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EVALUATION OF HYPOGLYCEMIA
Andrew Maclennan, MD April 23, 2010 Morning Report
& Insulin Autoimmune Syndrome (Hirata disease)
SYMPTOMS OF HYPOGLYCEMIA
“Neuroglycopenic symptoms” Cognitive impairment, behavioral changes,
psychomotor abnormalities, coma, death “Neurogenic symptoms”
Tremors, palpitations, anxiety/arousal, sweating, hunger, paresthesias
WHO TO EVALUATE?
Whipple’s Triad: Symptoms consistent with hypoglycemia A low plasma glucose - measured with a
precise method (not a glucometer) Relief of symptoms after glucose level
normal
Allen Oldfather Whipple
DIAGNOSTIC APPROACH
Fast (overnight or post-prandial) 72 hr fast if initial fast is negative
End fast when glucose ≤45 mg/dL Pt has signs/sx of hypoglycemia 72 hours have elapsed glucose <55 mg/dL if Whipple's triad documented previously
Check Q6 hrs, more frequently when glucose < 60 mg/dL plasma glucose, insulin, C-peptide, proinsulin, BHOB, and oral
hypoglycemic agents At end of fast
IV glucagon and measure glucose 10, 20, and 30 minutes later Feed patient
WHAT TO MEASURE?
In symptomatic patients with hypoglycemia Insulin > 3 microU/mL is excess insulin; consistent w/ insulinoma
Caution! Glucose < 50 mg/dL in some normal subjects & >50 mg/dL in some patients with insulinoma.
Proinsulin > 5 pmol/L consistent w/ insulinoma Beta-hydroxybutyrate - Insulin is antiketogenic
BHOB levels lower in insulinoma patients than in normal subjects. C-peptide - distinguishes endogenous from exogenous hyperinsulinemia Sulfonylurea and meglitinide screen Glucose response to glucagon
Insulin is antiglycogenolytic and hyperinsulinemia permits retention of glycogen within the liver.
In insulin-mediated hypoglycemia, response to glucagon is release of glucose Normal patients have virtually exhausted hepatic glycogen stores after 72hrs and
can’t respond as vigorously. (Insulin & insulin receptor antibodies)
LOCALIZING STUDIES
Radiologic studies — CT, MRI, transabdominal US can detect most insulinomas
Arterial calcium stimulation — to distinguish between insulinoma and a diffuse process (islet cell hypertrophy/nesidioblastosis). Inject calcium gluconate into gastroduodenal, splenic
and superior mesenteric artery Sample hepatic vein for insulin Increased insulin secretion localizes area of
hyperfunctioning islets.
TREATMENT OF HYPERINSULINEMIC HYPOGLYCEMIC STATES
Insulinoma – surgical resection of tumor
Nesidioblastosis – partial or subtotal pancreatectomy
Antibodies to insulin receptors – immunosuppressants (poor response)
Antibodies to insulin – glucocorticoids (good response)
INSULIN AUTOIMMUNE SYNDROME
CLINICAL MANIFESTATIONS
Episodes of hyperinsulinemic hypoglycemia Often post-prandial, after exercise
Paradoxic hyperglycemia May occur after meal or oral glucose
challenge
EPIDEMIOLOGY
Extremely uncommon in West (58 case reports in non-Asian populations) 3rd leading cause of hypoglycemia in Japan
No sex preference Age > 40yrs Associated with rheumatologic disease
SLE, RA, May see positive ANA, anti DSDNA, RF
Association with medications Captopril, penicillamine, hydralazine, procainamide, INH,
penicillin G Meds with sulfhydryl group (especially methimazole)
PATHOPHYSIOLOGY
1. Insulin secreted after meal bound by antibodies (IgG)
2. Hyperglycemia persists causing more insulin secretion (results in high A1C over time)
3. As hyperglycemia abates, insulin-bound to antibodies is released, with inappropriately high insulin levels
4. Hypoglycemia results.
LABORATORY AND CLINICAL FINDINGS
Autoimmune Forms of Hypoglycemia.Lupsa, Beatrice; Chong, Angeline; Cochran, Elaine; MSN, CRNP; Soos, Maria; Semple, Robert; MB, PhD; Gorden, Phillip
Medicine. 88(3):141-153, May 2009.DOI: 10.1097/MD.0b013e3181a5b42e
REFERENCES
Lupsa BC et al, Autoimmune Forms of Hypoglycemia. Medicine, vol 88(3):141-153; May 2009.
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