Kembara Xtra - Medicine - Non-Diabetic Hypoglycemia

Kembara Xtra - Medicine - Non-Diabetic Hypoglycemia 
The Whipple triad is used to define hypoglycemia. Low plasma glucose levels (60 mg/dL) accompanied by hypoglycemia symptoms that are restored when blood sugar levels are raised are prevalent in diabetics on insulin secretagogues (sulfonylureas, meglitinides), but less frequent in people without diabetes.
Postprandial hypoglycemia, also known as reactive hypoglycemia, can develop two to three hours after a meal or even later in reaction to medications, herbal remedies, or minerals. This is a noncongenital beta-islet dysregulation with or without insulin secretion and hyperplasia. In patients with hypoglycemia unawareness, autonomic symptoms are typically noticed when the serum glucose is below 60 mg/dL, and neuroglycopenic symptoms when the serum glucose is 50 mg/dL or below.
– After GI or bariatric surgery, hypoglycemia is also common (in certain cases in conjunction with dumping syndrome).
The fundamental ailments hypopituitarism, Addison disease, myxedema, or disorders connected to critical illness, heart failure, liver, or renal failure may be accompanied with spontaneous (fasting) hypoglycemia. Take extrapancreatic tumors and hyperinsulinism into consideration if hypoglycemia manifests as a main disease.

65 years or older without diabetes; 0.5-8.6% of hospitalized patients; 25% of cases; asymptomatic

Prevalence

Unknown is the true prevalence:
Older adult as the predominant age 
Female is more prevalent than male.

Pathophysiology and Etiology 
Reactive, postprandial - Alimentary hyperinsulinism - Meals including liquid versions of fructose, sucrose, or glucose, as well as refined or processed carbs - A few nutrients, such as leucine and galactose
- Intolerance to glucose (diabetes)
- General and/or bariatric surgery, such as Roux-en-Y gastric bypass - Idiopathic (causes unknown)
Spontaneous - Fasting - Situations or housing with limited availability to food (e.g., those without a place to live, those in hospitals, or those incarcerated) - Nonprescription over-the-counter (OTC) medications, such as insulin, sulfonylureas, meglitinides, thiazolidinediones, incretin mimics, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, DPP-IV inhibitors, angiotensin-converting enzyme inhibitors, -blockers, salicylates, quinine, hydroxychloroquine, flu Imported phosphodiesterase inhibitors and performance-enhancing drugs frequently have sulfonylureas and other hypoglycemic ingredients in them.
– Consider medication administration mistakes as a possible cause of unexplained hypoglycemia in individuals without diabetes, particularly in those who have polypharmacy (the use of six or more medications).
This includes the inadvertent, covert, or intentional use of oral hypoglycemics or insulin.
- Herbs or natural medicines (vanadium, bitter melon, chromium, fenugreek, ginseng, guarana, mate, stevia, cassia cinnamon, caffeine) - Postsurgical (such as gastrectomy or Roux-en-Y bariatric surgery)
Hypoglycemia/dumping syndrome - Insulinoma or islet cell hyperplasia
- Large tumors that secrete insulin-like growth factor 2 (IGF-2) and extrapancreatic insulin-secreting tumors - Insulin receptor mutations and autoimmune hypoglycemia (Hirata illness) - Heart failure treated with SGLT-2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) or not - Renal illness or failure; hepatic illness or failure
kidney glycosuria
- Deficiencies in glucagon, adrenal insufficiency, catecholamines, hypopituitarism, and hypothyroidism
- Food addictions
- Physical activity, such as manual labor,
Fever, pregnancy, childhood ketotic hypoglycemia, severe dietary shortages (such as selenium), and more.
congenital illnesses such as sepsis, cachexia, and anorexia

Genetics Inborn errors of metabolism, such as glycogenoses, fructose intolerance, neoglucogenesis, and fatty acid or beta-oxidation problems Monogenic and congenital hyperinsulinism (i.e., channelopathies, enzyme and transport anomalies, transcription factor or enzyme abnormalities) 


Prevention 

Follow nutrition and exercise recommendations. Patient should be aware of early symptoms and know what to do to get better. 

Child Safety Considerations

 Typically broken down into two syndromes: - Transient hypoglycemia in newborns
- Hypoglycemia of infancy and childhood - When maternal diabetes complicated pregnancy, infants should be screened for hypoglycemia.
Children who were receiving propranolol for infantile hemangioma cases of hypoglycemia were noted. 
Used in conjunction with indomethacin to treat patent ductus arteriosus.

Geriatric considerations: Iatrogenic hypoglycemia is common in hospitalized elderly patients with renal insufficiency; more likely to have underlying problems or be brought on by drugs.

Heart failure, severe chronic hepatic and renal illness, alcoholism, Addison disease, adrenocortical insufficiency, myxedema, malnutrition (in patients with renal failure), gastrointestinal and bariatric surgery, panhypopituitarism, and insulinoma are all associated conditions.

Diagnosis: An sudden reduction in glucose of 60 mg/dL is accompanied by significant signs of adrenalin release.
- Trembling, drowsiness, diaphoresis, warmth/flushing, and heart palpitations.
At a serum glucose level of 50 mg/dL, CNS (neuroglycopenic) symptoms start to manifest.
- Visual disturbances - Headache - Confusion - Lightheadedness - Fatigue and weakness
- Personality changes digestive symptoms
- Belching, nausea, and hunger

clinical assessment 

 CNS (neuroglycopenic) symptoms are more prevalent as glucose is gradually decreased: - Seizures
- Coma - Hypotension - Adrenergic symptoms that are more pronounced with a sharp drop in blood sugar - Unsteadiness
The diaphoresis
- Heart palpitations - Warmth/flushing

Differential Diagnosis CNS Disorders Psychogenic Pseudohypoglycemia: Hypoglycemic symptoms or self-diagnosis in patients in whom low blood glucose may not be detected and in whom it may be difficult to persuade that they do not have hypoglycemia after all tests are shown to be normal.

Initial test results from the laboratory and imaging
If symptomatic, blood glucose 45 mg/dL (2.5 mmol/L), followed by symptom relief with eating
Overnight fasting plasma glucose: 60 mg/dL (3.33 mmol/L); confirm twice.

Plasma glucose levels after a 72-hour fast should be less than 45 mg/dL (2.5 mmol/L) for women and 55 mg/dL (3.05 mmol/L) for men; the fast may be broken when the Whipple triad is reached or hypoglycemia is evident.

 Transabdominal ultrasonography, CT, MRI, or PET imaging (abdominal) 


Tests in the Future & Special Considerations
Hypoglycemia may be misdiagnosed as a result of incorrect interpretation of glucose tolerance tests; during a 4-hour glucose tolerance test, about one-third of healthy persons experience hypoglycemia, with or without symptoms. These patients could be at risk for type 2 diabetes in the future.
C-peptide analysis
Verify liver examinations, insulin levels in the blood, cortisol, and adrenocorticotropic hormone (ACTH). When glucose is less than 60 mg/dL, serum insulin should be reduced.
The presence of low serum glucose, high serum insulin, and serum -hydroxybutyrate (2.7 mg/dL) points to excessive insulin production.
Elevated insulin levels point to islet cell hyperplasia or malignancy, according to the insulin radioimmunoassay.
Substances that could affect test results: Many medications can impact blood glucose levels; evaluate medications separately and use a medication or laboratory reference.
Other/Diagnostic Procedures
Patients need to have the following for a conclusive diagnosis: Documented low glucose levels Symptoms when glucose levels are low Evidence that symptoms are treated specifically by consuming glucose or food Identification of the particular kind of hypoglycemia

Management 

If a patient is aware and not experiencing a narcotic overdose, give them an oral carbohydrate (2–3 tbsp of sugar in a glass of water or fruit juice, 1–2 cups of milk, a piece of fruit, or several soda crackers). If they are unable to swallow, give them glucagon IM or SC.
If caused by a drug or nutrient: Steer clear of or manage the cause.
If meals are the cause, try a high-protein, low-carbohydrate diet.
● Pseudohypoglycemia or nonhyperglycemic hypoglycemia
– Many patients (typically females between the ages of 20 and 45) are diagnosed with reactive or post-prandial hypoglycemia due to self-diagnosis or incorrect test interpretation.
– Chronic fatigue and somatic problems are two possible signs (stress frequently contributes to these symptoms).
- Management is challenging; listening is crucial. Try eating 120 g of carbohydrates.
– Counseling may be beneficial for difficulties such as stress.

Medication Once a diagnosis has been made, start the right kind of therapy for the underlying illness.
If you are unable to swallow, provide glucagon 1 mg (1 unit) IV, IM, or SC.
If there is no reaction, administer a 25–50 g IV bolus of a 50% glucose solution followed by a continuous infusion until the patient is able to swallow. Intranasal glucagon is administered as 3 mg (one actuation per device) into a single nostril; if no reaction is seen after 15 minutes, the procedure may be repeated once.

Propantheline, psyllium, fiber, or oat bran may be helpful for postoperative gastrectomy patients who are not responding to dietary adjustments in order to postpone gastric emptying.
SURGICAL AND OTHER PROCEDURE
Surgery is the preferred course of treatment for islet cell tumors (insulinoma) and other tumors that secrete insulin; if surgery is not an option, diazoxide may help with symptoms.

Hypoglycemia at admission resistant to oral intake


Follow-Up Your daily activity or exercise regimen may need to be reevaluated.
Patients with recurrent hypoglycemia should keep a glucose source nearby for quick consumption when symptoms arise.

Patient Monitoring Sulfonylurea-induced hypoglycemia can last for hours to days depending on the drug's half-life and renal function. It also depends on the nature, severity, and treatment of the underlying cause.


Diet: a high-protein, high-fiber, complex-carbohydrate diet that includes some fat and entire foods consumed in moderation
Six modest, frequent meals each day; avoid liquid calories.

Prevent fasting.
Patient education, dietary advice, stress counseling, where needed, and knowledge of early signs of hypoglycemia and how to treat it are all included.

Prognosis 
favorable, with proper handling

Complications 
Insulinoma: If the tumor is found and removed, there is some surgical risk.
Organic brain syndrome: may be brought on by severe, protracted hypoglycemia.