Hypoglycaemia

Commonest endocrine emergency

Plasma glucose <3 mmol/L (but 4 is the floor to start treatment)

Causes/Factors

Insulin or sulfonylurea treatment in a diabetic. Increased activity, missed meal or overdose can be a cause

In non-diabetics EXPLAIN the mechanism:

Exogenous drugs - Insulin, alcohol with no food, Aspirin poisoning, ACEi, $\beta$-blockers, pentamidine, quinine sulfate, aminoglutethamide, Insulin-like growth factor

Pituitary insufficiency

Liver failure - plus rare inherited enzyme defects

Addison’s Disease

Islet cell tumours (insulinoma) and immune hypoglycaemia (anti-Insulin receptor anti-bodies in Hodgkin’s disease)

Non-prancreatic neoplasms - fibrosarcoma, haemangiopericytomas

Symptoms

Autonomic:

• Sweating
• Anxiety
• Hunger
• Tremor
• Palpitations
• Dizziness

Neuroglycopenic:

• Confusion
• Drowsiness
• Visual trouble
• Sizures
• Coma
• Mutism
• Personality change
• Restlessness

Signs

• Pale Skin: Skin may appear pale and cool.
• Rapid Heartbeat: Increased heart rate is a common sign.
• Dilated Pupils: Pupils may dilate in response to low blood sugar.

Diagnostic Tests

Whipple’s triad

Symptoms or signs of hypoglycaemia + $\downarrow$ plasma glucose + resolution of symptoms or signs post glucose rise $\to$ caused by hypoglycaemia

• Document BM during attack and lab glucose if in hospital
• Take drug history and exclude Liver failure
• 72h fasting to confirm with close monitoring.
• Bloods: glucose, Insulin, c-peptide, plasma ketones (if endogenous hyperinsulinism suspected) proinsulin, $\beta$-hydroxybutrate

Hypoglycaemic hyperinsulinaemia (HH)

• Causes: insulinoma, sulfonylureas, Insulin injection (no detectable c-peptide - this only released with endogenous Insulin)

Insulin low or undetectable

• No excess ketones
  • Non-pancreatic neoplasm; anti-Insulin receptor antibodies
• Excess ketones
  • Alcohol, pituitary insufficiency, Addison’s Disease

Management

• Oral Glucose: Consuming a source of glucose, such as fruit juice or candy. If events frequent advise many high starch meals.
• Glucagon Injection: In severe cases, a glucagon injection may be administered.
• Adjustment of Medications: Modifying diabetes medications and Insulin dosages as needed.

Complications/red Flags

• Loss of Consciousness: Severe hypoglycemia can lead to unconsciousness.
• Seizures: In some cases, hypoglycemia may trigger seizures.
• Impaired Cognitive Function: Prolonged low blood sugar levels can impair cognitive function.