Endocrine topic reviews. Artit Sangkakam, MD 19, september 2013

Transcription

1 Endocrine topic reviews Artit Sangkakam, MD 19, september 2013

2 Hypoglycemia in Non-DM

3 Definition In diabetic mellitus : Plasma glucose 70 mg/dl In Non-diabetic mellitus : Plasma glucose 55 mg/dl Normal Plasma glucose : mg/dl

4 Source of glucose Absorption GI tract Gluconeogenesis Glycogenolysis

5 Physiology of glucose counterregulation

6 Clinical manifestation Neuroglycopenic symptoms Cognitive impairments Behavioral changes Psychomotor abnormalities Seizure and coma

7 Clinical manifestation Neurogenic or autonomic symptoms Adrenergic ( catecholamine- mediated) symptoms : palpitation, tremor, and anxiety/ arousal Cholinergic ( acetylcholine- mediated) symptoms : sweating, hunger, and paresthesias

8 Diagnosis Whipple's triad ประกอบด วย 1. Signs and symptoms of hypoglycemia 2. Low Plasma glucose 3. Improve clinical after receive glucose

9 Evaluation of hypoglycemia in person without DM 1. Review history, physical findings, all available lab data seeking clue to specific disorders : drugs, critical illnesses, hormone deficiencies, nonislet cell tumors 2. When cause of hypoglycemia not evident, Seemingly well individual measure : plasma glucose, insulin, C- peptide, proinsulin, B- hydroxybutyrate, oral hypoglycemic agents, plasma glucose response to injection of 1 mg glucagon

10 Evaluation of hypoglycemia in person without DM 3. When spontaneous hypoglycemic episode cannot be observed: recreat in symptomatic hypoglycemia by 72 hrs fast or after mixed meal, plasma glucose < 55 mg/dl 4. Document endogenous hyperinsulinemic hypoglycemia, negative for OHA, no insulin antibody,localizing insulinoma : CT,MRI, ultrasound

11 Causes of hypoglycemia in adults ill or medicated individual 1. Drugs Insulin Insulin secretagogue, Alcohol, Other 2. Critical illness Hepatic Renal Cardiac failure Sepsis

12 Causes of hypoglycemia in adults ill or medicated individual 3. Hormone deficiency Cortisol Glucagon Epinephrine 4. Nonislet cell tumor Hepatoma Adrenocortical CA Carcinoid (Due to overproduction : IGF-II)

13 Causes of hypoglycemia in adults Seemingly well individual 1. Endogenous hyperinsulinism 1.Insulinoma 2. Functional ß-cell disorders : noninsulinoma pancreatogenous hypoglycemia (NIPH), postgastric bypass hypoglycemia 3. Insulin autoimmune hypoglycemia 4. Insulin secretagogue 5. Other

14 Causes of hypoglycemia in adults Seemingly well individual 2. Accidental, surreptitious, or malicious hypoglycemia

15 Classification of hypoglycemia in person without DM I. Postabsorptive(fasting) hypoglycemia # Insulinoma : typical is postabsorptive II. Postprandial(reactive) hypoglycemia # Post gastric bypass : typical is postprandial

16 Drugs can cause hypoglycemia Moderate quality of evidence Cibenzoline Gatifloxacin Pentamidine Quinine Indomethacin Glucagon ( during endoscopy)

17 Drugs can cause hypoglycemia Low quality of evidence Chloroquineoxaline sulfonamide Artesunate/ artemisin / artemether IGF-1 Lithium Propoxyphene/dextropropoxyphene

18 Drugs can cause hypoglycemia Very low quality of evidence Angiotensin converting enzyme inhibitor Angiotensin receptor antagonists B- adrenergic receptor antagonist Levofloxacin Mifepristone Disopyramide Trimethoprim-sulfamethoxazole Heparin 6- Mercaptopurine

19 Laboratory test Test Cut- point Plasma glucose < 55 mg/dl Plasma insulin 3 uu/ml C- peptide 0.6 ng/ml Plasma proinsulin 5 pm/l B-hydroxybutyrate 2.7 mmol/l glucose after glucagon 25 mg/dl Circulating OHA No/yes Antibody to insulin +/-

20 Laboratory interpretation Insulin uu/ml C -peptide ng/ml Proinsulin pmol/l Circulate OHA Insulin Ab Dx < 3 < 0.6 < 5 No No Normal >> 3 < 0.6 < 5 No Neg(pos) >or= 3 >or=0.6 >or=5 No Neg Exogenous Insulin Insulinoma, NIPHS >or=3 >or=0.6 >or=5 Yes Neg OHA >>3 >>0.6 >>5 No Pos Autoimmune

21 If can not test during whipple s triad 1. Postabsorptive(fasting) hypoglycemia Prolong diagnostic fast ( 72 hrs fast ) 2. Postprandial hypoglycemia Mixed- meal diagnostic test

22 Image for diagnostic insulinoma CT % MRI 85 % Somatostatin receptor scintigraphy 80 % EUS with fine needle aspiration 90 %

23 Image for diagnostic insulinoma Negative image not exclude insulinoma Because insulinoma size < 1cm Not seen mass ; Selective pancreatic arterial calcium injection: NIPHS

24 Treatment Depend on cause of hypoglycemia I. Drugs : stop drugs II. Hormone deficiency : glucocorticoid, growth hormone III. Non- islet cell tumor : surgery, irradiation,cmt, drug

25 Treatment IV. Insulinoma : surgery, cannot Sx ; diazoxide, octreotide V. NIPHS / PGBH : Surgery, frequent meal, α- glucosidase inh., Octreotide *** Frequent meal in daytime, uncooked cornstarch before bedtime

26 References Evaluation and Management of Adult Hypoglycemic Disorders : An Endocrine Society Clinical Practice Guideline, J Clin Endocrinol Metab, March 2009, 94(3) : Principles of Internal medicine 18th edition,chapter 345 : MKSAP 15th edition,endocrinology and Metabolism โรคต อมไร ท อในเวชปฎ บ ต, The Endocrine Society Of Thailand