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Toxin INduced Hypoglycemia - Dr. Alwasiyah

3/2/2017

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Picture
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
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  • Prospective Applicants
    • 2020 MATCH
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      • EM GuideWire
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      • Dr. Patel's Coding Blog
      • Global Health Blog
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    • Schedules >
      • Conference/Flashpoint
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