Hypoglycaemia

Question 1

What is the definition of hypoglycaemia?

Answer 1

Plasma glucose 3mmol/L or less but depends on context

Question 2

What are symptoms of hpoglycaemia?

Answer 2

Autonomic: sweating, anxiety, huger, tremor, palpitations, dizziness
N
Neuroglycopenic: confusion, drowsiness, visual trouble, seizures, coma
Mutism, personality change, restlessness and incoherence

Question 3

What is the main cause of hypoglycaemia in diabetics?

Answer 3

Insulin or sulfonylurea treatment

e.g. increased activity, missed meal, accidental or non-accidental overdose

Question 4

What are causes of hypoglycaemia in patients without diabetes?

Answer 4

EXPLAIN
Exogenous drugs - e.g. insulin, oral hypoglycaemics - bodybuilders, alcohol - binge with no food, aspirin poisoning, ACE-i, beta-blockers

Pituitary insufficiency
Liver failure
Addison's disease
Islet cell tumours (insulinoma) and immune hypoglycaemia (e.g. anti-insulin receptor antibodies in Hodgkin's)
Non-pancreatic neoplasms - firbosarcoma

Question 5

When should you investigate hypoglycaemia?

Answer 5

Whipple’s triad:

Symptoms/signs of hypoglycaemia + low plasma glucose + resolution of symptoms or signs post glucose rise

Question 6

How should you investigate hypoglycaemia?

Answer 6

Take a drug history and exclude liver failure
72h fasting may be needed
Bloods: Glucose, insulin, C-peptide, plasma ketones, proinsulin, beta-hydroxybutyrate
Circling oral hypoglycaemics

Question 7

What causes hypoglycaemic hyperinsulinaemia?

Answer 7

Insulinoma
Sulfonylureas
Insulin injection (no decidable c-peptide - only released with endogenous insulin)

Question 8

What does c-peptide tell you?

Answer 8

If circulating insulin is endogenous or not - only released with endogenous insulin.

Question 9

What cases hypoglycaemia with low insulin or undetectable and no excess ketones?

Answer 9

Non-pancreatic neoplasm

Anti-insulin receptor antibodies

Question 10

What causes low insulin and raised ketones with hypoglycaemia?

Answer 10

Alcohol, Addison’s pituitary insufficiency.

Question 11

What is the management for hypoglycaemia?

Answer 11

If conscious and able to swallow - 15-20g of quick acting care snack e.g. 200ml orange juice

If conscious but uncooperative - squirt glucose gel between teeth and gums

If unconscious or not responding start glucose IVI (10% at 200ml/15mins if unconscious.

Once blood glucose > 4mmol/L and patient has recovered give long acting carb - slice of toast