Drug-induced hypoglycaemia without coma

Emergency Medicine

Clinicals - History

Fact Explanation
Tremors, Palpitations, anxiety Due to catecholamine mediated (adrenergic) autonomic effects
Neurogenic (autonomic) symptoms are triggered by a falling glucose level.These symptoms are activated by the autonomic nervous system and are mediated in part by sympathoadrenal release of catecholamines (norepinephrine and epinephrine) from the adrenal medullae and acetylcholine from postsynaptic sympathetic nerve endings
Tremors, Palpitations, anxiety
Due to catecholamine mediated (adrenergic) autonomic effects
Neurogenic (autonomic) symptoms are triggered by a falling glucose level.These symptoms are activated by the autonomic nervous system and are mediated in part by sympathoadrenal release of catecholamines (norepinephrine and epinephrine) from the adrenal medullae and acetylcholine from postsynaptic sympathetic nerve endings
Sweating,hunger, tingling Due to acetylcholine mediated (cholinergic) autonomic effects Sweating,hunger, tingling
Due to acetylcholine mediated (cholinergic) autonomic effects
Neuroglycopenic symptoms-Irritability, Drowsiness,Blurred vision,Difficulty with speech,Confusion, Feeling faint, Seizure,Changes in behavior Neuroglycopenic symptoms occur as a result of brain neuronal glucose deprivation Neuroglycopenic symptoms-Irritability, Drowsiness,Blurred vision,Difficulty with speech,Confusion, Feeling faint, Seizure,Changes in behavior
Neuroglycopenic symptoms occur as a result of brain neuronal glucose deprivation
History of renal failure (risk factor) Renal insufficiency increase the risk of drug-induced hypoglycemia due to decreased insulin clearance History of renal failure (risk factor)
Renal insufficiency increase the risk of drug-induced hypoglycemia due to decreased insulin clearance
History of liver failure (risk factor) Hepatic insufficiency increase the risk of drug-induced hypoglycemia due to decreased gluconeogenesis History of liver failure (risk factor)
Hepatic insufficiency increase the risk of drug-induced hypoglycemia due to decreased gluconeogenesis
Other risk factors - excessive alcohol intake,decreased food intake (skipping meals) , advancing age, polypharmacy Excessive alcohol intake -
Decreased gluconeogenesis Advanced age - Decreased awareness,
decreased counter regulatory response to low blood glucose
Decreased food intake - Insufficient glucose intake
Polypharmacy - Increased risk of drug interactions resulting in
hypoglycemia
Other risk factors - excessive alcohol intake,decreased food intake (skipping meals) , advancing age, polypharmacy
Excessive alcohol intake -
Decreased gluconeogenesis Advanced age - Decreased awareness,
decreased counter regulatory response to low blood glucose
Decreased food intake - Insufficient glucose intake
Polypharmacy - Increased risk of drug interactions resulting in
hypoglycemia
Improper use of anti diabetic drugs treatment-limiting adverse effect in patients with diabetes
Leads to reduction of blood glucose levels to a level which is more than the required level
insulin and sulphonylureas
are the most common drugs which causes hypoglycemia
Insulin treated patients have a higher mortality due to hypoglycemia than the patients who are not treated with insulin
Improper use of anti diabetic drugs
treatment-limiting adverse effect in patients with diabetes
Leads to reduction of blood glucose levels to a level which is more than the required level
insulin and sulphonylureas
are the most common drugs which causes hypoglycemia
Insulin treated patients have a higher mortality due to hypoglycemia than the patients who are not treated with insulin
Usage of drugs which can lead to hypoglycemia (eg : ACE inhibitors, Fluoroquinolones,Indomethacin,Quinine,Beta blockers ) ACE inhibitors- Increase insulin sensitivity
Fluoroquinolones- May increase insulin secretion from pancreas
Indomethacin- Increase insulin secretion from pancreas, decrease in
insulin clearance, decrease in gluconeogenesis
Quinine- Increased insulin secretion from pancreas
Beta blockers- Mask signs/symptoms of hypoglycemia, increase in
glucose uptake in the periphery
Usage of drugs which can lead to hypoglycemia (eg : ACE inhibitors, Fluoroquinolones,Indomethacin,Quinine,Beta blockers )
ACE inhibitors- Increase insulin sensitivity
Fluoroquinolones- May increase insulin secretion from pancreas
Indomethacin- Increase insulin secretion from pancreas, decrease in
insulin clearance, decrease in gluconeogenesis
Quinine- Increased insulin secretion from pancreas
Beta blockers- Mask signs/symptoms of hypoglycemia, increase in
glucose uptake in the periphery
History of depression Should be assessed as drug induced hypoglycemia may be a suicidal attempt (self-harm with hypoglycemic agents)
Recurrent hypoglycemia can also cause depression
History of depression
Should be assessed as drug induced hypoglycemia may be a suicidal attempt (self-harm with hypoglycemic agents)
Recurrent hypoglycemia can also cause depression

Clinicals - Examination

Fact Explanation
Assessment of level of consciousness Assessed according to Glasgow coma scale.

Motor Response
6 Obeying command
5 Localizing response to pain.
4 Withdrawal to pain
3 Flexor response to pain
2 Extensor posturing to pain
1 No response to pain.

Verbal Response
5 Oriented
4 Confused conversation
3 Inappropriate speech
2 Incomprehensible speech
1 No verbal response.

Eye Opening
4 Spontaneous eye opening.
3 Eye opening in response to speech
2 Eye opening in response to pain.
1 No eye opening
Assessment of level of consciousness
Assessed according to Glasgow coma scale.

Motor Response
6 Obeying command
5 Localizing response to pain.
4 Withdrawal to pain
3 Flexor response to pain
2 Extensor posturing to pain
1 No response to pain.

Verbal Response
5 Oriented
4 Confused conversation
3 Inappropriate speech
2 Incomprehensible speech
1 No verbal response.

Eye Opening
4 Spontaneous eye opening.
3 Eye opening in response to speech
2 Eye opening in response to pain.
1 No eye opening
Pallor Drop of blood glucose level triggers adrenalin release and constriction of skin arteries Pallor
Drop of blood glucose level triggers adrenalin release and constriction of skin arteries
Increased heart rate Autonomic symptoms are triggered by a falling glucose level Increased heart rate
Autonomic symptoms are triggered by a falling glucose level
Elevated systolic blood pressure Autonomic symptoms are triggered by a falling glucose level Elevated systolic blood pressure
Autonomic symptoms are triggered by a falling glucose level
Diaphoresis Due to sympathoadrenal activation triggered by a falling glucose level Diaphoresis
Due to sympathoadrenal activation triggered by a falling glucose level

Investigations - Diagnosis

Fact Explanation
Plasma glucose levels Classification of drug induced hypoglycemia
1) Severe hypoglycemia.
An event requiring assistance of another person to actively administer carbohydrate, glucagons, or other resuscitative actions.
2) Documented symptomatic hypoglycemia.
An event during which typical symptoms of hypoglycemia are accompanied by a measured plasma glucose concentration ≤70 mg/dl (3.9 mmol/l).
3) Asymptomatic hypoglycemia.
An event not accompanied by typical hypoglycemic symptoms but with a measured concentration of plasma glucose ≤70 mg/dl (3.9 mmol/l).
4) Probable symptomatic hypoglycemia.
An event during which symptoms of hypoglycemia are not accompanied by a plasma glucose determination (but that was presumably caused by a plasma glucose concentration ≤70 mg/dl [3.9 mmol/l]).
5) Relative hypoglycemia.
An event during which the person with diabetes reports any of the typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but with a measured plasma glucose concentration >70 mg/dl (3.9 mmol/l).
Plasma glucose levels
Classification of drug induced hypoglycemia
1) Severe hypoglycemia.
An event requiring assistance of another person to actively administer carbohydrate, glucagons, or other resuscitative actions.
2) Documented symptomatic hypoglycemia.
An event during which typical symptoms of hypoglycemia are accompanied by a measured plasma glucose concentration ≤70 mg/dl (3.9 mmol/l).
3) Asymptomatic hypoglycemia.
An event not accompanied by typical hypoglycemic symptoms but with a measured concentration of plasma glucose ≤70 mg/dl (3.9 mmol/l).
4) Probable symptomatic hypoglycemia.
An event during which symptoms of hypoglycemia are not accompanied by a plasma glucose determination (but that was presumably caused by a plasma glucose concentration ≤70 mg/dl [3.9 mmol/l]).
5) Relative hypoglycemia.
An event during which the person with diabetes reports any of the typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but with a measured plasma glucose concentration >70 mg/dl (3.9 mmol/l).
Usage of drugs which can lead to hypoglycemia (eg : ACE inhibitors, Fluoroquinolones,Indomethacin,Quinine,Beta blockers ) ACE inhibitors- Increase insulin sensitivity
Fluoroquinolones- May increase insulin secretion from pancreas
Indomethacin- Increase insulin secretion from pancreas, decrease in
insulin clearance, decrease in gluconeogenesis
Quinine- Increased insulin secretion from pancreas
Beta blockers- Mask signs/symptoms of hypoglycemia, increase in
glucose uptake in the periphery
Usage of drugs which can lead to hypoglycemia (eg : ACE inhibitors, Fluoroquinolones,Indomethacin,Quinine,Beta blockers )
ACE inhibitors- Increase insulin sensitivity
Fluoroquinolones- May increase insulin secretion from pancreas
Indomethacin- Increase insulin secretion from pancreas, decrease in
insulin clearance, decrease in gluconeogenesis
Quinine- Increased insulin secretion from pancreas
Beta blockers- Mask signs/symptoms of hypoglycemia, increase in
glucose uptake in the periphery

Investigations - Management

Fact Explanation
Serum creatinin, blood urea To check for the renal functions as renal insufficiency increase the risk of drug-induced hypoglycemia Serum creatinin, blood urea
To check for the renal functions as renal insufficiency increase the risk of drug-induced hypoglycemia
Liver enzyme levels To check liver functions as hepatic insufficiency increase the risk of drug-induced hypoglycemia Liver enzyme levels
To check liver functions as hepatic insufficiency increase the risk of drug-induced hypoglycemia
HbA1c To see the diabetic control HbA1c
To see the diabetic control
Full blood count Check the hemoglobin levels in patients with pallor Full blood count
Check the hemoglobin levels in patients with pallor
Fasting blood sugar, oral glucose tolerance test Done to diagnose diabetic Fasting blood sugar, oral glucose tolerance test
Done to diagnose diabetic
Renal function tests (Serum creatinine ,blood urea levels, glomerular filtration rate ) Renal insufficiency increase the risk of drug-induced hypoglycemia due to decreased insulin clearance Renal function tests (Serum creatinine ,blood urea levels, glomerular filtration rate )
Renal insufficiency increase the risk of drug-induced hypoglycemia due to decreased insulin clearance
Liver function tests ( Liver enzyme levels, bilirubin levels ) Hepatic insufficiency increase the risk of drug-induced hypoglycemia due to decreased gluconeogenesis Liver function tests ( Liver enzyme levels, bilirubin levels )
Hepatic insufficiency increase the risk of drug-induced hypoglycemia due to decreased gluconeogenesis
Other risk factors - excessive alcohol intake,decreased food intake (skipping meals) , advancing age, polypharmacy Excessive alcohol intake -
Decreased gluconeogenesis Advanced age - Decreased awareness,
decreased counter regulatory response to low blood glucose
Decreased food intake - Insufficient glucose intake
Polypharmacy - Increased risk of drug interactions resulting in
hypoglycemia
Other risk factors - excessive alcohol intake,decreased food intake (skipping meals) , advancing age, polypharmacy
Excessive alcohol intake -
Decreased gluconeogenesis Advanced age - Decreased awareness,
decreased counter regulatory response to low blood glucose
Decreased food intake - Insufficient glucose intake
Polypharmacy - Increased risk of drug interactions resulting in
hypoglycemia

Management - Supportive

Fact Explanation
Recognition of signs and symptoms of hypoglycemia Hypoglycemia should be clinically diagnosed prior to treatment.Should differentiate between mild – moderate versus severe signs and symptoms Recognition of signs and symptoms of hypoglycemia
Hypoglycemia should be clinically diagnosed prior to treatment.Should differentiate between mild – moderate versus severe signs and symptoms
Initial treatment of hypoglycemia 1)Consume 15-20 grams of glucose or simple carbohydrates
2)Recheck your blood glucose after 15 minutes 3)If hypoglycemia continues, repeat
4)Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away
Initial treatment of hypoglycemia
1)Consume 15-20 grams of glucose or simple carbohydrates
2)Recheck your blood glucose after 15 minutes 3)If hypoglycemia continues, repeat
4)Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away
Appropriate treatment of hypoglycemia Patient-treated with a quick acting glucose
source versus caregiver assisted with glucagon or healthcare provider treatment with
dextrose
Appropriate treatment of hypoglycemia
Patient-treated with a quick acting glucose
source versus caregiver assisted with glucagon or healthcare provider treatment with
dextrose
Treatment in chronic alcohol abused patients If the patient has a history of malnutrition or chronic alcohol abuse, intravenous (IV) thiamine at a bolus dose of 1–2 mg/kg should be given before initiation of glucose treatment, to avoid precipitating Wernicke's encephalopathy Treatment in chronic alcohol abused patients
If the patient has a history of malnutrition or chronic alcohol abuse, intravenous (IV) thiamine at a bolus dose of 1–2 mg/kg should be given before initiation of glucose treatment, to avoid precipitating Wernicke's encephalopathy

Management - Specific

Fact Explanation
Plan for prevention of future episodes of drug induced hypoglycemia Evaluation of offending medication for adjustment in dosage and length of therapy
Consider of timing of administration of medication with meals
Consistent intake of meals/snacks
Institute blood glucose monitoring
Plan for prevention of future episodes of drug induced hypoglycemia
Evaluation of offending medication for adjustment in dosage and length of therapy
Consider of timing of administration of medication with meals
Consistent intake of meals/snacks
Institute blood glucose monitoring
Patient Education Demonstration of self-monitoring of
blood glucose
Discussion of timing of blood glucose
monitoring and target levels
Monitor for signs/symptoms of
hypoglycemia
Review appropriate treatment of
hypoglycemia
Patient Education
Demonstration of self-monitoring of
blood glucose
Discussion of timing of blood glucose
monitoring and target levels
Monitor for signs/symptoms of
hypoglycemia
Review appropriate treatment of
hypoglycemia
glucagon IM injections Glucagon 1mg IM- May take up to 15 minutes to take effect, mobilises
glycogen from the liver and will be less effective in those who are chronically malnourished (e.g. alcoholics), or in
patients who have had a prolonged period of starvation and have depleted glycogen stores or in those with severe
liver disease
glucagon IM injections
Glucagon 1mg IM- May take up to 15 minutes to take effect, mobilises
glycogen from the liver and will be less effective in those who are chronically malnourished (e.g. alcoholics), or in
patients who have had a prolonged period of starvation and have depleted glycogen stores or in those with severe
liver disease
In ward management of hypoglycemia with IV dextrose If IV access available, give 75-80ml of 20% glucose or 50ml of 50% dextrose (over 10-15 minutes).
If an infusion pump is available use this, but
if not readily available the infusion should not be delayed.Repeat capillary blood glucose measurement 10 minutes later.If it is still less than
4.0mmol/L, repeat
In ward management of hypoglycemia with IV dextrose
If IV access available, give 75-80ml of 20% glucose or 50ml of 50% dextrose (over 10-15 minutes).
If an infusion pump is available use this, but
if not readily available the infusion should not be delayed.Repeat capillary blood glucose measurement 10 minutes later.If it is still less than
4.0mmol/L, repeat
In ward management when the patient is recovered Once the blood glucose is greater than 4.0mmol/L and the patient has recovered give a long acting carbohydrate of the patient’s choice where possible, taking into consideration any specific dietary requirements In ward management when the patient is recovered
Once the blood glucose is greater than 4.0mmol/L and the patient has recovered give a long acting carbohydrate of the patient’s choice where possible, taking into consideration any specific dietary requirements

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