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Pathology - Y5 > Hypoglycaemia > Flashcards

Hypoglycaemia Flashcards

1
Q

What is the acute management of hypoglycaemia in an alert and orientated adult?

A

Oral Carbohydrates

Rapid acting: Juice/sweets

Longer acting: Sandwich

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2
Q

What is the acute management of hypoglycaemia in a drowsy/confused but swallow intact?

A

Buccal glucose e.g. Hypostop/glucogel

Start thinking about IV access

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3
Q

What is the acute management of hypoglycaemia in an unconscious or concerned about swallow adult?

A

IV access

50 ml, 50% glucose mini-jet

Or 100 mls, 20% glucose

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4
Q

What is the acute management of hypoglycaemia in a deteriorating/refractory/insulin induced/difficult IV access adult patient?

A

Consider IM /SC 1mg Glucagon

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5
Q

What are adrenergic symptoms of hypoglycaemia?

A

Tremors

Palpitations

Sweating

Hunger

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6
Q

What are neuroglycopaenic symptoms of hypoglycaemia?

A

Somnolence

Confusion

Incoordination

Seizures, coma

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7
Q

What is the normal physiological response to hypoglycaemia?

A

Reduce peripheral uptake of glucose

Increase glycogenolysis

Increase gluconeogenesis

Increase lipolysis

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8
Q

What is the normal physiological response to low neuronal glucose sensed in the hypothalamus?

A

Sympathetic Activation: Catecholamines

ACTH, cortisol and GH production

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9
Q

What occurs first in response to hypoglycaemia?

A. Suppression of insulin

B. Release of glucagon

C. Release of adrenaline

D. Release of cortisol

A

A. Suppression of insulin

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10
Q

What are appropriate investigations for hypoglycaemia?

A

Confirm there is hypoglycaemia

Easy in a patient with diabetes – usually monitor blood glucose (BG).

Difficult in an otherwise healthy person – May need to conduct a prolonged fast to demonstrate hypoglycaemia.

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11
Q

How is glucose measured in a lab?

A
  • Grey top (flouride oxalate)
  • Venous sample
  • 2mls blood
  • Gold std to make the diagnosis
  • Delay in results
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12
Q

How is glucose measured using a glucometer?

A
  • Point-of-care device
  • Instant result
  • Capillary blood

But:

  • Poor precision at low glucose levels
  • Often poorly maintained
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13
Q

What may hypoglycaemia in diabetes be related to?

A
  • Medications
  • Inadequate CHO intake/missed meal
  • Impaired awareness
  • Excessive alcohol
  • Strenuous exercise
  • Co-existing autoimmune conditions
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14
Q

Which diabetes medications can cause hypoglycaemia?

A
  • Sulphonylureas
  • Meglitinides
  • GLP-1 agents

Insulin:

  • Rapid acting with meals: Inadequate meal
  • Long-acting: Hypos at night or in between meals
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15
Q

What other drugs can cause hypoglycaemia?

A

B-blockers

Salicylates

Alcohol (inhibits lipolysis)

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16
Q

Which comorbidities can result in hypoglycaemia when coexisting with diabetes?

A

Co-existing renal/liver failure alters drug clearance, and reduced doses needed.

Rarely concurrent Addison’s can result in hypos (polygladular autoimmune syndrome).

17
Q

How can we differentiate the cause of hypoglycaemia?

A

Thorough history and examination.

Biochemical Tests:

  • Insulin levels
  • C-peptide
  • Drug screen
  • Auto-antibodies
  • Cortisol /GH
  • Free fatty acids / blood ketones
  • Lactate
  • Other specialist tests – IGFBP/IGF-2/Carnitines etc.
18
Q

When should bloods be taken when investigating hypoglycaemia?

A

Take bloods at the time of hypoglycaemia.

19
Q

C-peptide

A. Is the cleavage product of insulin

B. Is secreted in equimolar amounts to insulin

C. Has a half-life of 2 hours

D. Interferes with insulin measurement

A

B. Is secreted in equimolar amounts to insulin

20
Q

What is C-peptide?

A

Product of cleavage of proinsulin.

Half-life, ~ 30 minutes

Renal clearance

21
Q

Hypoglycaemia due to excess injected insulin would result in:

A. A low C-peptide

B. A high C-peptide

A

A. A low C-peptide

22
Q

What does it mean if a patient is hypoglycaemic with low insulin and low C-peptide?

A

Hypoinsulinaemic hypoglycaemia

Appropriate response to hypoglycaemia:

  • Fasting/starvation
  • Strenuous exercise
  • Critical illness
  • Endocrine deficiencies:
    • Hypopituitarism
    • Adrenal failure
  • Liver failure
  • Anorexia Nervosa
23
Q

What does it mean if a patient is hypoglycaemic with high insulin and high C-peptide?

A

Hyperinsulinaemic hypoglycaemia

24
Q

What does it mean if a patient is hypoglycaemic with high insulin and low C-peptide?

A

Exogenous insulin

25
Q

What does the absence of ketones signify (glucose 1.9, ketones negative)?

A. Insulin deficiency

B. Fatty acid oxidation defect

C. Starvation

A

B. Fatty acid oxidation defect

26
Q

What are causes of neonatal hypoglycaemia?

A

Explainable:

  • Premature, co-morbidities, IUGR, SGA
  • Inadequate glycogen and fat stores
  • Should improve with feeding

Pathological:

  • Inborn metabolic defects
27
Q

What are causes of neonatal hypoglycaemia with suppressed insulin and C-peptide?

A

FFA raised, but low ketones.

Inherited metabolic disorders:

  • FAOD: No ketones produced
  • GSD type 1 (gluconeogentic disorder)
  • Medium chain acyl coA dehydrogenase deficiency
  • Carnitine disorders
28
Q

What are appropriate investigations for neonatal hypoglycaemia?

A
  • Expect high FFA
  • Expect detectable ketone bodies (beta-hydroxybutyrate, acetoacetate/acetone)

Good differentiators in neonatal hypoglycaemia:

  • Insulin/C-peptide
  • FFA
  • KB
  • Lactate
  • Hepatomegaly
29
Q

What are causes of increased insulin levels with hypoglycaemia?

A

Islet cell tumours: Insulinoma

Drugs: Insulin, sulphonylurea

Islet cell hyperplasia:

  • Infant of a diabetic mother
  • Beckwith Weidemann syndrome
  • Nesidioblastosis
30
Q

What is an insulinoma?

A
  • 1-2/million/year
  • Usually small solitary adenoma
  • 10% malignant
  • 8% associated with MEN1

Diagnosis, based on biochemistry + localisation

Treatment: Resection

31
Q

What is non-islet cell tumour hypoglycaemia?

A

Tumours that cause a paraneoplastic syndrome

Secretion of ‘big IGF-2’

Big IGF2 binds to IGF-1 receptor and insulin receptor

Mesenchymal tumours (mesothelioma/fibroblastoma)

Epithelial tumours (carcinoma)

32
Q

What are some autoimmune causes of hypoglycaemia?

A

Autoimmune conditions are rare. Antibodies to insulin receptors usually present with insulin resistance but rarely hypoglycaemia.

Autoimmune insulin syndrome:

Ab’s directed to insulin, sudden dissociation may precipitate hypoglycaemia. Prevalent in Japan.

Certain drugs: Hydralazine, procainamide etc

33
Q

What are some genetic causes of hypoglycaemia?

A

Glucokinase activating mutation

Congenital hyperinsulinism:

  • KCNJ11/ABCC8
  • GLUD-1
  • HNF4A
  • HADH
34
Q

What is reactive/post-prandial hypoglycaemia?

A
  • Hypoglycaemia following food intake. Can occur post-gastric bypass.
  • Hereditary fructose intolerance
  • Early diabetes
  • In insulin sensitive individuals after exercise or large meal.

True post-prandial hypo are difficult to define.

Pathology - Y5 (59 decks)

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