QuestionSBA
QuestionChoice
This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
32881
d
IV dextrose and calcium replacement
QuestionChoice
This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
32879
b
IV 0.9% sodium chloride and potassium replacement
QuestionChoice
This patient requires immediate glucose replacement. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
32878
a
IV dextrose and potassium replacement
QuestionChoice
This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than sodium. This is due to the effect that insulin has on increasing potassium uptake within cells
32880
c
IV dextrose and sodium replacement
QuestionChoice
This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
32882
e
IV 0.9% sodium chloride and calcium replacement
Concept
Chapter
# Hypoglycaemia

# Summary

Hypoglycaemia, defined as a blood glucose level below 3.5 mmol/L (NICE CKS), presents with symptoms like trembling, sweating, palpitations, hunger, headache, double vision, difficulty concentrating, slurred speech, confusion, and coma. Common causes include various drugs (e.g., insulin, sulphonylureas, GLP-1 analogues), acute liver failure, sepsis, adrenal insufficiency, insulinoma, and glycogen storage disease. The investigation plan typically includes a medication history review, serum insulin, C-peptide and proinsulin levels, a 72-hour fast test, 8am cortisol and/or synACTHen testing, and imaging for insulinoma. Management depends on the severity of the condition and can range from intake of fast-acting carbohydrates for mild cases to intravenous dextrose or intramuscular glucagon for severe cases.

# Definition
Hypoglycaemia is a metabolic condition characterized by an abnormally low blood glucose level, typically defined as less than 3.5 mmol/L.

# Epidemiology
Hypoglycaemia is common in patients with diabetes, especially those on insulin or sulphonylurea therapies. The prevalence increases with the duration of diabetes and the intensity of glucose-lowering treatment.

# Aetiology
Causes of hypoglycaemia include:

- **Drugs:** Insulin, Sulphonylureas, GLP-1 analogues, DPP-4 inhibitors, Beta-blockers
- **Alcohol**
- **Acute liver failure**
- **Sepsis**
- **Adrenal insufficiency**
- **Insulinoma**
- **Glycogen storage disease**

# Signs and Symptoms
**Adrenergic Symptoms (Blood glucose concentrations <3.3 mmol/L):**

- Trembling
- Sweating
- Palpitations
- Hunger
- Headache

**Neuroglycopenic Symptoms (Blood glucose concentrations below <2.8 mmol/L):**

- Double vision
- Difficulty concentrating
- Slurred speech
- Confusion
- Coma



# Differential Diagnosis
Conditions to consider:

- **Diabetic ketoacidosis:** May cause hypoglycaemia due to insulin treatment. Symptoms include polydipsia, polyuria, fatigue, and abdominal pain.
- **Adrenal insufficiency:** Lack of cortisol may lead to hypoglycaemia. Features include fatigue, weight loss, hyperpigmentation, and hypotension.
- **Insulinoma:** Insulin-secreting tumor resulting in hypoglycaemia. Symptoms mimic hypoglycaemia but can occur after meals.
- **Alcohol intoxication:** Alcohol can inhibit hepatic gluconeogenesis, leading to hypoglycaemia. Symptoms include confusion, ataxia, slurred speech, and coma.

#Investigations

Whipple's triad:

* Plasma hypoglycaemia
* Symptoms attributable to a low blood sugar level
* Resolution of symptoms with correction of the hypoglycaemia

The diagnostic approach for hypoglycaemia may involve the following:

- Review medication history for potential drug-induced causes.
- Measure serum insulin, C-peptide, and proinsulin levels to differentiate between exogenous and endogenous insulin sources.
	- High insulin AND high C-peptide and proinsulin imply endogenous production e.g. insulinoma
	- High insulin AND low C-peptide and proinsulin suggest exogenous administration.
- Perform a 72-hour fast test to demonstrate episodic hypoglycaemia.
- Conduct 8am cortisol and/or synACTHen testing for adrenal insufficiency.
- Consider abdominal imaging (CT/MRI/PET) to locate an insulinoma.

# Management
**Mild Hypoglycaemia (Patient is conscious):**

- ABCDE approach
- Consume 15-20g of fast-acting carbohydrate (e.g., glucose tablets, non-diet soda, sweets, fruit juice).
- Avoid chocolate due to slower absorption.
- Follow up with slower-acting carbohydrates (e.g., toast).

**Severe Hypoglycaemia (e.g. Seizures, Unconsciousness):**

- ABCDE approach
- Administer 200ml 10% dextrose IV (alternatively dextrose 20% can be administered via a large vein). 
- Administer 1mg glucagon IM if no IV access (Note: this won't work if alcohol ingestion is the cause due to its action blocking gluconeogenesis).
- Manage prolonged or repeated seizures.

**Aftercare:**

- Consider medication changes.
- Investigate non-drug causes if necessary.

# DVLA Guidance on Hypoglycaemia
The DVLA has specific regulations for patients with hypoglycaemia who are driving. Requirements depend on the severity and frequency of episodes, type of driving license, and specific medication regimen.

# NICE Guidelines

[NICE CKS - hypoglycaemia management](https://cks.nice.org.uk/topics/insulin-therapy-in-type-2-diabetes/management/insulin-therapy-type-2-diabetes/#hypoglycaemia)


# References
 [Patient.info on Hypoglycaemia](https://www.patient.info/doctor/hypoglycaemia)
 
 [DVLA Guidance on Hypoglycaemia and Driving](https://www.gov.uk/hypoglycaemia-and-driving)

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An insulinoma is a pancreatic tumor that causes excessive insulin secretion and hypoglycemia. IV dextrose quickly raises blood glucose, and potassium replacement may be needed due to insulin-induced cellular potassium shifts.
A 62-year-old male patient presents to A&E due to a history of intermittent confusion, sweating and dizziness. These often improved towards the end of the day. His bloods are as follows:


 - Fasting glucose 1.2 (normal range 3.5-5.5 mmol/L)
 - Proinsulin raised
 - C-peptide raised


A diagnosis of insulinoma is made. What is the most appropriate initial management?
a