37-2

HYPOGLYCEMIA

Rationale
Maintenance of the blood sugar within normal limits is essential for health. In the short-term, hypoglycemia is much more dangerous than hyperglycemia. Fortunately, it is an uncommon clinical problem outside of therapy for diabetes mellitus.

Causal Conditions
1. Postprandial hypoglycemia a. Alimentary hyperinsulinism (previous gastrectomy, gastrojejunostomy) b. Idiopathic 2. Fasting hypoglycemia a. Secondary to overutilization of glucose i. Associated with hyperinsulinism A. Exogenous insulin, sulfonylureas (including factitious hypoglycemia) B. Insulinoma/Islet hypertrophy C. Miscellaneous drugs (pentamidine, quinine) ii. Associated with normal insulin levels (large extrapancreatic mesenchymal tumors) b. Secondary to impaired glucose production i. Hormone deficiencies A. Adrenal insufficiency B. Hypopituitarism ii. Substrate deficiency (severe malnutrition, muscle wasting, anorexia) iii. Drugs (alcohol, salicylate intoxication, quinine, pentamidine) iv. Enzyme defects (glucose-6-phosphatase) v. Critical illnesses (severe hepatic failure, cardiac disease, sepsis) vi. Autoimmune hypoglycemia c. In infancy (neonates of diabetics, glycogen storage dis., galactosemia)

Key Objective(s)
2 Differentiate the causes of hypoglycemia based on whether it occurs in the postprandial or fasting state. 2 Determine which patients are at risk for being unaware of hypoglycemia.

Objectives
2 Through efficient, focused, data gathering: Identify those patients with true hypoglycemia as opposed to pseudohypoglycemia. Differentiate the cause for hypoglycemia. 2 List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: Evaluate the blood sugar in patients with symptoms suggestive of postprandial hypoglycemia. Outline the optimal laboratory work-up for a patient with fasting hypoglycemia and conduct the investigations at the time of the spontaneous hypoglycemia.
Page 142 2005 The Medical Council of Canada Generated Friday, 29 April 2005

HYPOGLYCEMIA

2 Conduct an effective plan of management for a patient with hypoglycemia: Outline the management of an acute hypoglycemic episode. Counsel and educate patients with diabetes and hypoglycemia unawareness on methods to prevent hypoglycemia. Select patients in need of specialized care.

Applied Scientific Concepts

1. Outline the normal homeostatic response to fasting that prevents blood glucose concentrations from falling. 2. Outline the roles of epinephrine, glucagon, growth hormone, and cortisol in the fasting state.

Page 143 2005 The Medical Council of Canada Generated Friday, 29 April 2005