399 Hypoglycemia

Question 1

What is Whipple’s triad

Answer 1

1. symptoms consistent with hypoglycemia 2. a low plasma glucose concentration measures with a precise method 3. relief of symptoms after the plasma glucose is raised

Question 2

lower limit of fasting plasma glucose concentration

Answer 2

About 70 mg/dl or 3.9 mmol

Question 3

normal plasma glucose range in fasting state

Answer 3

70-110 mg/dl or 3.9-61. mmol/L

Question 4

how long can hepatic glycogen stores sufficient to maintain plasma glucose levels

Answer 4

for about 8 hours

Question 5

Causes of hypoglycemia in ill or medicated patients

Answer 5

1. drugs such as alcohol, insulin or insulin secretatgogue 2. critical illness as in hepatic, renal, cardiac failure, sepsis 3. hormone deficiency as in cortisol, glucagon, and epinephrine 4. non islet cell tumor

Question 6

causes of hypoglycemia in seemingly well individual

Answer 6

1. endogenous hyperinsulinism, insulinism, functional beta cell disorders, 2. disorders of gluconeogenesis and fatty acid oxidation, 3. exercise, 4. accidental surreptitious or malicious hypoglycemia

Question 7

conditions when blood glucose is normall less than 70 mg/dl

Answer 7

later after a meal, pregnancy, during prolong fasting of more than 24 hrs

Question 8

In a glucagon deficient individual, what is the most critical physiologic response to hypoglycemia

Answer 8

increase in epinephrine

Question 9

primary glucose counter regulatory hormones

Answer 9

alpha cell glucagon and adrenomedullary epinephrine

Question 10

what does glucagon do during hypoglycemia

Answer 10

stimulates hepatic glycogenolysis and gluconeogenesis

Question 11

what does epinephrine do during hypoglycemia

Answer 11

epinephrine also stimulates glycogenolysis and gluconeogenesis but limits peripheral uptake of glucose and stimulates lipolysis

Question 12

when hypoglycemia is prolonged for 4 hours, what hormons support glucose production and restrict glucose utilization

Answer 12

cortisol and growth hormone

Question 13

True or false. Cortisol and growth hormone play no rule in defense againts acute hyypoglycemia

Answer 13

True.

Question 14

Response to decreasing plasma glucose concentrations. Glycemic threshold. Decrease in cognition

Answer 14

less than 2.8 mmol or less than 50 mg/dl

Question 15

Response to decreasing plasma glucose concentrations. Glycemic threshold. Decrease insulin

Answer 15

4.4- 4.7 mmol or 80-85 mg/dl

Question 16

first defense against hypoglycemia

Answer 16

decrease in insulin production

Question 17

second defense against hypoglycemia

Answer 17

increase in glucagon

Question 18

Response to decreasing plasma glucose concentrations. Glycemic threshold 3.6-3.9 or 65-70 mg/dl.

Answer 18

increase in glucagon, increase in epinephrine, increase in cortisol and growth hormone

Question 19

third defense against hypoglycemia

Answer 19

epinephrine

Question 20

True or false. Neuroglycopenic manifestations of hypoglycemia are the direct results of central nervous system glucose deprivation.

Answer 20

True.

Question 21

The limiting factor in glycemic management of diabetes mellitus

Answer 21

hypoglycemia

Question 22

True or false. Incidence of hypoglycemia is lower in T2DM than in T1DM

Answer 22

True.

Question 23

sole determinant of risk for hypoglycemia

Answer 23

relative or absolute insulin excess

Question 24

loss of the warning adrenergic and cholinergic symptoms that previously allowed the patient to recognize developing hypoglycemia and therefore to abort the episode by ingesting carbohydrates

Answer 24

hypoglycemia unawareness

Question 25

Manifested as isolated episodes of hypoglycemia with no decrease in insulin and no increase in glucagon leading to attenuated sympathoadrenal responses to hypoglycemia

Answer 25

hypoglycemia associated autonomic failure (HAAF)

Question 26

3 manifestation of HAAF

Answer 26

defective glucose counterregulation, recurrent hypoglycemia, hypoglycemia unawareness

Question 27

additional risk factor for HAAF in diabetes

Answer 27

impaired renal function resulting in reduced clearance of endogenous and exogenous insulin, classical diabetic autonomic neuropathy and lower HbA1c or lower glycemic goals even at elevated HbA1c levels

Question 28

study that attempts to control in hospital plasma glucose values towards physiologic levels resulted in increased mortality risk

Answer 28

SUGAR

Question 29

study where severe hypoglycemia with accompanying serious cardiovascular morbidity and mortality also occur

Answer 29

ACCORD and VADT

Question 30

True or false. Severe hypoglycemia can occurs in T1DM and T2DM with HbA1c values of 8-10%

Answer 30

True.

Question 31

the mechanism alcohol intake leads to hypoglycemia

Answer 31

ethanol blocks gluconeogenesis but not glycogenolysis

Question 32

occurs after several day enthanol binge which the person eat little food with consequent glycogen depletion

Answer 32

alcohol induced hypoglycemia

Question 33

True or false. Blood ethanol levels correlate poorly with plasma glucose concentrations

Answer 33

True.

Question 34

How does extensive liver destruction cause fasting hypoglycemia

Answer 34

liver is the major site of endogenous glucose production

Question 35

how does sepsis lead to hypoglycemia

Answer 35

increased glucose utilization is induced by cytokine production in macrophage rich tissue such as the liver, spleen, and lung

Question 36

True or false. Cytokine induced inhibition of gluconeogenesis in the setting of nutritional glycogen depletion, in combination with hepatic and renal hypoperfusion can lead to hypoglycemia

Answer 36

True

Question 37

True or false. Hypoglycemia is not a feature of epinephrine deficient state that results from bilateral adrenalectomy when glucocorticoid replacement is adequate nor does it occur during pharmacologic adrenergic blockade

Answer 37

True.

Question 38

Why does epinephrine deficient state does not lead to hypoglycemia

Answer 38

as long as other counterregulatory systems are intact

Question 39

what is the cause of exercise induced hypoglycemia

Answer 39

increased activity of monocarboxylate transporter 1 in Beta cells

Question 40

Differential diagnosis for CBG less than 55 mg/dl. Plasma insulin high, Plasma proinsulin low. Plasma C peptide low. Plasma beta hydoxylate low. No circulating oral hypoglycemic. No antibody to insulin.

Answer 40

Exogenous insulin

Question 41

Differential diagnosis for CBG less than 55 mg/dl. Plasma insulin high, Plasma proinsulin high Plasma C peptide high Plasma beta hydoxylate low. No circulating oral hypoglycemic. No antibody to insulin.

Answer 41

Insulinoma

Question 42

differential diagnosis for CBG less than 55 mg/dl. Plasma insulin high, Plasma proinsulin high Plasma C peptide high Plasma beta hydoxylate low. With circulating oral hypoglycemic. No antibody to insulin.

Answer 42

SU or insulin secretagogue

Question 43

Differential diagnosis for CBG less than 55 mg/dl. Plasma insulin high, Plasma proinsulin high Plasma C peptide high Plasma beta hydoxylate low. No circulating oral hypoglycemic. With antibody to insulin.

Answer 43

Insulin autoimmune hypoglycemia

Question 44

when is plasma insulin high

Answer 44

more than 3 uU/ml or more than 18 mmol

Question 45

when is plasma C peptide high

Answer 45

more than 0.6 ng/ml or more than 0.2 mmol

Question 46

when is plasma proinsulin high

Answer 46

more than 5.0 pmol/L

Question 47

when is beta hydoxybutarate low

Answer 47

less than 2.7 mmol

Question 48

refers to pattern of diffuse islet involvment with beta cell hypertrophy

Answer 48

mesidioblastosis

Question 49

refers to pattern of diffuse islet involvment with beta cell hypertrophy but patients postprandial hypoglycemia

Answer 49

noninsulinoma pancreatogenous hypoglycemia

Question 50

used to treat hypoglycemia caused by insulinoma

Answer 50

diazoxide, octreotide

Question 51

initial dose of glucose in a patient who is able and willing

Answer 51

15-20 g of glucose

Question 52

additional treatment to be given in addition to glucose injection in patients with T1Dm

Answer 52

SC or IM glucagon 0.1 mg

Question 53

Why is glucagon injection less useful in T2Dm

Answer 53

also stimulate insulin secretion

Question 54

whys is glucagon not useful in alcohol induced hypoglycemia

Answer 54

is stimulates glycogenolysis, glucagon is ineffective in glucagon depleted individuals as in alcohol induced hypoglycemia

Question 55

Treatment for hypoglycemia. Autoimmune hypoglycemia

Answer 55

Glucocorticoids; immunosuppresive drugs

Question 56

Treatment for hypoglycemia. Nontumor beta cell disorder

Answer 56

Partial pancreatectomy

Question 57

Treatment for hypoglycemia. Non resectable insulinoma

Answer 57

octreotide; diazoxide

Question 58

Treatment for hypoglycemia.Insulinoma

Answer 58

Surgical resection