Hypoglycemia PDF

12.7 Hypoglycemia normal blood glucose range 3,9-5.5 mmol/L Hypoglycemia  abnormal reduction or lowering of blood glucose common in patients with diabetes on treatment that aims to reduce elevated blood glucose very NB Neuroglycopenia Hormonal responses if glucose level is low=i...

12.7 Hypoglycemia normal blood glucose range 3,9-5.5 mmol/L Hypoglycemia  abnormal reduction or lowering of blood glucose common in patients with diabetes on treatment that aims to reduce elevated blood glucose very NB Neuroglycopenia Hormonal responses if glucose level is low=insulin secretion stops immediately thus LOW glucose=LOW insulin insulinopenia facilitation facilitate glycogenolysis and lypolysis facilitate gluconeogenesis and ketogenesis reduce glucose utilization by muscle - GLUCAGON( counter regulator in acute hypoglycemia which acts within minutes) produced & secreted by pancreatic alpha cells mobilize liver glycogen stores via glucogenolysis facilitate gluconeogenesis in liver increase in circulatory glucose level, more glucose available to brain NB LOW glucose, LOW insulin, HIGH glucagon Catecholamines(adrenaline) increase hepatic glycogenolysis and gluconeogenesis mobilize muscle glycogen, improve lypolysis and provide gluconeogenic precursors = more glucose to the brain major back up system for glucagon NB LOW glucose, LOW insulin, HIGH glucagon ,adrenergic response with symptoms Cortisol and Growth Hormone: Cortisol: mobilizes energy stores(2-3hrs) Growth hormone: antagonize insulin effects these hormones work synergistically=combined effect NB LOW glucose LOW insulin HIGH Glucagon Adrenergic response with symptoms HIGH Cortisol HIGH GH Implication in clinical practice low blood glucose with high insulin and low cortisol signify pathology Clinical picture symptoms due adrenergic response= BG< 3.8mmol/L inadequate glucose delivery to brain= neuroglycopenic =BG < 2.8mmol/L ADRENERGIC NEUROGLYCOPENIA Anxiety Vision Tremor Weakness Sweating Tiredness Hunger Confusion Palpitations Behavioral abnormalities  ADRENERGIC NEUROGLYCOPENIA Dizzy….. Convulsions Coma More prominent patient present with subtle to overt features of brain dysfunction evokes similar symptoms repeatedly in same patient. ALARM: main warning of falling blood glucose Whipple's triad = diagnostic triad for hypoglycemia especially in non diabetic patients Pathophysiology if hypoglycemia confirmed by whipple triad: Fasting hypoglycemia in healthy person occurs if glucose utilization by peripheral tissues exceeds hepatic glucose production postprandial hypoglycemia-is self-limiting, do not produce ominous symptoms, is non-progressive and rarely suggestive of underlying disease. hypoglycemia in patients with diabetes on treatment cause in patients with diabetes most common and serious acute complication in treated diabetics on Exogenous insulin Two treatment classes (insulin and sulphonylureas) Risk factors drug use Type1 DM pregnancy renal impairment excessive exercise Fasting hypoglycemia in patients without diabetes  inappropriate high insulin level 1. -endogenous excess production=INSULINOMA Normal/reduced insulin levels 1. malnourished alcoholic 2. unwell patient(liver/kidney) Tests to make if hypoglycemia in non diabetic fasting suspect blood glucose insulin cortisol c-peptide fasting hypoglycemia in the patient without diabetes and HIGH insulin levels INSULINOMAS i. rare insulin secreting tumors of the pancreatic β-cells ii. hallmark the inappropriate uncontrolled release of insulin irrespective of blood glucose iii. hypoglycemia with high insulin levels in patient not on treatment for diabetes Fasting hypoglycemia in the patients without diabetes and LOW insulin levels  very sick patients endocrinopathies with low cortisol alcohol associated with malnutrition -(alcohol suppress glucose mobilization via gluconeogenesis) Postprandial hypoglycemia in patients without diabetes and with low insulin level i. mostly seen after gastric bypass surgery as part of dumping ii. seldom due to serious underlying disease, mostly functional managed with small, frequent, high fiber meals and avoidance of fine carbohydrates