values. For further details, please refer to the Supplementary Material.

The primary end point was the nadir PG during the 240-min MMT. Secondary end points included time spent in level 1 and 2 hypoglycemia (PG <3.9 and <3.0 mmol/L) and time in hyperglycemia (PG >7.8 mmoL/L). The area under the curve from the mean time of administration (AUC_{administration}) was used to evaluate hormone excursions.

Continuous outcomes were compared using a general linear model with Šidák correction for multiple comparisons. All statistical analyses were performed using SPSS. Graphical presentations of the results were produced in Prism 9.0 (GraphPad Software, La Jolla, CA). A P value <0.05 was considered statistically significant.

Ten RYGB-operated individuals with continuous glucose monitoring (CGM)–verified recurrent PBH were included and randomly assigned (Supplementary Fig. 1): eight women and two men, median (interquartile range [IQR]) age 46 (38; 48) years, BMI 34.6 (26; 36) kg/m², and hemoglobin A_1c (HbA_1c) 5.1% (4.9; 5.3) (32 mmol/mol [30; 34]) (Supplementary Table 1).

Nine out of 10 participants experienced postprandial hypoglycemia during the MMT with placebo administration (mean ± SEM, nadir PG 3.0 ± 0.2 mmol/L). Compared with placebo, the nadir PG was raised by 0.9 mmol/L (95% CI 0.35 to 1.35; P = 0.002) and 1.4 mmol/L (95% CI 0.81 to 2.05; P = 0.0002) following administration of 80 and 200 µg dasiglucagon (Fig. 1A and B).

Time in level 1 hypoglycemia (PG <3.9 mmol/L) was reduced from 70.0 min (38.8; 80.0) (median [IQR]) after placebo administration to 0.0 min (0.0; 58.8) (P = 0.03) and 0.0 min (0.0; 11.3) (P = 0.008) following administration of 80 and 200 µg dasiglucagon (Fig. 1C and E).

Level 2 hypoglycemia (PG <3.0 mmol/L) occurred in 5 out of 10 participants following placebo administration, while only 1 participant experienced level 2 hypoglycemia after administration of 80 µg and no level 2 hypoglycemia occurred following administration of 200 µg dasiglucagon (0.0 min [0.0; 0.0] vs. 5.0 min [0.0; 26.3] with placebo) (Fig. 1D and Supplementary Table 2). Administration of both 80 and 200 µg dasiglucagon led to increased integrated insulin and C-peptide response and decreased endogenous plasma glucagon concentrations in the later phase of the MMT (AUC_{administration}) (Fig. 1F and G and Table 1).

There were no differences in plasma acetaminophen, GLP-1, GLP-2, glucose-dependent insulinotropic polypeptide (GIP), pancreatic polypeptide, norepinephrine, epinephrine, growth hormone, or cortisol levels between trial days (Table 1).

Dasiglucagon was well tolerated, with mild to moderate and transient adverse events (Supplementary Table 3). No difference in hypoglycemic symptom scores was detected (Fig. 1H).

The current study demonstrates clinically relevant mitigation of PBH in RYGB-operated individuals using dasiglucagon.

To date, only a few treatment options, not being dietary, of PBH have been investigated, and most of these have failed to provide relief of hypoglycemia. Treatment with acarbose, somatostatin analogs, GLP-1 receptor agonists, or calcium channel antagonists has either not corrected PBH in experimental settings or has proven unsuccessful when evaluated in an outpatient setting due to persistent hypoglycemia or intolerable gastrointestinal side effects (6–9). Glucagon administration has previously been attempted in treating PBH; a continuous glucagon infusion during an MMT resulted in hyperglycemia and subsequent hypoglycemia that required glycemic rescue intervention (10). In another study by Mulla et al. (11), glucagon administered using a CGM-controlled closed-loop system prevented severe hypoglycemia in 5 out of 12 participants during an MMT; however, moderate hypoglycemia (PG <3.6 mmol/L) was not prevented. Moreover, in subsequent work from the same group, using a sophisticated CGM detection algorithm in conjunction with glucagon administration did not adequately prevent hypoglycemia in patients with PBH (12). In our study, we achieved a marked 70-min reduction in level 1 hypoglycemia (<3.9 mmol/L) and complete prevention of level 2 hypoglycemia (<3.0 mmol/L) following a single dose of 200 µg dasiglucagon, with no subsequent hyperglycemia. The lack of hyperglycemia following administration of dasiglucagon may be explained by a concomitant increase in C-peptide levels, probably explained by the insulinotropic effect of dasiglucagon. As a result of mitigated hypoglycemia, the endogenous glucagon response was diminished following the administration of dasiglucagon.

We did not observe mitigation, nor exacerbation, in related hypoglycemic symptoms following administration of dasiglucagon. Early dumping syndrome was evident before the onset of hypoglycemia, as illustrated by a robust increase in hematocrit and heart rate and intense dumping symptoms within the first hour of the MMT (Supplementary Fig. 3B–H). The early dumping symptoms were followed by a period of immense exhaustion, possibly blunting the subjective sensation of symptomatic hypoglycemia as assessed by the Edinburgh Hypoglycemia Symptom Scale questionnaire.

In conclusion, we demonstrate that single-dose treatment with either 80 µg or 200 µg dasiglucagon effectively mitigates PBH in RYGB-operated individuals. While both dasiglucagon doses raised the nadir PG and reduced time in level 1 hypoglycemia, the 200-μg dose completely prevented level 2 hypoglycemia without inducing hyperglycemia. These findings suggest dasiglucagon as a potential new therapeutic in PBH.

Acknowledgments. The authors thank all study participants for participation in the study. The authors also thank Dorthe B. Nielsen, Kirsten Abelin, Ulla Kjærulff-Hansen, and the laboratory team at Panum for laboratory assistance; Anne M. Ellegaard for assistance in editing the manuscript; and Martin L. Kårhus, Pernille H. Hellmann, and Sebastian M.N. Heimbürger (Center for Clinical Metabolic Research, Copenhagen University Hospital) for helping prepare the trial drug and assistance during trial days.

Funding. This study was an independent investigator-initiated study. Zealand Pharma A/S funded the study and produced, packed, and delivered the trial drug.

The funding and the trial drug were received as pure support without any kind of obligation to Zealand Pharma A/S. The investigators own all data.

Duality of Interest. T.V. has served on scientific advisory panels and speakers bureaus or has served as a consultant to and received research support from AstraZeneca, Bristol Myers Squibb, Boehringer Ingelheim, Eli Lilly and Company, Gilead Sciences, Inc., Merck Sharpe & Dohme/Merck, Mundipharma, Novo Nordisk, Sanofi, and Sun Pharmaceuticals. F.K.K. has served on scientific advisory panels and been part of speakers bureaus for, served as a consultant to, and received research support from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Carmot Therapeutics, Eli Lilly and Company, Gubra, Lupin Pharmaceuticals, MedImmune, Merck Sharpe & Dohme/Merck, Mundipharma, Norgine, Novo Nordisk, Pharmacosmos, Sanofi, ShouTi, Zealand Pharma, and Zucara Therapeutics; and is a minority shareholder in Antag Therapeutics. No other potential conflicts of interest relevant to this article were reported.

Author Contributions. C.K.N. contributed to study conceptualization, drafted the protocol, planned the study, conducted all screening and trial visits, performed the statistical analyses, and drafted the manuscript. C.C.Ø. planned the study and contributed to the recruitment of study participants in addition to writing the protocol and the manuscript. U.L.K., D.L.H., and A.B.L. planned the study and contributed to the writing of the protocol. B.H. and J.J.H. conducted the analyses of GLP-1, GLP-2, GIP, glucagon, pancreatic polypeptide, and growth hormone. T.V. was involved in the planning of the study. Along with conceptualizing, planning, supervising, and acquiring funding for the study. F.K.K. helped write the protocol and the manuscript. All authors critically reviewed and edited the manuscript and subsequently approved the submitted version to be published. C.K.N. and F.K.K. are the guarantors of this work and, as such, had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation. Parts of this study have been presented at the 80th Scientific Sessions of the American Diabetes Association, 12–16 June 2020 and at 56th Annual Meeting of the European Association for the Study of Diabetes, 21–25 September 2020.