hypoglycaemia

Question 1

what is the definition of hyoglycaemia?

Answer 1

BM <4

Question 2

which drugs can cause hypoglycaemia?

Answer 2

insulin
oral hypogycaemics eg sulfonylureas (most common)
alcohol excess
ACEis
salicylate poisoning

Question 3

what is pituitary insufficiency?

Answer 3

when pituitary can’t produce 1 or more of its hormones

Question 4

how can pituitary insufficiency cause hypoglycaemia?

Answer 4

if not enough GH or ACTH is produced

Question 5

which hormones act to increase BM?

Answer 5

cortisol
adrenaline
GH
glucagon

Question 6

what is galactosaemia?

Answer 6

genetic disorder that stops you breaking down galactose

Question 7

what is an insulinoma?

Answer 7

tumour of pancreas that results in excess insulin being produced

Question 8

how can non pancreatic neoplasms, eg fibroma and sarcoma, cause hypoglycaemia?

Answer 8

they release insulin growth factor 2 (IGF2) which lowers blood sugar.

Question 9

what are the causes of hypoglycaemia?

Answer 9

drugs
affecting hormonal axes- pituitary insuffiency, adrenal inufficiency, CAH
direct lowering of BM -dumping syndrome, insulinoma, immune hypos, infections eg malaria, neoplasms
insufficient intake -starvation, galactosaemia
liver issues -severe liver failure, glycogen storage disease

Question 10

how would you diagnose insulinoma?

Answer 10

in a fasted state, glucose <2.2, inappropriately high insulin, and high c-peptide.

Question 11

what do c peptide levels mean?

Answer 11

For each molecule of insulin produced there is a molecule of c-peptide.

C-peptide is a useful marker of insulin production because c-peptide tends to remain in the blood longer than insulin.

Question 12

what investigations would you do for ?insulinoma?

Answer 12

CT scan
if -ve-consider endoscopic USS

Question 13

what is the treatment for insulinoma?

Answer 13

surgical removal of tumour

Question 14

what are the autonomic symptoms of hypoglycaemia?

Answer 14

sweating
anxiety
hunger
tremor
palpitations
dizziness

Question 15

what are the neuroglycopenic symptoms of hypoglycaemia?

Answer 15

confusion
change in behaviour
fatigue, drowsiness
weakness
slurred speech
seizures
coma

Question 16

how long does it take the brain to recover after an episode of hypoglycaemia?

Answer 16

45 mins

Question 17

what is the grading severity of hypoglycaemia?

Answer 17

grade 1: aware and can treat themselves
grade 2: needs assistance from others but can use oral therapy
grade 3: semi/un conscious, need IM or IV assistance from others

Question 18

what is the whipple’s triad for diagnoses of hypoglycaemia?

Answer 18

1) signs and symptoms of hypoglycaemia
2) low BM
3) relief of sx with increased BM

Question 19

what investigations can you do to explore the underlying cause of hypoglycaemia?

Answer 19

hba1c
TFTs -?pituitary issues
LFTs -?liver issues
U+Es
09:00 cortisol /short synacthen test -?adrenal insufficiency
blood and urine assays for sulfonylureas
plasma insulin, glucose, and c-peptide -?insulinoma

Question 20

what is the management pathway for acute hypoglycaemia?

Answer 20

conscious and able to cooperate and swallow: 10-20g fast acting carb, preferably liquid, eg 200ml fruit juice
conscious, unable to cooperate, can swallow: glucogel/dextrogel squeezed into mouth (1-2 tubes of 10g)
check BM 10-15mins after oral treatments, max 3 oral treatments before moving to IM/IV
conscious and unable to swallow: glucagon IM (1mg if >8yo, 0.5mg if under)
unconscious: abcde approach, stop insulin therapy. if IV access available, IV glucose eg 10% dextrose over 15 min. if IV unavailable, IM glucagon.
once BM >4, long acting carbohydrate eg biscuits, sandwich, milk

Question 21

what are some limitations to IM glucagon use?

Answer 21

has relatively slow onset of action and relies on glycogen stores -may not be suitable for those in starved states, liver disease, and young children. also doesn’t work of alcohol excess is the cause -liver ignores glucagon if there’s alcohol to worry about.