inpatient / endocrinology


Last Updated: 1/7/2023

# Hypoglycemia

-- History: *** diabetes, meds and adherence, nutrition and PO intake, weight loss, emesis, CKD
-- Clinical/Exam: *** diaphoresis, visual changes, headaches, AMS, seizure, coma
-- Data: *** insulin level, c-peptide level, beta-hydroxybutyrate, pro-insulin, sulfonylurea and meglitinide screen
-- Etiology/DDx: *** Insulin Mediated: insulin or sulfonylurea overdose or exogenous administration, insulinoma (endogenous), autoimmune insulin antibodies; Non-Insulin Mediated: malnutrition, chronic EtOH use, ESRD, cirrhosis, sepsis, adrenal insufficiency

-- (drawn while hypoglycemic) - insulin level, c-peptide level, beta-hydroxy butyrate, pro-insulin, sulfonylurea and meglitinide screen
-- If c/f insulinoma - will do PET scan to localize the tumor

-- PRN 15g PO dextrose gel > IV 12.5-25g D50
-- IV D5LR drip if needed

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If You Remember Nothing Else

Severe hypoglycemia can be life threatening, always check a level if a patient is altered. Differentiate between insulin mediated and non-insulin mediated etiologies. Make sure your workup is sent when the patient is actually hypogylcemic (if insulin is normal-high despite being hypoglycemic, indicates an inappropriate release). Avoid iatrogenic hypogylcemia int he hospital by reducing the home dose of insulin, especiall ythe long-acting dose when patients are NPO.

Clinical Pearls

  • Hypoglycemia is usually defined by glucose <70, but most patients will start to have clinically significant (symptomatic) hypoglycemia at levels <50
  • Whipple’s Triad - symptoms of low glucose, proven low blood glucose while having symptoms, resolution of symptoms with glucose correction
  • If the hypoglycemia is insulin-mediated, there will be no ketones present
  • C-peptide is cleaved from pro-insulin that is made in the body - will be high when insulin is made endogenously and not present when exogenous
  • Can see pseudo-hypoglycemia from peripheral vasoconstriction (finger stick), delayed sample processing, and leuko/erythrocytosis
  • Usually have symptoms (but are not a chronically sick person) when the hypoglycemia is insulin-mediated since insulin works fast and is not 2/2 anorexia, liver/kidney disease, sepsis, cancer, adrenal insufficiency, etc.

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