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ChemPath > Hypoglycaemia > Flashcards

Hypoglycaemia Flashcards

1
Q
  1. Outline the first step in the management of hypoglycaemic patients in the following states:
    a. Alert and orientated
    b. Drowsy/confused but swallow intact
    c. Unconscious or concerned about swallow
A

a. Alert and orientated
Oral carbohydrates (e.g. juice/sweets or long-acting forms such as a sandwich)
b. Drowsy/confused but swallow intact
Buccal glucose (e.g. glucogel)
c. Unconscious or concerned about swallow
IV 50 mL 50% glucose
NOTE: or 100 mL 20% glucose

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2
Q
  1. What should be considered if a hypoglycaemic patient is deteriorating or does not appear to be responding to the first step in their management?
A

IM/SC 1 mg glucagon

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3
Q
  1. What is the benefit of giving glucose sublingually?
A

Bypasses hepatic first-pass metabolism

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4
Q
  1. How long is it likely to take for IM glucagon to cause an increase in blood glucose?
A

15-20 mins

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5
Q
  1. Which group of patients may not respond to IM glucagon?
A

Starving
Anorexic
Hepatic failure
These patients will have poor liver glycogen stores that can be accessed by glucagon

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6
Q
  1. Describe the triad of features that is used to define hypoglycaemia.
A

Low glucose
Symptoms
Relief of symptoms by administration of glucose

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7
Q
  1. List some symptoms of hypoglycaemia.
A

Adrenergic: tremors, palpitations, sweating
Neuroglycopaenic: confusion, coma

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8
Q
  1. What is a consequence of recurrent episodes of hypoglycaemia?
A

Hypoglycaemia awareness (loss of adrenergic symptoms with hypoglycaemia)

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9
Q
  1. Describe the order in which physiological compensatory changes in response to hypoglycaemia take place.
A

Suppression of insulin
Release of glucagon
Release of adrenaline
Release of cortisol

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10
Q
  1. What effect do these measures have on blood glucose and FFA production?
A

Increases blood glucose
Increases FFAs
Not all FFAs can be used to generate ATP by beta-oxidation so some of them will become ketone bodies

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11
Q
  1. What investigation may need to be performed to demonstrate hypoglycaemia in an otherwise healthy person?
A

Prolonged fast

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12
Q
  1. List some causes of hypoglycaemia in people without diabetes.
A 
Fasting 
Paediatric
Critically unwell
Organ failure 
Hyperinsulinism
Post-gastric bypass 
Drugs 
Extreme weight loss 
Factitious (artefact)
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13
Q
  1. List some causes of hypoglycaemia in diabetics.
A 
Medications (inappropriate insulin)
Inadequate carbohydrate intake (missed meal)
Impaired awareness
Excessive alcohol 
Strenuous exercise 
Co-existing autoimmune conditions
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14
Q
  1. List some diabetic medications that can cause hypoglycaemia.
A

Oral hypoglycaemics: sulphonylureas, meglitinides, GLP1 analogues
Insulin

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15
Q
  1. List some non-diabetic medications that can cause hypoglycaemia.
A

Beta-blockers
Salicylates
Alcohol

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16
Q
  1. How could co-morbidities in a diabetic patient lead to increased risk of hypoglycaemia?
A

Renal/liver failure could lead to impaired drug clearance

Concurrent Addison’s disease could result in hypoglycaemia (polyglandular autoimmune syndrome)

17
Q
  1. What is continuous glucose monitoring?
A

The device is applied to the abdominal wall with a small cannula that sits in the interstitial space in the subcutaneous fat

The sensor does not accurately read blood glucose when < 2.2 mmol/L

18
Q
  1. List some biochemical tests that may help differentiate between causes of hypoglycaemia.
A

Insulin levels (NOTE: exogenous insulin can interfere with assays)
C-peptide (marker of endogenous insulin production)
Drug screen
Autoantibodies
Cortisol/GH
Free fatty acids/ketone bodies
Lactate

19
Q
  1. What would you expect the insulin and C-peptide levels to be in a hypoglycaemic patient who has anorexia nervosa but not diabetes?
A

Low insulin and low C-peptide
The patient is hypoglycaemic because of poor liver glycogen stores (not an issue with insulin) so their insulin response will be normal

20
Q
  1. List some causes of Hypoinsulinaemic hypoglycaemia.
A

Fasting/starvation
Strenuous exercise
Critical illness
Endocrine deficiencies (adrenal failure, hypopituitarism)
Liver failure
Anorexia nervosa
NOTE: this is a normal response to hypoglycaemia

21
Q
  1. Name 3 ketone bodies.
A

3-hydroxybutyrate
Acetone
Acetoacetate

22
Q
  1. What does hypoglycaemia with high FFAs and low ketones suggest?
A

Fatty acid oxidation defect

23
Q
  1. List some physiologically explicable causes of neonatal hypoglycaemia.
A

Prematurity
IUGR
Inadequate glycogen/fat stores
NOTE: this should improve with feeding

24
Q
  1. List some tests that may be useful in the investigation of neonatal hypoglycaemia.
A 
Insulin/C-peptide
FFA 
Ketone bodies 
Lactate 
Hepatomegaly
25
Q
  1. List some causes of neonatal hypoglycaemia with high FFAs and low ketones.
A 
Fatty acid oxidation defects 
MCAD deficiency
Carnitine disorders 
HMG-CoA lyase deficiency 
GSD type 1
26
Q
  1. List some causes of neonatal hypoglycaemia with low FFAs and low ketones.
A

Hyperinsulinism

Hypopituitarism

27
Q
  1. List some causes of neonatal hypoglycaemia with high FFAs and high ketones.
A 
Galactosaemia
Glycogen storage disease 
Neonatal haemochromatosis 
GH deficiency 
Glucocorticoid deficiency 
Septicaemia
28
Q
  1. List some causes of inappropriately high insulin levels in neonates.
A

Islet cell tumours (e.g. insulinoma)
Drugs (e.g. insulin, sulphonylureas)
Islet cell hyperplasia
• Infant with diabetic mother
• Beckwith-Wiedemann syndrome (overgrowth disorder)
• Nesidioblastosis (excessive function of beta cells with abnormal microscopic appearance)

29
Q
  1. State two causes of Hyperinsulinaemic hypoglycaemia with a high C-peptide.
A

Insulinoma
Sulphonylurea abuse

DOURINE OR SERUM SULPHONYLUREAS

30
Q
  1. Describe the mechanism by which beta cells release insulin in response to blood glucose.
A

Glucose crosses the membrane of beta cells and enters glycolysis via glucokinase
Glycolysis produces ATP
The rise in ATP leads to the closure of ATP-sensitive K+ channels
This leads to membrane depolarisation, calcium influx and insulin exocytosis

31
Q
  1. Describe the mechanism of action of sulphonylureas.
A

They bind to the ATP-sensitive K+ channel making it close independently of ATP

32
Q
  1. What can cause the following: low glucose, low insulin, low C-peptide, low FFAs and low ketones?
A

This suggests that something is pretending to be insulin
This is non-islet cell hypoglycaemia caused by secretion of big IGF-2
Big IGF-2 binds to IGF-1 receptors and insulin receptors
It behaves like insulin, so it causes hypoglycaemia and suppresses insulin and FFA/ketone production
It is a paraneoplastic syndrome usually caused by mesenchymal tumours (e.g. mesothelioma, fibroblastoma) and epithelial tumours (carcinoma)

33
Q
  1. Describe two autoimmune causes of hypoglycaemia.
A

Autoimmune conditions – antibodies against insulin receptors can cause insulin resistance and hypoglycaemia (rarely)
Autoimmune insulin syndrome – antibodies are directed towards insulin so sudden dissociation of the antibodies can precipitate hypoglycaemia (could be caused by drugs e.g. hydralazine, procainamide)

34
Q
  1. List some genetic causes of hypoglycaemia.
A 
Glucokinase activating mutation 
Congenital hyperinsulinism (GLUD-1, HNF4A, HADH, KNJJ11)

ChemPath (11 decks)

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