Hypoglycemia: Difference between revisions

(Linked differential diagnosis items to relevant pages where available.)
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===Drugs===
===Drugs===
* Anti-hyperglycemic
*Anti-hyperglycemic
** [[Insulin]]
**[[Insulin]]
** Oral secretagogue
**Oral secretagogue
* Other
*Other
** [[EtOH]]
**[[EtOH]]
** [[B-blocker]]
**[[B-blocker]]
** ACE
**ACE
** [[Acetaminophen Overdose|Acetaminophen (OD)]]
**[[Acetaminophen Overdose|Acetaminophen (OD)]]
===Systemic Illness===
===Systemic Illness===
* Critical Illness
*Critical Illness
** [[Sepsis]]
**[[Sepsis]]
** [[MI]]
**[[MI]]
* Organ Failure
*Organ Failure
** Hepatic failure
**Hepatic failure
** [[Renal failure]]
**[[Renal failure]]
* Endocrinopathy
*Endocrinopathy
** [[Adrenal insufficiency]]
**[[Adrenal insufficiency]]
* [[Seizure]]
*[[Seizure]]
===Malignancy===
===Malignancy===
* Insulinoma
*Insulinoma
* Non-islet cell
*Non-islet cell
* Insulin/receptor autoantibodies
*Insulin/receptor autoantibodies
* High tumor burden
*High tumor burden
===Other===
===Other===
* Artifactual
*Artifactual
** Specimen collection
**Specimen collection
** Consumption
**Consumption
*** [[Leukemia]]
***[[Leukemia]]
*** Erythrocytosis
***Erythrocytosis
*** Hemolytic disease
***Hemolytic disease
* Post-surgical
*Post-surgical
** [[Gastric bypass surgery|Gastric bypass]]
**[[Gastric bypass surgery|Gastric bypass]]
** Gastrectomy
**Gastrectomy
** Pyloroplasty
**Pyloroplasty
* Starvation
*Starvation
** [[Anorexia nervosa]]
**[[Anorexia nervosa]]


===Precipitants of anti-hyperglycemic induced hypoglycemia===
===Precipitants of anti-hyperglycemic induced hypoglycemia===
* Decreased glucose
*Decreased glucose
** Missed meal
**Missed meal
** Consumption (exercise, illness)
**Consumption (exercise, illness)
* Increased drug
*Increased drug
** Error (patient, provider)
**Error (patient, provider)
** Intentional overdose
**Intentional overdose
** Increased availability
**Increased availability
*** Hepatic failure
***Hepatic failure
*** Renal failure
***Renal failure
*** Drug interaction
***Drug interaction


==Diagnosis==
==Diagnosis==
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*Patients with known diabetes who are not systemically ill and can identify a clear precipitant, no extensive workup is required.  
*Patients with known diabetes who are not systemically ill and can identify a clear precipitant, no extensive workup is required.  
*In severely ill patients, consider:
*In severely ill patients, consider:
** BMP
**BMP
** LFT
**LFT
** EtOH
**EtOH
** Infectious workup: [[CXR]], UA, urine and blood cultures
**Infectious workup: [[CXR]], UA, urine and blood cultures
** [[ECG]], [[troponin]]
**[[ECG]], [[troponin]]
** Other studies (not normally done in ED): insulin, C-peptide, pro-insulin, glucagon, growth hormone, cortisol, B-OH, insulin antibodies
**Other studies (not normally done in ED): insulin, C-peptide, pro-insulin, glucagon, growth hormone, cortisol, B-OH, insulin antibodies


===Evaluation<ref>Jalili M. Type 2 Diabetes Mellitus In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1431-1432</ref>===
===Evaluation<ref>Jalili M. Type 2 Diabetes Mellitus In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1431-1432</ref>===
"Whipple's Triad"
"Whipple's Triad"
* Symptoms suggestive of hypoglycemia
*Symptoms suggestive of hypoglycemia
**See ''Clinical Features''  
**See ''Clinical Features''  
* Low glucose
*Low glucose
** Serum glucose <60mg/dL
**Serum glucose <60mg/dL
** Generally symptomatic at <55mg/dL though threshold is variable depending on chronicity
**Generally symptomatic at <55mg/dL though threshold is variable depending on chronicity
* Resolution of symptoms after administration of glucose
*Resolution of symptoms after administration of glucose


==Management==
==Management==
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==Disposition==
==Disposition==
Admission or observation for oral anti-hyperglycemic agent or intermediate- to long-acting insulin. Consider discharge after 4h uneventful observation if:<ref>Self, W. H., & McNaughton, C. D. (2013). Hypoglycemia. In Emergency Medicine (2nd ed., pp. 1379-1390). Elsevier.</ref>
Admission or observation for oral anti-hyperglycemic agent or intermediate- to long-acting insulin. Consider discharge after 4h uneventful observation if:<ref>Self, W. H., & McNaughton, C. D. (2013). Hypoglycemia. In Emergency Medicine (2nd ed., pp. 1379-1390). Elsevier.</ref>
* Hypoglycemia fully and rapidly reversed without continuous infusion of dextrose
*Hypoglycemia fully and rapidly reversed without continuous infusion of dextrose
* Tolerated a full meal in ED
*Tolerated a full meal in ED
* Clear and innocuous cause identified with recurrence unlikely
*Clear and innocuous cause identified with recurrence unlikely
* Adequate patient understanding, home support/monitoring, and ability to detect/prevent recurrence with close primary care follow-up
*Adequate patient understanding, home support/monitoring, and ability to detect/prevent recurrence with close primary care follow-up


==See Also==
==See Also==

Revision as of 08:52, 9 July 2016

Background

  • Brain depends on glucose as primary source of energy, but is unable to synthesize or store glucose

Common Anti-hyperglycemic Drugs and Pharmacology

Drug Pharmacology
Onset Peak Duration
Rapid-acting insulin

  • Aspart (Novolog)
  • Lispro (Humalog)
 15-30min 1-2h 3-5h
Short-acting insulin

  • Regular
 30-60min 2-4h 6-10h
Intermediate-acting insulin

  • NPH (Humulin, Novolin)
 1-3h 4-12h 18-24h
Long-acting insulin

  • Glargine (Lantus)
 2-4h None 24h
Sulfonylurea

  • Glimepiride
  • Glipizide (Glucotrol)
  • Glyburide (Glycron, Micronase)
 – 2-6h 12-24h

See also GLP-1 agonists

Clinical Features[1]

Neuroglycopenic

Autonomic

Differential Diagnosis

Differential diagnosis of hypoglycemia

Drugs

Systemic Illness

Malignancy

  • Insulinoma
  • Non-islet cell
  • Insulin/receptor autoantibodies
  • High tumor burden

Other

Precipitants of anti-hyperglycemic induced hypoglycemia

  • Decreased glucose
    • Missed meal
    • Consumption (exercise, illness)
  • Increased drug
    • Error (patient, provider)
    • Intentional overdose
    • Increased availability
      • Hepatic failure
      • Renal failure
      • Drug interaction

Diagnosis

Workup

  • Patients with known diabetes who are not systemically ill and can identify a clear precipitant, no extensive workup is required.
  • In severely ill patients, consider:
    • BMP
    • LFT
    • EtOH
    • Infectious workup: CXR, UA, urine and blood cultures
    • ECG, troponin
    • Other studies (not normally done in ED): insulin, C-peptide, pro-insulin, glucagon, growth hormone, cortisol, B-OH, insulin antibodies

Evaluation[2]

"Whipple's Triad"

  • Symptoms suggestive of hypoglycemia
    • See Clinical Features
  • Low glucose
    • Serum glucose <60mg/dL
    • Generally symptomatic at <55mg/dL though threshold is variable depending on chronicity
  • Resolution of symptoms after administration of glucose

Management

Algorithm for the management of hypoglycemia
  • If altered mental status
    • Dextrose 50% 50mL bolus (equals "one amp")
      • Contains 25mg glucose
  • If awake
    • Oral glucose
  • Glucagon[3]
    • Efficacy dependent on hepatic glycogen stores (less effective in chronic ETOH, cirrhosis, malnourished, neonate, in-born errors, glycogen storage disease, etc.)[4]
    • Onset of action slower than IV dextrose (7-10min)
    • 1mg SC or IM

Hypoglycemia from Sulfonylureas[5][6]

Activated charcoal[7]

  • Administer activated charcoal, preferably within 1 hr of ingestion
  • Multiple doses may be beneficial, especially for glipizide

Glucose Treatment

  • Initial therapy regardless of known cause
Adults
  • 50mL D50W bolus
  • Start a D10 1/2NS drip (100mL/hr)
Children
  • 1mL/kg of D50W OR
  • 2mL/kg D25W OR 5-10mL/kg D10W
  • Neonate: 5-10 mL/kg D10W

Octreotide[8]

  • Theoretical benefit to reduce risk of recurrent hypoglycemia
  • Hyperpolarization of the beta cell results in inhibition of Ca influx and prevents insulin release
  • 50-100 mcg subcutaneous in adults with repeat dosing Q6hrs
  • 2 mcg/kg (max 150mcg) subcutaneously Q6hrs should be used in children
  • Continuous infusion of 50-125 mcg/hr is an alternative in adults
  • Administer octreotide for 24 hours, then after discontinuing, monitor for hypoglycemia for another 24 hours

Special Considerations

  • Glucagon 5mg IM may be used as temporizing measure, e.g. while obtaining IV access
    • Dependent on glycogen stores which may be depleted in prolonged hypoglycemia
    • Also short duration of action
    • Caution in using glucagon drip
      • Glucagon also has an insulin-releasing effect
      • May subsequently cause initial paradoxical hypoglycemia

Hypoglycemia from Long Acting Insulin

  • Similar treatment as for Sulfonylureas except no role for Octreotide
  • Treatment should include oral intake as well as maintenance glucose containing drip either D5 or D10

Disposition

Admission or observation for oral anti-hyperglycemic agent or intermediate- to long-acting insulin. Consider discharge after 4h uneventful observation if:[9]

  • Hypoglycemia fully and rapidly reversed without continuous infusion of dextrose
  • Tolerated a full meal in ED
  • Clear and innocuous cause identified with recurrence unlikely
  • Adequate patient understanding, home support/monitoring, and ability to detect/prevent recurrence with close primary care follow-up

See Also

References

  1. ↑ Jalili M. Type 2 Diabetes Mellitus In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1431-1432
  2. ↑ Jalili M. Type 2 Diabetes Mellitus In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1431-1432
  3. ↑ Carstens S, Sprehn M. Prehospital treatment of severe hypoglycaemia: a comparison of intramuscular glucagon and intravenous glucose. Prehosp Disaster Med. 1998 Apr-Dec;13(2-4):44-50
  4. ↑ Cydulka RK, Maloney GE. Diabetes Mellitus and Disorders of Glucose Homeostasis, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 126: p 1652-1667.
  5. ↑ Rowden AK, Fasano CJ. Emergency management of oral hypoglycemic drug toxicity. Emerg Med Clin N Am 2007; 25:347-356
  6. ↑ Howland MA. Antidotes in Depth: Octreotide. In: Flomenbaum NE, Goldfrank LR, Hoffman RS et al, eds: Goldfrank’s Toxicologic Emergencies. New York NY, 2006;770-773
  7. ↑ Tran D et al. Oral Hypoglycemic Agent Toxicity Treatment & Management. Jul 14, 2015. http://emedicine.medscape.com/article/1010629-treatment#showall.
  8. ↑ Fasano CJ et al. Comparison of Octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med 2008; 51:400-406
  9. ↑ Self, W. H., & McNaughton, C. D. (2013). Hypoglycemia. In Emergency Medicine (2nd ed., pp. 1379-1390). Elsevier.
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