Toxin INduced Hypoglycemia - Dr. Alwasiyah

Definition of hypoglycemia:

• Organ dysfunction in the setting of inadequate glucose concentrations
• Whipple’s Triad:
  • Symptoms consistent with hypoglycemia
  • Low serum glucose
  • Improvement of symptoms after glucose levels have been raised

Interferences with Point of Care Glucose Testing:

• Point of care testing can be inaccurate in both extremes of blood glucose.
  • From the package insert for Accu-Chek®
  • The ACCU-CHEK® test strips are for testing fresh capillary, venous, arterial, or neonatal whole blood. Cord blood samples cannot be used.

​











Important Toxicologic Considerations:

• Beta blockers do not cause hypoglycemia
• Sulfonylureas
• Ethanol
• Insulin
• Salicylates

Pediatric Hypoglycemic Concepts:

• Normal functioning pancreas:
  • Hypoglycemia can be profound
  • Dextrose boluses can stimulate insulin secretion
  • Increase basal insulin at night for growth demands
• Low threshold for admission/observation
• Prophylactic dextrose is not needed
• IV dextrose if they are symptomatic
• Oral carbohydrates if they are asymptomatic

Sulfonylureas:
Glimepiride
Glyburide
Chlorpropamide
Tolbutamide
Tolazamide

• One pill can kill
• Hypoglycemia can be delayed
• Long duration of action
• All patients must be observed for 24-hours

Meglitinides
Nateglide
Repaglinide
Similar action to sulfonylureas but shorter duration of action.
Ethanol:

• Decreases glucose supply by:
  • Inhibiting gluconeogenesis
  • Decreased oral intake
  • Decreased glycogen stores leading to ineffective glycogenolysis.

GLP-1 analogs:

• Do not Cause hypoglycemia

Albiglutide (Tanzeum®)
Dulaglutide (Trulicity®)
Exenatide (Byetta,Bydureon®)
Liraglutide (Victoza®)

Amylin analogue:
Do not cause hypoglycemia
Pramlintide (Symlin®)

Antidiabetic drugs that are expected to cause hypoglycemia

• Sulfonylureas
• Maglitinides
• Insulin
• SGLT-2 inhibitors, in overdose 

---

---

Normoglycemic Ketoacidosis:

• Associated with SGLT-2 inhibitors:
  • End with “flozin”
    • Canagloflozin
    • Dapagloflozin
  • Can be in combination with metformin
• Blood glucose less than expected for DKA
• High anion gap acidosis
• Ketosis:
  • Ketonemia with or without ketonuria

• Pathophysiology:
  • Decreased glucose
  • Relative insulin deficiency
• Risk factors:
  • Surgery
  • Infections
  • Reduction or omission of insulin
  • Excessive alcohol intake
  • Diet restriction
  • Late onset autoimmune diabetes
• Management:
  • Insulin infusion
  • Hydration
  • Carbohydrate supplementation