Quick summary on what hypoglycaemia is and how it can be managed.

1. INTERNAL MEDICINE
• ENDOCRINE SYSTEM
• HYPOGLYCEMIA
Dr. Chongo Shapi (BSc.HB, MBChB).
Medical Doctor
5 March 2024 1
Dr. Chongo Shapi (BSc. HB, MBChB)

2. INTRODUCTION
• Hypoglycemia is basically plasma glucose less
than or equal to 3mmol/L. Threshold for
symptoms varies.
• Commonest endocrine emergency and
therefore prompt diagnosis and treatment is
essential as brain damage & death can occur if
severe or prolonged.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 2

3. SYMPTOMS
• Manifests as the autonomic and the neuroglycopenic
symptoms.
• Autonomic symptoms therefore include; Sweating,
anxiety ,Hunger, tremor, palpitations, dizziness.
• Neuroglycopenic symptoms therefore include;
Confusion, drowsiness, visual trouble, seizures, coma.
Rarely focal symptoms, eg transient hemiplegia.
Mutism, personality change, restlessness, and
incoherence may lead to misdiagnosis of alcohol
intoxication or even psychosis
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 3

4. CAUSES OF HYPOGLYCEMIA
• The chief cause is insulin or sulfonylurea treatment in a
diabetic, eg increased activity, missed meal, accidental
or non-accidental overdose (check for ciculating oral
hypoglycaemics).
• In non-diabetics you must EXPLAIN mechanism:
1. Exogenous drugs, eg insulin, oral hypoglycaemics
access through diabetic in the family? Body-builders
may misuse insulin to help stamina.
• Also: Alcohol, eg a binge with no food; aspirin
poisoning; ACE-i; B-blockers; pentamidine; quinine
sulfate; aminoglutethamide; insulin-like growth factor.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 4

5. CONT’
2. Pituitary insufficiency.
3. Liver failure, plus some rare inherited enzyme
defects.
4. Addison’s disease.
5. Islet cell tumours (insulinoma) and immune
hypoglycaemia (eg anti-insulin receptor antibodies
in Hodgkin’s disease).
6. Non-pancreatic neoplasms, eg fibrosarcomas
and haem angiopericytomas.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 5

6. WHEN TO INVESTIGATE
HYPOGLYCEMIA
• Whipple answered this (Whipple’s triad):
symptoms or signs of hypoglycemia +
decreased plasma glucose + resolution of
symptoms or signs post glucose rise.
• Document BM during attack and lab glucose if
in hospital (monitors often not reliable at low
readings).
• Take a drug history and exclude liver failure.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 6

7. CONT’
• 72h fasting may be needed (monitor closely).
Bloods: glucose, insulin, C-peptide, and
plasma ketones if symptomatic. If endogenous
hyperinsulinism suspected, do insulin, C-
peptide, proinsulin, B-hydroxybutyrate.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 7

8. INTERPRETING RESULTS
• Hypoglycaemic hyperinsulinaemia (HH):
Causes: insulinoma, sulfonylureas, insulin
injection (no detectable C-peptide—only
released with endogenous insulin);
• Non-insulinoma pancreatogenous
hypoglycaemia syndrome, mutation in the
insulin-receptor gene. Congenital HH follows
mutations in genes involved in insulin
secretion.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 8

9. CONT’
• Insulin low or undetectable, no excess
ketones. Causes: non-pancreatic neoplasm;
anti-insulin receptor antibodies.
• Decreased Insulin, increased ketones. Causes:
Alcohol, pituitary insufficiency, Addison’s
disease.
• Post-prandial hypoglycaemia May occur after
gastric/bariatric surgery (‘dumping’) and in
type 2 DM. Investigation: Prolonged OGTT.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 9

10. TREATMENT
• If conscious, orientated, and able to swallow,
give 15–20g of quick-acting carbohydrate
snack (eg 200mL orange juice) and recheck
blood glucose after 10–15mins (repeat snack
up to 3 times).
• If conscious but uncooperative, squirt glucose
gel between teeth and gums.
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 10

11. CONT’
• In unconscious patients, or those not
responding to these measures, start glucose
IVI (eg 10% at 200mL/h if conscious; 10% at
200mL/15mins if unconscious), or give
glucagon 1mg IV/IM (will not work in
malnourished patients).
• Expect prompt recovery. Once blood glucose
>4.0mmol/L and patient has recovered, give
long-acting carbohydrate (eg slice of toast).
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 11

12. Thanks
5 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 12