Chempath 17: Hypoglycaemia Flashcards
How should you give glucose to a diabetic who is drowsy and confused but able to swallow ?
Buccal glucose
Which one of these is an Adrenergic sign of hypoglycaemia ?
A)Confusion B)Solomolence C)Seizures D)Tremor E) loss of coordination
D) Tremor
All the other options are neuroglycopaenic signs/symptoms
Which 3 hormones are released as a result of Hypoglycaemia ?
Glucagon
Adrenaline
Cortisol
Which of these diabetic drugs does not induce Hypos ?
A) Sulphonylureas
B) GLP-1 agents
C) Metformin
D) Insulin
D) Metformin
All the others induce Hypos
Name a molecule that is a good marker of Beta cell function ?
C-peptide
During hypoglycaemia levels of FFA increases. FFAs enter the …… oxidation cycle to produce ATP. Some FFAs do not undergo …….. oxidation and form ………. instead.
Beta
Beta
Ketones
FFA- free fatty acids
A patient has a hypo. What cause is suggested by these test results:
Insulin: low
C-peptide: low
Appropriate response to hypoglycaemia
Fasting (no glycogen stores)
Adrenal failure (No cortisol)
Anorexia (no glycogen stores)
A patient has a hypo. What cause is suggested by these test results:
Insulin: High
C-peptide: High
Excess endogenous Insulin
A patient has a hypo. What cause is suggested by these test results:
Insulin: High
C-peptide: low
Excess exogenous Insulin (injecting too much insulin)
C peptide does not increase with unless endogenous insulin release
List 4 Inborn errors of metabolism that can cause a neonatal hypoglycaemia with low Insulin and low C-peptide ?
FAOD- fatty acid oxidation disorders (no ketones are made)
GSD- Glycogen storage disease type 1
MCAD deficiency
Carnitine disorders
List 4 causes of High insulin levels ?
Insulinoma (islet cell tumour)
Drugs: Insulin, Sulphonylurea
Islet cell hyperplasia: Beckwith-wiedemann syndrome, mother is diabetic, Nesidioblastosis
Which syndrome features insulinomas ?
MEN1
List 3 causes of hypoglycaemia with high insulin and high C-peptide ?
- Insulinoma
- islet cell hyperplasia
- Hyperinsulinaemic hypoglycaemia of infancy (When mother has gestational diabetes)
How should you treat someone who is hypoglycaemic but alert
oral carbs
rapid acting - juice/sweets
longer acting - sandwich
How should you treat someone who is hypoglycaemia and drowsy but with swallow intact
buccal glucose
eg hypostop/glucogel
start thinking about IV access
How should you treat someone who is hypoglycaemic and unconscious/ can’t swallow
IV access
50ml 50% glucose min-jet
or 100ml 20% glucose
How should you treat someone who is hypoglycaemic and deteriorating/ refractory/ insulin induced/ difficult IV access
IM/SC 1mg glucagon
how long does glucagon take to work
15-20 mins
mobilises glycogen stores
(consider whether they have adequate glycogen stores)
what level of blood glucose is considered hypoglycaemic
< 4 mmol/L in adults
<2.5 mmol/L in neonates
what are the two types of hypoglycaemia symptoms
ADRENERGIC - tremors, palpitations, sweating, hunger
NEUROGLYCOPAENIC - confusion, incoordination, seizures, coma
describe what happens normally when low blood glucose is detected
insulin secretion reduced increase in glucagon - reduce peripheral uptake of glucose - increase gluconeogenesis - increase glycogenolysis - increase lipolysis
Increases glucose levels and FFA levels
FFAs enter beta oxidation - ATP
If lots of FFA - ketone bodies
Also release of ATCH, cortisol, GH
how can we confirm hypoglycaemia
lab glucose - gold standard
- grey top (flouride oxalate)
blood glucose meter - less precise at low glucose levels
list causes of hypoglycaemia without diabetes
fasting critically unwell organ failure hyperinsulinism post gastric bypass drugs extreme weight loss facticious
list causes of hypoglycaemia in diabetics
medications inadequate carb intake impaired awareness excessive alcohol strenuous exercise co-existing AI conditions
list medications than can cause hypoglycaemia
sulphonylureas meglitinides GLP-1 agents insulin beta-blockers salicylates alcohol (inhibits lipolysis)
what co-morbidities may result in hypoglycaemia in someone with diabetes
renal/liver failure
Addisons
poor awareness in autonomic neuropathy
why is c peptide measured
marker of b cell function
30 min half life
what causes hypoinsulinaemic hypoglycaemia
something other than insulin
fatsing/starvation strenuous exercise illness endocrine - hypopituitarism/adrenal failure liver failure anorexia nervosa
what causes hyperinsulinaemic hypoglycaemia
excess endogenous insulin
high insulin + low c peptide - exogenous insulin
name 3 ketone bodies
3-hydroxybutarate
acetone
acetoacetate
what causes neonatal hypoglycaemia
explainable:
- premature, co-morbidities, IUGR, SGA, inadequate fat stores, should improve with feeding
pathological:
- inborn errors of metabolism
causes of neonatal hypoglycaemia with suppressed insulin and c peptide
fatty acid oxidation disorder - no ketones made
glycogen storage disease
MCAD deficiency
carnitide disorders
what would you expect to see in neonatal hypoglycaemia with low insulin and c peptide
high FFA
detectable ketone bodies
list causes of inappropriately high insulin
Islet cell tumours eg insulinoma
Drugs eg insulin, sulphonylureas
Islet cell hyperplasia eg infant of diabetic mother, Beckwidth-Wiedemann syndrome, Nesidioblastosis
how do sulphonylurease cause raised insulin
bind ATP sensitive K+ channels without ATP - makes them close - insulin released
what causes non-islet cell tumour hypoglycaemia
mesenchymal tumours or epithelial tumours secreting big IGF-2
binds IGF1 receptors and insulin receptors
endogenous insulin production stopped and FFA production suppressed
list genetic causes of hypoglycaemia
glucokinase activating mutations congenital hyperinsulinism: - KCNJ11/ABCC8 - GLUD-1 - HNF4A - HADH
what causes reactive/post-prandial hypoglycaemia
gastric bypass
hereditary fructose intolerance
early diabetes
insulin-sensitive individuals post large meals/ exercise
