Hypoglycaemia in Diabetes

•    Common complication in patients on insulin or sulfonylureas

•    Causes:

o    Missed/delayed meals

o    Excess insulin or sulfonylurea dose

o    Exercise, alcohol intake, renal impairment

•    Symptoms:

o    Autonomic: tremor, sweating, hunger, palpitations, anxiety

o    Neuroglycopenic: confusion, drowsiness, seizures, coma

•    Management:

o    If conscious: rapid-acting oral glucose (e.g. juice, glucose tabs)

o    If unconscious:

    IV 10–20% dextrose

    Or IM glucagon (ineffective in alcoholics/liver disease)

Non-Diabetic Hypoglycaemia

•    Causes:

o    Insulinoma (endogenous insulin secretion)

o    Adrenal insufficiency (cortisol deficiency impairs gluconeogenesis)

o    Severe liver disease (impaired glycogenolysis/gluconeogenesis)

o    Alcohol excess (inhibits gluconeogenesis)

o    Reactive (post-prandial) hypoglycaemia

o    Sepsis, starvation, bariatric surgery

Whipple’s Triad

•    Diagnostic criteria for true hypoglycaemia:

1.    Symptoms of hypoglycaemia

2.    Low plasma glucose

3.    Relief of symptoms with glucose administration

Factitious Hypoglycaemia

•    Deliberate or accidental misuse of hypoglycaemic agents

•    Clues:

o    Health care background

o    Discrepancy between insulin levels and clinical picture

•    Diagnosis:

o    ↑ Insulin + low C-peptide → exogenous insulin

o    ↑ Insulin + ↑ C-peptide → sulfonylurea or insulinoma

o    Confirm with sulfonylurea screen (if C-peptide ↑)

•    Consider psychiatric input (factitious disorder / Munchausen’s)