HYPOGLYCEMIA IN NON-DM Flashcards
UPTODATE
What glucose value indicates hypoglycemia in a symptomatic patient with diabetes?
Less than 70 mg/dL (3.89 mmol/L)
What should be done if a glucose test cannot be performed for a symptomatic patient suspected of hypoglycemia?
Treat as if hypoglycemia is confirmed
What actions should be taken in SUPERVISED FASTING TEST if the glucose is low (<55 mg/dL) and the patient does not have diabetes?
Draw blood for glucose, insulin, C-peptide, and an oral hypoglycemic agent screen, and then treat
When should treatment not be delayed for a patient with suspected symptomatic hypoglycemia?
If rapid blood glucose measurement is not available or blood for diagnostic studies cannot be collected
What should be administered to a conscious patient with a low glucose value who is able to drink and swallow safely?
A rapidly absorbed carbohydrate (e.g., glucose tablets, fruit juice, honey, table sugar)
What should be done if a patient with hypoglycemia has altered mental status, is unable to swallow, or does not respond to oral glucose administration within 15 minutes?
Give an IV bolus of 12.5 to 25 g of glucose (25 to 50 mL of 50% dextrose)
After administering an IV bolus of glucose, when should a blood glucose measurement be taken?
10 to 15 minutes after the IV bolus
How should glucose be administered if a patient cannot take it orally or parenterally?
Give glucagon 1 mg IM or subcutaneously
When should patients with ingestion of a long-acting hypoglycemic agent, recurrent hypoglycemia during observation, and those unable to eat be admitted?
Admit in these cases
What is the preferred means of maintaining glucose levels after an initial IV bolus of glucose?
Continuous IV infusion of glucose (e.g., 10% dextrose in water)
Rate 75-150ml/hr.
When should a blood glucose measurement be taken after the initial IV bolus and how frequently should it be monitored?
10 to 15 minutes after the IV bolus, and every 30 to 60 minutes thereafter until stable (minimum of 4 hours)
What type of glucose should be given to patients taking alpha-glucosidase inhibitors ( acrobose) with symptomatic hypoglycemia?
Pure glucose (dextrose)
What laboratory findings indicate hypoglycemia in a non-DM patient taking exogenous insulin?
Low glucose,
Low C-peptide
Low beta-hydroxybutyrate
high insulin
What laboratory findings suggest hypoglycemia caused by an insulinoma, NIPHS, or PGBH?
Low glucose,Low beta-hydroxybutyrate high insulin, high proinsulin high C-peptide.
What laboratory findings indicate hypoglycemia in a non-DM patient taking oral hypoglycemic agents?
Low glucose,
Low BHB
HI insulin
Hi c-peptide
What diagnostic sign suggests autoimmune hypoglycemia?
Low glucose, HI insulin, presence of GAD antibodies
What role does growth hormone play in the body’s response to hypoglycemia?
Growth hormone helps prevent hypoglycemia.
Which THYROID condition can worsen hypoglycemia by reducing gluconeogenesis and glycogenolysis?
Hypothyroidism
But rarely cause hypos
What can contribute to more severe or prolonged hypoglycemia episodes when caused by another factor?
Hormone deficiency, CORTOSOL DEF, HYPOTHYROIDISM
Which individuals are more prone to hypoglycemia?
Infants and children with primary adrenal insufficiency
What is the term for persistent hyperinsulinemic hypoglycemia in infants?
Persistent hyperinsulinemic hypoglycemia of infancy (PHHI)
Which hormone deficiency can increase the chances of hypoglycemia in individuals with type 1 diabetes?
Adrenal insufficiency
What are the autonomic symptoms of hypoglycemia?
Sweating, weakness, palpitations, trembling, hunger, and paresthesias
What are the neuroglycopenic symptoms of hypoglycemia?
Irritability, drowsiness, confusion, and vision changes
What is the most common cause of persistent hypoglycemia in infants?
Congenital hyperinsulinism
What causes endogenous hyperinsulinism?
Beta cell tumor (insulinoma)
What is the term for hypoglycemia caused by an underlying illness or medication?
Secondary hypoglycemia
What is the diagnostic assessment required for individuals suspected of having hypoglycemia?
A diagnostic assessment is required for healthy individuals experiencing hypoglycemia
What should be investigated when autonomic symptoms occur with a fingerstick glucose measurement of <65 mg/dL?
Other causes of autonomic symptoms
What should be investigated when autonomic symptoms occur with a fingerstick glucose measurement of ≥65 to 79 mg/dL?
Underlying hypoglycemic disorder
How should home blood glucose monitoring be done?
Using fingersticks and a glucose meter.
When should continuous glucose monitoring be used?
It should not be used in the evaluation of hypoglycemic symptoms in individuals without diabetes.
What factors determine the duration of continued monitoring for hypoglycemic symptoms?
Factors include frequency of symptoms and clinical suspicion for an underlying hypoglycemic disorder.
What are the options for supervised testing in the evaluation of hypoglycemia?
Supervised testing can entail a supervised fast, mixed meal test, or evaluation during a spontaneous episode of hypoglycemia.
When should a supervised test be selected for evaluating hypoglycemia?
It depends on the timing of symptoms in relation to meals.
How should hypoglycemia be evaluated in asymptomatic adults without diabetes mellitus?
Repeat laboratory glucose measurement with exclusion of analytical errors.
What glucose level indicates a hypoglycemic disorder in asymptomatic adults?
If laboratory glucose is less than 40 mg/dL (2.2 mmol/L).
What does a low glucose level in individuals aged ≥40 years usually warrant?
Further evaluation to determine the underlying cause.
What can cause artifactual hypoglycemia?
If an antiglycolytic agent is not present in the blood collection tube or there is leukocytosis, erythrocytosis, or hemolysis.
What type of testing should be done for individuals who report the loss of symptomatic response to hypoglycemia over time?
They should undergo additional evaluation to assess impaired awareness of hypoglycemia.
Which drugs are reported to cause hypoglycemia?
Cibenzoline, Gatifloxacin, Pentamidine, Quinine, Indomethacin, and Glucagon (during endoscopy) are among the drugs reported.
Which drugs have been identified with more than 25 cases of hypoglycemia?
Angiotensin-converting enzyme inhibitors, Angiotensin receptor antagonists, Beta-adrenergic receptor antagonists, and others.
What are the symptoms suggestive of adrenal insufficiency?
Weakness, fatigue, weight loss, hyponatremia, and orthostasis.
What should be done if adrenal insufficiency is suspected as the cause of hypoglycemia?
Perform appropriate diagnostic testing to confirm.
What should be done if hypoglycemia is caused by medication or alcohol use?
Remove exposure to the suspected agent and assess if hypoglycemia resolves.
What individuals may not require further evaluation for hypoglycemia?
Those with a history of bariatric surgery, access to insulin or other glucose-lowering agents, and no recurrent, severe episodes of neuroglycopenic symptoms.
What is hypoglycemia?
Hypoglycemia is low glucose, proinsulin, and C-peptide levels caused by various factors.
What are the possible causes of hypoglycemia?
Possible causes of hypoglycemia include insulinoma, autoimmune hypoglycemia, noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS), and post-gastric bypass hypoglycemia.
How can insulinoma be diagnosed?
Insulinoma can be diagnosed through the measurement of proinsulin levels and specialized testing for insulin analogs.
What is the significance of elevated proinsulin levels?
Elevated proinsulin levels suggest the presence of insulinoma/proinsulinoma.
How can insulin- or IGF-mediated causes of hypoglycemia be excluded?
They can be excluded by observing an increase in blood glucose concentration ≤25 mg/dL after glucagon administration.
What is considered a normal fasting glucose value in (SOME) healthy, young adults?
Fasting glucose values between 40 to 60 mg/dL (2.2 to 3.3 mmol/L) can reflect normal physiology.
What further evaluation is required if antibodies are negative?
If antibodies are negative, further evaluation is needed for insulinoma through tumor localizing studies.
What is the fasting duration required for an adequate supervised fast?
The supervised fast should be continued for 72 hours or until the laboratory glucose level reaches <55 mg/dL (3 mmol/L).
What should be considered if BHB level is >2.7 mmol/L during a supervised fast?
If BHB level is >2.7 mmol/L, ketogenesis is not suppressed.
What should be done if glucose values after a glucagon challenge are uninterpretable?
Repeat the supervised fast and measure glucose values again.
What does a rise of ≤25 mg/dL in glucose levels after a glucagon challenge indicate?
A rise of ≤25 mg/dL in glucose levels after a glucagon challenge suggests an underlying hypoglycemic disorder is unlikely.
What symptoms are associated with hypoglycemia?
Symptoms of hypoglycemia include autonomic responses, sweating, weakness, tachycardia, palpitations, tremor, nervousness, hunger, and paresthesias.
What are the diagnostic features of hypoglycemia?
Diagnostic features of hypoglycemia include an acute change in mental status, coma, irritability, confusion, seizure, loss of consciousness, and visual disturbance.
How can blood glucose concentration be measured for diagnostic evaluation of hypoglycemia?
Blood glucose concentration can be measured as soon as possible using a meter and strips.
What are the symptoms of hypoglycemia?
Low glucose (<65 mg/dL or 3.6 mmol/L) with hypoglycemia symptoms.
What is Whipple’s triad?
Improvement of symptoms after treating hypoglycemia to confirm Whipple’s triad.
What is the suggestive plasma C-peptide concentration for an insulinoma?
Plasma C-peptide concentration above 0.2 nmol/L is suggestive of an insulinoma.
What is the suggestive plasma proinsulin concentration for an insulinoma?
Plasma proinsulin concentration above 5 pmol/L is suggestive of an insulinoma.
What is the suggestive plasma beta-hydroxybutyrate concentration for an insulinoma?
Plasma beta-hydroxybutyrate concentration below 2.7 mmol/L is suggestive of an insulinoma.
What should be done if a patient accidentally observes low blood sugar symptoms?
The patient should have glucose, insulin, C-peptide, beta-hydroxybutyrate, and proinsulin levels tested.
What is the choice of test for determining the etiology of hypoglycemia?
Testing may include glucose level, insulin level, C-peptide level, beta-hydroxybutyrate level, and proinsulin level.
What testing is done under medical supervision during a spontaneous episode of low blood sugar?
Glucose level, insulin level, C-peptide level, beta-hydroxybutyrate level testing is done.
What test is conducted for fasting-related symptoms of hypoglycemia?
A supervised fast is conducted.
What test is recommended for postprandial symptoms of hypoglycemia?
A mixed meal test is recommended.
What factors determine the choice of test for hypoglycemic patients?
The patient’s clinical history and logistical factors determine the choice of test.
What can be indicated by a plasma C-peptide concentration below 0.2 nmol/L?
Insulin deficiency can be indicated.
What can be indicated by a plasma proinsulin concentration below 5 pmol/L?
Insulin deficiency can be indicated.
What can be indicated by a plasma beta-hydroxybutyrate concentration above 2.7 mmol/L?
Normal people
None IGF/ insulin mediated
What types of tests are done for fasting hypoglycemia?
Supervised fast and Mixed meal test
Can supervised fast be done as an outpatient or inpatient?
Yes
What should be done if the glucose level is below 55 mg/dL?
More blood samples should be taken to measure insulin, proinsulin, C-peptide, and betahydroxybutyrate (BHB) levels
What is screened for in the oral hypoglycemic agents test?
Oral hypoglycemic agents
What is the purpose of the mixed meal test?
To test for postprandial hypoglycemia
What is the procedure for the mixed meal test?
Patient consumes a non-liquid meal and is observed for up to five hours
What should be done if the glucose levels are low and hypoglycemic symptoms are present during the mixed meal test?
Additional blood samples should be taken
What should be measured in the mixed meal test?
Insulin and C-peptide levels
What should be screened for in non-diabetic hypoglycemia?
Oral hypoglycemic agents
What are the possible causes of hypoglycemia in a patient with history of malignancy?
Endogenous hyperinsulinism, factitious illness, organ dysfunction.
What is the next step if both conditions apply: patient has acute or chronic endogenous hyperinsulinism and hypoglycemia is a possible etiology?
Proceed with supervised testing.
When should further evaluation usually not be needed for hypoglycemia?
If hypoglycemia is likely caused by factitious illness or organ dysfunction.
What may suggest underlying adrenal insufficiency in a patient with hypoglycemia?
Personal or family history of autoimmunity.
What type of testing is recommended for the evaluation of hypoglycemia in adults without diabetes mellitus?
Supervised testing.
What are some symptoms that indicate a high clinical suspicion for an underlying hypoglycemic disorder?
Autonomic symptoms such as sweating, nervousness, and paresthesias.
What are some symptoms that indicate a high clinical suspicion for an underlying hypoglycemic disorder?
Neuroglycopenic symptoms such as irritability, confusion, and vision changes.
What is the duration of an outpatient supervised fast for hypoglycemia evaluation?
Approximately 20 to 24 hours.
What is the purpose of supervised tests for hypoglycemia evaluation?
To provoke hypoglycemia and enable etiologic evaluation for insulin or insulin-like growth factor-mediated causes.
Where is the supervised fast for hypoglycemia evaluation usually performed?
Inpatient or outpatient setting.
What are the criteria that must be met to diagnose a true hypoglycemic disorder?
Whipple’s triad: symptoms of hypoglycemia, low plasma glucose concentration, symptoms resolve after raising glucose level.
What are the clinical manifestations of hypoglycemia?
Autonomic symptoms (tremor, palpitations, anxiety), neuroglycopenic symptoms (dizziness, weakness, confusion), and behavioral changes.
What are the signs of hypoglycemia?
Diaphoresis, pallor, elevated heart rate, modestly elevated systolic blood pressure, decreased diastolic blood pressure, increased pulse pressure.
What are the neuroglycopenic manifestations of hypoglycemia?
Cognitive impairment and behavioral changes.
What is the lower limit of normal blood glucose (BG) according to LAB?
70 mg/dL.
What can cause hypoglycemia in ill or medicated individuals?
Drugs (insulin, alcohol, others), critical illnesses (hepatic, renal, or cardiac failure, sepsis), hormone deficiency (cortisol, glucagon, and epinephrine), nonislet cell tumor.
What can cause hypoglycemia in seemingly well individuals?
Endogenous hyperinsulinism (insulinoma, functional beta cell disorders), accidental, surreptitious, or malicious hypoglycemia.
What are some hormonal causes of hypoglycemia?
Cortisol deficiency, hypothyroidism, and/or growth hormone deficiency.
