Hypoglycemia and the hormonal background of a woman. Taking various medications that have a side effect of hypoglycemic

Diabetes mellitus is a disease that requires knowledge and a high level of discipline from the patient. If it is not treated, sooner or later there will be consequences in the form of damage to nerve tissues and blood vessels, if treated too hard, overestimating the dose of drugs, hypoglycemia will develop.

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Excessively low blood sugar is even more dangerous than high blood sugar, as changes in the body occur much faster, and medical help may simply be late. To protect yourself from the consequences of hypoglycemia, each patient with diabetes should clearly understand the mechanism of development of this complication, be able to determine the decrease in sugar by the first signs, and know how to stop hypoglycemia of varying severity.

Due to the fact that this condition quickly leads to clouding of consciousness and fainting, it will not be superfluous to teach the rules of emergency care to your relatives and colleagues.

Hypoglycemia - what is it

Hypoglycemia is considered any decrease in blood sugar to or below 3.3 mmol/l as measured by a portable glucometer, regardless of its cause and the presence or absence of symptoms. For venous blood, a decrease to 3.5 is considered dangerous.

Healthy people do not even think about what complex processes are taking place in their body after a regular breakfast. The digestive organs process the incoming carbohydrates, saturate the blood with sugar. The pancreas in response to an increase in glucose levels produces the right amount of insulin. The latter, in turn, signals the tissues that it is time to eat, and helps sugar get inside the cell. Several chemical reactions take place in the cell, as a result of which glucose breaks down into carbon dioxide and water, and the body receives the energy it needs. If a person goes to training, the muscles will need more sugar, the missing one will lend the liver. During the next meal, glucose stores in the liver and muscles will be restored.

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In diabetes mellitus, patients are forced to manually regulate the process of glucose uptake by controlling its intake with food and stimulating its uptake by cells with the help of hypoglycemic drugs and insulin. Naturally, the artificial maintenance of blood glucose cannot be without errors. Once the sugar in the blood is more than expected, it begins to destroy the vessels and nerves of the patient, it arises. Sometimes there is not enough glucose, and hypoglycemia develops.

The task of a diabetic patient is to ensure that these fluctuations are minimal, to eliminate deviations of blood sugar from normal levels in time. Diabetes without sudden spikes in sugar is called compensated. Only long-term diabetes compensation guarantees an active and long life.

Causes of hypoglycemia

The causes of hypoglycemia are quite varied. They include not only a lack of nutrition or an overdose of drugs in diabetes mellitus, but also a drop in glucose levels due to physiological reasons and due to the pathology of various organs.

Causes of hypoglycemia		a brief description of
Physiological
carbohydrate starvation	In healthy people, the absence of food turns on compensatory mechanisms; glucose from the liver enters the bloodstream. Hypoglycemia develops gradually, a strong decrease in sugar is a rarity. In type 2 diabetes, glycogen stores are insignificant, as the patient adheres to. Hypoglycemia develops faster.
Physical exercise	Long-term muscle work requires an increased amount of glucose. After the depletion of reserves in the liver and muscles, its level in the blood also decreases.
Stress	Nervous tension activates the work of the endocrine system, insulin production increases. It is the lack of glucose that explains the desire to "seize" the problem. Such hypoglycemia can be dangerous in type 2 diabetes with a high preservation of pancreatic function.
Reactive hypoglycemia due to a single dose of a large amount	The pancreas responds to the rapid rise in sugar by releasing a portion of insulin with a margin. As a result, blood glucose decreases, the body requires new carbohydrates to eliminate hypoglycemia, and a feeling of hunger arises.
Transient hypoglycemia	It is observed in newborns with a small supply of glycogen. The reasons are prematurity, diabetes mellitus in the mother, difficult childbirth with large blood loss in the mother or hypoxia in the fetus. After the start of nutrition, glucose levels return to normal. In difficult cases, transistor hypoglycemia is eliminated by intravenous administration of glucose.
False hypoglycemia	It develops if, in diabetes, blood sugar drops sharply to values ​​close to normal. Despite the same symptoms as true hypoglycemia, this condition is not dangerous.
Pathological
Exhaustion or dehydration	When glycogen drops to a critical level, even in healthy people, severe hypoglycemia occurs.
Liver disease	Violation of liver function leads to impaired access to the glycogen depot or its depletion.
Diseases of the endocrine system	Hypoglycemia leads to a lack of hormones involved in glucose metabolism: adrenaline, somatropin, cortisol.
Digestive disorders	Insufficient absorption of carbohydrates due to diseases of the gastrointestinal tract.
Lack or defect of enzymes	The chemical processes of sugar breakdown are disturbed, the lack of cell nutrition is compensated by lowering blood glucose.
kidney failure	The reabsorption of sugar is weakened, as a result of which it is excreted from the body in the urine.
Alcoholic hypoglycemia	When intoxicated, all the forces of the liver are aimed at eliminating intoxication, glucose synthesis is inhibited. Especially dangerous without snacks or on a low-carbohydrate diet.
	A pancreatic tumor that produces large amounts of insulin.

In diabetes, hypoglycemia can also lead to errors in treatment:

1. An overdose of insulin or sugar-lowering drugs.
2. After taking medication, a diabetic patient forgets to eat.
3. Malfunction of the glucometer or insulin delivery devices.
4. Incorrect calculation of the dose of drugs by the attending physician or a patient with diabetes -.
5. Incorrect injection technique -.
6. Replacing low-quality insulin with fresh, with better action. Change from short insulin to ultrashort insulin without dosage adjustment.

What signs are observed

The severity of symptoms increases as blood sugar falls. Mild hypoglycemia requires treatment within half an hour after the onset, otherwise the decrease in glucose progresses. Most often, the signs are quite obvious and easily recognized by patients. With frequent hypoglycemia, constantly low sugar levels, in the elderly and with a significant history of diabetes, the symptoms can be erased. These patients are the most likely.

Stage of hypoglycemia	Sugar indicators, mol/l	The possibility of cupping	Symptoms
Light	2,7 < GLU < 3,3	Easily eliminated by diabetic patients on their own	Paleness of the skin, internal trembling and tremor of the fingertips, a strong desire to eat, causeless anxiety, nausea, fatigue.
Medium	2 < GLU < 2,6	Requires the help of others	Headache, uncoordinated movements, numbness of the extremities, dilated pupils, incoherent speech, amnesia, convulsions, dizziness, inadequate reactions to what is happening, fear, aggression.
heavy	GLU< 2	Immediate medical attention needed	Hypertension, impaired consciousness, fainting, respiratory and cardiac disorders, coma.

Hypoglycemia during sleep can be recognized by clammy, cold skin, rapid breathing. A diabetic patient wakes up from a disturbing sleep, after waking up feels tired.

How to provide first aid

As soon as a diabetic feels any symptoms that can be attributed to the consequences of hypoglycemia, he immediately needs to measure his blood sugar. To do this, always have a glucometer with strips with you. First aid for hypoglycemia is the oral intake of fast carbohydrates. For a slight rise in sugar, this is enough to completely normalize the patient's condition.

Low sugar before meals is not a reason to delay treating hypoglycemia in the hope that carbohydrates will eliminate it from food. The diabetic diet severely restricts easily digestible sugars, so hypoglycemia can worsen even before the food is digested.

The relief of hypoglycemia at the beginning of development is carried out with the help of glucose tablets. They act faster than other drugs, since absorption into the blood during their use begins in the oral cavity, and then continues in the gastrointestinal tract. In addition, the use of tablets makes it easy to calculate the dose of glucose that will eliminate hypoglycemia, but will not lead to hyperglycemia.

On average, in a person with diabetes weighing 64 kg, 1 g of glucose provokes an increase in blood sugar by 0.28 mmol / l. If your weight is greater, you can calculate the approximate effect of a glucose tablet on sugar indicators using the inverse proportion.

With a weight of 90 kg, an increase of 64 * 0.28 / 90 \u003d 0.2 mmol / l will occur. For example, sugar dropped to 3 mmol/L. To raise it to 5, (5-3) / 0.2 \u003d 10 g of glucose, or 20 tablets of 500 mg, will be required.

These pills are inexpensive, sold in every pharmacy. With diabetes, it is advisable to buy several packs at once, put them at home, at work, in all bags and pockets of outerwear. To eliminate hypoglycemia, glucose tablets should always be with you.

In extreme cases, quickly raise sugar can:

• 120 g of sweet juice;
• a couple of sweets or pieces of chocolate;
• 2-3 cubes or the same number of tablespoons of refined sugar;
• 2 tsp honey;
• 1 banana;
• 6 dates.

Signs of hypoglycemia in diabetes can be observed within an hour after the normalization of sugar. They are not dangerous and do not require additional intake of sweets.

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How can hypoglycemia be treated and managed?

If a patient with diabetes has already begun starvation of the brain, he is not able to help himself on his own. Difficult treatment is a violation of the ability to chew food, so glucose will have to be given in liquid form: either a special drug from a pharmacy, or sugar or honey dissolved in water. If there is a tendency to improve the condition, an additional 15 g of complex carbohydrates should be given to the patient. It can be bread, porridge, cookies.

When a diabetic patient begins to lose consciousness, oral glucose should not be given to him because of the threat of asphyxia. In this case, the treatment of hypoglycemia is carried out with the help of intramuscular or subcutaneous injection of glucagon. This drug is sold in pharmacies in the form of emergency kits for diabetes. The kit includes a plastic case, a solvent syringe and a vial of glucagon powder. The cap of the bottle is pierced with a needle, the liquid is squeezed into it. Without removing the needle, the vial is shaken well, and the drug is drawn back into the syringe.

Glucagon stimulates the rise in sugar, causing the liver and muscles to give up the remaining glycogen. Within 5 minutes after the injection, consciousness should return to the patient. If this does not happen, the patient's glucose depot is already depleted and repeated injection will not help. You need to call an ambulance, which will inject glucose intravenously.

If the diabetic is better, after 20 minutes he will be able to answer questions, and after an hour almost all symptoms will disappear. During the day after the introduction of glucagon, blood sugar should be given increased attention, every 2 hours use a glucometer. A second drop in performance at this time can be rapid and deadly.

What to do when a diabetic passes out:

1. If you have a glucometer, measure your sugar.
2. At a low level, try to pour a sweet liquid into his mouth, making sure that the patient swallows.
3. If there is no glucometer, one should proceed from the fact that giving carbohydrates to a diabetic is less dangerous than not giving.
4. If swallowing is disturbed, inject glucagon.
5. Lay the patient on his side, as he may vomit.
6. If the condition does not improve, call an ambulance.

What is the danger

In the absence of help, a hypoglycemic coma occurs, due to a lack of nutrition, brain cells begin to die. If resuscitation is not started by this time, the consequences of severe hypoglycemia are fatal.

What is the danger of mild hypoglycemia:

• Frequent episodes blur the symptoms, making it easy to miss a major drop in blood sugar.
• Regular malnutrition of the brain affects the ability to remember, analyze, and think logically.
• The risk of ischemia and myocardial infarction increases.
• Occurs limbs and retina.

Each case of hypoglycemia must be carefully analyzed, identified and eliminated its cause. Due to amnesia, this is not always possible, so it is imperative to keep a diary with diabetes. It shows fluctuations in blood sugar during the day, the amount of carbohydrates consumed and drugs received, unusual physical activity, cases of alcohol consumption and exacerbation of concomitant diseases are recorded.

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Glucose is the main source of energy for the human body. In the required amount it is found in food. In the absence of dietary intake, glucose is formed from the natural reserves of internal glycogen located in the liver cells. This compound is synthesized from excess glucose with the help of insulin. If necessary, the reverse process is “turned on”. Insulin, in turn, is a waste product of the beta cells of the islets of Langerhans of the pancreas. Therefore, in some diseases associated with this organ (), the metabolism of carbohydrates, in particular sugar, is disturbed.

Causes of low blood sugar

In some human problems and diseases, the amount of glucose in the blood progressively decreases. This phenomenon is called - hypoglycemia. It can lead to serious health problems.

note

The blood of a healthy person contains from 3.5 to 5.5 mmol / l of glucose.

The causes of low sugar concentration can be physiological and pathological.

As a result of a number of diseases, constant or intermittent hypoglycemia can occur.

The most common pathological causes of low blood sugar:

Levels of low blood sugar

Hypoglycemia happens:

1. mild degree . With this variant of the pathology, the sugar level becomes below 3.8 mmol/l. And although the lower limit of the norm is 3.5 mmol / l, all the same, for patients prone to this condition, doctors try to take preventive therapeutic measures. Particular alertness is caused by complaints of weakness, emotional imbalance, chills, numbness of the skin, slight shortness of breath.
2. Intermediate degree. In this case, glucose is reduced up to the level of 2.2 mmol/l. The patient develops severe anxiety, fear, anxiety. The problem of visual perception (“dots and flies”) joins these phenomena, everything is seen “as if in a fog”.
3. Severe degree . The amount of sugar below 2.2 mmol/l. In the body of a person suffering from this disorder, convulsions, fainting, epileptiform seizures may develop. If help is not provided, the patient falls into a coma. Body temperature drops, heart and respiratory rhythm disturbances are recorded. This condition requires emergency care.

note

Of particular danger is a sharp decrease in blood sugar at night. The patient can wake up when he becomes very ill and can no longer do without the intervention of medicine.

A night attack can be suspected if there were nightmares. During awakening, the patient notices that underwear and bed linen are soaked through with sweat. The general condition is characterized by severe weakness.

Symptoms of a sudden drop in blood sugar (hypoglycemic coma)

Regardless of the cause that led to hypoglycemia, patients experience:

• Progressive weakness throughout the body.
• Pronounced feeling of hunger.
• , accompanied by .
• A sharp increase in heart rate;
• Severe sweating;
• Small trembling in the body with chilliness;
• Increased sensitivity to sounds and light;
• "Darkness in the eyes", loss of color vision.
• confusion;
• Nervousness, anxiety, fears;
• Gradual development of drowsiness,.

note

Sometimes a coma is manifested by paradoxical complaints - agitation, loud laughter, conversation, convulsions that mimic epilepsy. (hysteroid type).

On examination, attention is drawn to itself - pronounced pallor, skin moisture, increased tendon reflexes.

People with diabetes and those familiar with the manifestation of hypoglycemic coma will quickly recognize this problem themselves. In most cases, they manage to take measures to prevent the further development of this disease.

Features of hypoglycemia in children

Complaints that manifest themselves in children and adolescents with disorders associated with changes in blood sugar are similar to those experienced by adult patients. In childhood, this painful process has the same roots as in adults, it develops much faster. Therefore, help cannot be delayed. A dangerous sign can be considered the appearance, which is clearly felt in the room where the child is.

A prolonged decrease in sugar leads to developmental disorders in children, forms mental and physical retardation.

Features of the diagnosis of hypoglycemia in newborns:

Features of hypoglycemia in pregnant women

When diagnosing this condition in women preparing for motherhood, it should be noted that complaints and manifestations may develop with higher analysis numbers. This is due to the body's increased need for carbohydrates.

Emergency care and treatment of cases of low blood sugar

An acute hypoglycemic state develops suddenly, if no assistance is provided, it can go into a coma. Therefore, a person who is familiar with this problem tries to take measures at the first sign to stop the process. Most often, patients with diabetes mellitus experience hypoglycemia. Therefore, they always have a “first aid” with them - a candy, a piece of sugar, a cookie. With the manifestations of this disease, the patient immediately eats them, drinks sweet tea, eats a cake, any carbohydrate product.

note

With this kind of self-treatment, a reasonable measure should be observed so as not to cause additional harm to yourself. Doses of carbohydrates should not exceed the required dose.

• sugar - 5-10 g (1-2 teaspoons);
• sweets (1-2) caramel is better, chocolate is also allowed;
• honey - 1 tablespoon;
• sweet compote, jelly, lemonade, lemonade, juice - 200 ml.

If these measures did not give the desired effect, and hypoglycemic syndrome developed, then it is necessary to call an ambulance.

The situation can be alleviated by the following measures:

An ambulance prescribes a concentrated solution of glucose intravenously to the injured person and transports it to the hospital. If the patient does not get better from the received treatment, then an adrenaline solution is injected under the skin. In severe coma, corticosteroids are prescribed.

Diet for hypoglycemia

Compliance with the rules of nutrition in patients with a tendency to develop this condition is very important.

In the event of a hypoglycemic episode, the patient is recommended:

• In the acute period- cereals, omelettes, vegetable salads, juices from fresh fruits and vegetables, boiled sea fish, green tea.
• With gradual normalization conditions, river fish, boiled and stewed meat, berries can be introduced into the diet.
• During the period of remission cheeses, chicken eggs should be added to food (up to 2 pieces per week). The amount of necessary carbohydrates, sugars, flour should be agreed with the doctor.

Preventive actions

All patients with a tendency to hypoglycemia are recommended to follow a diet consisting of a list of necessary products that should be taken in a fractional method as directed by a nutritionist. Physical activity in terms of energy consumption must necessarily correspond to the amount of carbohydrates consumed.

Blood sugar should be measured as often as possible. You must have first aid supplies with you in case of hypoglycemia.

With an increase in attacks of high blood sugar, you should undergo an additional examination and adjust the diet and treatment. Additional use of insulin is possible.

Lotin Alexander, doctor, medical commentator

Many people complain of nausea, constant fatigue, headache. After passing the examination, it is quite possible to find out about the presence of such a condition as hypoglycemia. Most often it accompanies patients with diabetes mellitus. However, healthy people can also experience this unpleasant phenomenon.

What is hypoglycemia

This medical term implies a decrease in glucose levels below the norm, which is necessary for the normal functioning of the whole organism as a whole and brain activity in particular. The incidence of hypoglycemia has increased in recent years due to different diets and malnutrition.

Hypoglycemia: causes

This condition usually develops due to excessive production of insulin. As a result, the normal process of converting carbohydrates into glucose is disrupted. The most common cause is, of course, diabetes. But other reasons also take place in medical practice. Let's take a closer look at what other conditions can lead to hypoglycemia.

• The presence of neoplasms in the gastrointestinal tract.
• Taking a number of medications (salicylates, sulfur preparations, quinine, drugs for the treatment of diabetes).
• Alcohol abuse. A very dangerous form of hypoglycemia, may be accompanied by stupor and complete clouding of the mind.
• Excessive physical activity.
• Improper nutrition with a predominance of a large amount of carbohydrates in the diet.
• Severe infectious diseases (which you need to pass).
• Heart failure.
• Renal failure.
• Prolonged fasting.
• Violation of the functioning of the liver, cirrhosis, improper production of enzymes.
• Improper metabolism (see also -).
• Pathological processes in the adrenal glands.
• Insufficient amount of water ().
• Idiopathic hypoglycemia resulting from a congenital defect in insulinase at the gene level.
• Decreased thyroid function.
• Severe circulatory failure.
• Insufficient synthesis of alanine.

The development of hypoglycemia (video)

This video discusses the mechanism of hypoglycemia and the main reasons why this condition occurs.

Symptoms and signs of hypoglycemia

The peculiarity of the clinical symptoms of hypoglycemia is that it may differ in different patients. However, there are some common symptoms that may be present regardless of gender and age of patients. They need to pay close attention, as they greatly simplify the diagnosis of the disease.

• Strong.
• Strong.
• Pale skin, sometimes with cyanosis (blue).
• Increased sweating.
• Chill feeling.
• Impaired coordination of movements.
• The patient is constantly hungry.
• , decreased concentration.
• Drowsiness (see also -).
• With the progression of the disease - loss of consciousness, coma, death.

Low blood sugar, what to do? (video)

In this video, an endocrinologist talks about what symptoms may accompany a hypoglycemic state, and what should be done in such a situation.

Complications and consequences of hypoglycemia, hypoglycemic syndrome

Of course, the state of hypoglycemia is very dangerous and can lead to serious complications, including death. Even regular fluctuations in blood sugar levels threaten a person with health problems.

If treatment is not started on time, then constant jumps in sugar levels will lead to the destruction of small peripheral vessels. This, in turn, leads to the development of angiopathy and blindness.

The greatest danger to the human brain is transient hypoglycemia. Our brain is not able to do without the amount of sugar it needs for a long time. He needs energy in large quantities. Therefore, with an acute shortage of glucose, he will immediately begin to give signals and demand food.

A drop in glucose below a certain level (about 2 mmol / l) contributes to the development hypoglycemic coma. In the absence of urgent resuscitation, mass death of brain cells occurs. With hypoglycemia, there is a weakening of brain functions, which is fertile ground for the development of strokes, amnesia, and various disorders of internal organs.

Hypoglycemic syndrome- a concept that combines several symptoms of a mental, nervous and vegetative nature. It usually forms when blood glucose falls below 3.5 mmol/L. It can develop both on an empty stomach and after a meal.

Hypoglycemia in children

The reasons:

• Lack of a balanced diet.
• Stress (see also -).
• Excessive physical activity.
• Availability .
• Diseases of the nervous system.
• Congenital intolerance to leucine.
• Elevated levels of ketone bodies in the blood.

Signs of hypoglycemia in children will be: the smell of acetone from the mouth, pale skin, lack of appetite, vomiting. Repeated vomiting can lead to dehydration, loss of consciousness, elevated body temperature. In some cases, it will be advisable to use glucose droppers and treatment in a hospital under the supervision of doctors.

If the decrease in glucose in a child is not associated with internal diseases, then when the first symptoms appear, you need to give him something sweet (a piece of sugar, a spoonful of honey).

After the sugar is reduced, it is necessary to establish the right diet with plenty of vegetables, fruits, seafood. It is better to eat little and often, so as not to burden the internal organs.

In the presence of leucine hypoglycemia, which is congenital and characterized by impaired metabolic processes, a more serious approach to therapy is required. In this case, the doctor selects the diet, since a specific correction in the consumption of protein foods is necessary here (exclusion of eggs, fish, nuts and other products).

The state of hypoglycemia has an extremely negative impact on the development of the child. Moreover, it is life-threatening due to severe metabolic disorders.

Treatment of hypoglycemia, hypoglycemic drugs

Therapy of this pathology at the initial stage implies a sufficient intake of carbohydrate-containing food by the patient.

The second stage requires the immediate consumption of easily digestible carbohydrates (sweet tea, compote, jam). Such products prevent the further development of hypoglycemia and normalize the patient's condition.

Urgent care is required in the third stage. Intravenous administration of 40% glucose solution is recommended to prevent cerebral edema. Hospitalization is already shown here to prevent possible complications and corrective therapy aimed at lowering sugar.

All hypoglycemic drugs have a similar mechanism of action. They are divided into several groups:

• Sulfonylurea derivatives ("Glibenclamide", "Gliquidone"). This is the most popular group of funds used.
• Meglitinides (Repaglinide).
• Thiazolidinediones ("Rosiglitazone", "Troglitazone").
• Biguanides ("Glucophage", "Siofor").
• Alpha-glucosidase inhibitors (Miglitol, Acarbose).

When choosing a drug for a particular patient, it is necessary to take into account the individual characteristics of the patient and the possible side effects of medications. In addition, it is important to correctly calculate the desired dosage.

Hypoglycemic coma always treated in the intensive care unit. As a rule, jet administration of glucose intravenously and injection of glucagon intramuscularly are used. In some cases, the introduction of adrenaline is indicated in order to increase the effectiveness of therapy.

If none of the above measures has brought results, intravenous or intramuscular administration of hydrocortisone is prescribed. This usually results in stabilization of the patient's condition.

In order to prevent cerebral edema, magnesium sulfate can be administered intravenously.

A good effect in the treatment of hypoglycemic conditions has shown in medical practice oxygen therapy.

After the patient is taken out of a coma, he must be prescribed medications to improve microcirculation processes (Cavinton, Cerebrolysin, glutamic acid).

Diet for hypoglycemia

In the diet, it is important to eat regularly to prevent hunger.

As for the diet, you need to limit yourself to simple carbohydrates in the form of confectionery, wheat flour, honey, sweet fruits and vegetables.

Of course, at first it will be difficult to follow this diet, because the body is used to sweets. But you need to be patient a little, and in a couple of weeks this craving will disappear. Preference should be given to complex carbohydrates and proteins.

6. HYPOGLYCEMIA

1. Define hypoglycemia.
The state of hypoglycemia was defined by the Third International Symposium on Hypoglycemia as the amount of glucose in the blood below 2.8 mmol/L (50.4 mg/dL).

2. What are the important clinical signs considered in the diagnosis of hypoglycemia?
Early onset of fasting or postprandial symptoms helps to make a differential diagnosis despite a variety of etiologies. Serious, life-threatening conditions are classified as fasting hypoglycemic disorders. Less serious and often diet-corrected conditions occur after meals (reactive hypoglycemia). Often, the symptoms associated with fasting hypoglycemia are those of neuroglycopenia, which is accompanied by an altered mental state or neuropsychiatric manifestations. Postprandial disorders (reactive hypoglycemia) are associated with a rapid decrease in plasma glucose, as occurs with an insulin response. The symptoms observed in this case are due to a catechol-myiomediated reaction and manifest themselves in the form of increased sweating, palpitations, feelings of anxiety, fear, headache, "veil before the eyes" and, occasionally, progression to neuroglycopenia and confusion. Although this distinction is important for clinical classification, some patients may present with mixed symptoms.

3. What are the causes of fasting hypoglycemia?

Diseases of the pancreas
Hyperfunction (3-cells of the islets of Langerhans (adenoma, carcinoma, hyperplasia). Hypofunction or insufficiency of a-cells of the islets.

Liver disease
Severe liver disease (cirrhosis, hepatitis, carcinomatosis, circulatory failure, ascending infectious cholangitis).

Fermentopathies(glycogens, galactosemia, hereditary fructose intolerance, familial intolerance to galactose and fructose, fructose-1-6-diphosphatase deficiency).

Pituitary-adrenal disorders(hypopituitarism, Addison's disease, adrenogenital syndrome).

Diseases of the central nervous system(hypothalamus or brain stem).
muscles(hypoalaninemia?).
Neoplasms not related to the pancreas Mesodermal tumors (spindle cell fibrosarcoma, leiomyosarcoma, mesothelioma, rhabdomyosarcoma, liposarcoma, neurofibroma, reticulocellular sarcoma). Adenocarcinoma (hepatoma, cholangiocarcinoma, gastric carcinoma, adrenocorticocarcinoma, caecum carcinoma).

Unclassified
Excessive loss or utilization of glucose and/or inadequate substrate (prolonged or strenuous exercise, fever accompanied by diarrhea, chronic fasting). Ketotic hypoglycemia in childhood (idiopathic hypoglycemia of childhood).

Exogenous causes
Iatrogenic (associated with treatment with insulin or oral sugar-lowering drugs).
Unnatural (observed, as a rule, among nursing staff). Pharmacological (Ackee nut, salicylates, antihistamines, monoamine oxidase inhibitors, propranolol, phenylbutazone, pentamidine, phenotolamine, alcohol, angiotensin-converting enzyme inhibitors).

4. What are the causes of postprandial hypoglycemia or reactive hypoglycemia?

Reactive to refined carbohydrates (glucose, sucrose)
reactive hypoglycemia.
Alimentary hypoglycemia (includes patients with previous surgical intervention on the gastrointestinal tract, peptic ulcer, gastrointestinal motility disorder syndromes and functional diseases of the gastrointestinal tract).

Early type II diabetes mellitus.
Hormonal (includes hyperthyroidism and cortisol deficiency syndromes,
adrenaline, glucagon, thyroid hormone and growth hormone).
Idiopathic.

Other states.
Insufficient early gluconeogenesis in the liver (fructose-1-6-di-phosphatase deficiency).

Drugs (alcohol [gin and tonic], lithium).

insulinoma.

Insulin or autoantibodies to insulin receptors.

Reactive to another substrate (fructose, leucine, galactose).

5. What are the artifactual causes of hypoglycemia?
Pseudohypoglycemia occurs in some chronic leukemias, when the number of leukocytes is markedly increased. This artifactual hypoglycemia reflects the utilization of glucose by leukocytes after a blood sample has been taken. This hypoglycemic state is therefore not associated with symptoms of diabetes. Other artefact hypoglycaemias may occur when samples are not taken or stored correctly, errors in assay procedure, or confusion between plasma and whole blood glucose concentrations. The content of glucose in plasma is about 15% higher than in whole blood.

6. When hypoglycemia occurs, what reverse regulation occurs to conserve glucose for brain metabolism?
Glucagon and adrenaline are the main hormones of reverse regulation. Other hormones that respond to hypoglycemic stress are norepinephrine, cortisol, and growth hormone, but their action is delayed.
The metabolic effects of glucagon and adrenaline are immediate: stimulation of hepatic glycogenolysis and, later, gluconeogenesis results in increased hepatic glucose production. Glucagon appears to be the most important downregulated hormone during acute hypoglycemia. If the secretion of glucagon is not disturbed, then the symptoms of hypoglycemia are eliminated quickly. If glucagon secretion is reduced or absent, then catecholamines are the main reverse-regulated hormones with an immediate effect.

7. What laboratory tests are helpful in assessing fasting hypoglycemia?
Initially, the simultaneous determination of fasting blood glucose and insulin levels is useful. Hypoglycemia with inappropriate hyperinsulinemia suggests the presence of conditions of functionally independent insulin secretion, which are possible in patients with insulinoma (carcinoma and hyperplasia) or with artificial use of insulin or hypoglycemic agents. When hypoglycemia is associated with correspondingly lower insulin values, non-insulin-mediated causes of fasting hypoglycemia should be investigated.

8. What laboratory tests help in the examination of patients with suspected insulinoma?
In patients with insulinomas, impaired insulin secretion eventually leads to excess insulin despite the presence of hypoglycemia. During symptomatic hypoglycemia, patients have high insulin activity and an increased insulin-to-glucose ratio. This hormonal profile can also be observed in patients who take oral sulfonylurea; Screening of medications taken helps to separate these two nosological forms. The ratio of insulin to fasting plasma glucose is normally less than 0.33. Normally, immunoreactive proinsulin accounts for less than 10-20% of total fasting insulin immunoreactivity; the ratio increases in patients with insulinoma, but this was not observed in patients with an overdose of oral sulfonylurea.

9. What tests help differentiate insulin-related events from insulinoma?
In addition to the above laboratory tests for diagnosing insulinoma, measuring the C-peptide level during an episode of hypoglycemia helps to distinguish between these two conditions. Patients with insulinoma have evidence of excessive secretion of insulin, in the form of a high content of insulin, proinsulin and C-peptide against the background of hypoglycemia. In patients who inject themselves with insulin on their own, on the contrary, the function of endogenous insular (3-cells) is inhibited, and the content of C-peptide decreases with hypoglycemia, while insulin values ​​are elevated. / ml It should be noted that in patients who inattentively or without a doctor's prescription take sulfonylurea by mouth, laboratory results are similar to those in patients with insulinoma, for example, an increased content of C-peptide; however, their proinsulin level is normal.

10. If the suspicion of insulinoma is significant, and the results of the examination are not convincing, what additional studies can still be performed?
Stimulation and inhibition tests are useless, and the results obtained are often misleading. An extended 72-hour fast with measurements of glucose and insulin every 6 hours will help detect latent hypoglycemia in most patients with insulinoma. Hypoglycemia usually occurs within 24 hours of fasting. It is important to take blood samples when the patient has symptoms of hypoglycemia. If the patient's status is asymptomatic after 72 hours, then the patient must exercise to induce the hypoglycemia seen in patients with insulinoma.

11. What conditions cause (3-cell hyperinsulinemia?
In 75-85% of cases, the main cause of insulinoma is an adenoma of the islet tissue of the pancreas. In about 10% of cases, multiple adenomas (adenomatosis) are noted. In 5-6% of cases, insular cell hyperplasia is detected.

12. If other family members had pancreatic tumors, what conditions should be assumed?
Multiple endocrine neoplasia (MEN-1) occurs as an autosomal dominant tumor in family members with functioning and non-functioning pituitary tumors, parathyroid adenomas, or islet cell hyperplasia and tumors, any of which may include insulinoma and gastrinoma (Zollinger-Ellison syndrome). Such pancreatic tumors can secrete many other polypeptides, including glucagon, pancreatic polypeptide, somatostatin, ACTH, melanocyte stimulating hormone (MSH), serotonin, or growth hormone releasing factor. If MEN-1 is suspected, many family members should be evaluated for components of tumor-related polyglandular disorders.

13. What is nesidioblastosis?
Nesidioblastosis is a type of insular cell hyperplasia in which primary pancreatic ductal cells leave undifferentiated islet cells capable of polyhormonal secretion (gastrin, pancreatic polypeptide, insulin, and glucagon). This disease is the leading cause of hyperinsulinemic hypoglycemia in neonates and infants, but can also cause hypoglycemia in adolescents and adults.

14. When the diagnosis of pancreatic islet cell hyperinsulinemia is established, what methods can help determine the location of the tumor?
Methods such as ultrasound diagnostics, abdominal angiography, aortography and computed tomographic scanning of the abdominal cavity are often uninformative and reveal localization of about 60% of insulin. Some insulinomas are extremely small (less than a few millimeters) and easily elude detection. Endoscopic ultrasonography may be helpful. Transhepatic, percutaneous venous blood sampling can aid in the localization of occult tumors and in differentiating an isolated solitary insulinoma from a diffuse lesion (adenomatosis, hyperplasia, or nesidioblastosis). Ultrasound is most useful during surgery to locate these pancreatic tumors.

15. If surgical resection is not possible, or if the patient has metastatic or inoperable carcinoma, adenomatosis, hyperplasia, or nesidioblastosis, then what drugs can stop hypoglycemia?
The most commonly used in this situation is diazoxide, a long-acting somatostatin analog, or streptozocin. The basis of medical care is a diet with frequent meals and snacks. Adjuvant therapy with other drugs is generally ineffective, but may be tried in difficult cases. Possible drugs of choice include calcium channel blockers, propranolol, phenytoin, glucocorticoids, glucagon, and chlorpromazine. Other cancer chemotherapy drugs include mithramycin, adriamycin, fluoro-racil, carmustine, mitomycin-C, L-asparaginase, doxorubicin, or chlorozotocin.

16. What are the causes of childhood hypoglycemia?
The frequency of cases of hypoinsulinemic hypoglycemia in newborns and young children suggests hereditary disorders of interstitial metabolism, such as glycogenosis, disorders of gluconeogenesis (deficiency of fructose-1-6-diphosphatase, pyruvate carboxylase and phosphoenolpyruvate carboxykinase), galactosemia, hereditary fructose intolerance, maple syrup disease ", carnitine deficiency and ketotic hypoglycemia. Hormonal deficiency (glucagon, growth hormone, thyroid and adrenal hormones) can also cause hypoglycemia. Moreover, children are very sensitive to accidental drug overdose, especially salicylates and alcohol. As previously mentioned, children with hyperinsulinemic hypoglycemia may have nesidioblastosis or diffuse insular cell hyperplasia.

17. What are the most common drugs that can cause hypoglycemia in adults?
In adults, the most common causes of drug-induced hypoglycemia include antidiabetic (oral) sulfonylurea drugs, insulin, ethanol, propranolol, and pentamidine. A complete list of drugs associated with hypoglycemia in 1418 cases is provided by Zeltzer.

18. How does alcohol cause hypoglycemia?
Ethanol can cause hypoglycemia in normal, healthy volunteers after a short 36-72 hour fast. Insignificant intakes of alcohol inside (about 100 g) can work. Alcohol causes hypoglycemia when it is associated with poor food intake or fasting, which reduces liver glycogen stores. Alcohol induces hypoglycemia in these situations by disrupting the metabolic pathway of glucopeogenesis through changes in the cytosolic NAD H2/H BP ratio. In addition to intracellular processes, ethanol also inhibits hepatic uptake of lactate, alanine, and glycerol, all of which typically promote hepatic glyconeogenic glucose production. Ethanol also dramatically reduces the amount of alanine in the blood by inhibiting its influx from the muscles.

19. Sometimes hypoglycemia is not caused by insulomas. What tumors are implied and what is the mechanism of hypoglycemia?
Various mesenchymal tumors (mesothelioma, fibrosarcoma, rhabdomyosarcoma, leiomyosarcoma, liposarcoma, and hemangiopericytoma) and organ-specific carcinomas (hepatic, adrenocortical, urogenital, and breast) can be associated with hypoglycemia. Hypoglycemia may accompany pheochromocytoma, carcinoid, and malignant blood diseases (leukemia, lymphoma, and myeloma). The mechanism varies according to the type of tumour, but in many cases hypoglycemia is associated with malnutrition due to the tumour, and weight loss due to fat, muscle and tissue wasting that impairs gluconeogenesis in the liver. In some cases, glucose utilization by exceptionally large tumors can lead to hypoglycemia. Tumors can also secrete hypoglycemic factors such as unsuppressed insulin-like activity and insulin-like growth factors, most prominently insulin-like growth factor-P (IGF-II). By binding to hepatic insulin receptors, IGF-II inhibits hepatic glucose production and promotes hypoglycemia. Tumor cytokines are also under suspicion, especially tumor necrosis factor (cachectin). Very rarely, the tumor secretes extrahepatic insulin.

20. What autoimmune syndromes can be associated with hypoglycemia?
Autoantibodies directed against insulin or its receptors can provoke the development of hypoglycemia. Insulin mimetic antibodies to insulin receptors bind the receptors and mimic the action of insulin by increasing the utilization of absorbed glucose in the affected tissue. Autoantibodies that bind insulin can undergo untimely dissociation, usually within a short period immediately after a meal, and dramatically increase serum free insulin concentrations, thus causing hypoglycemia. This autoimmune insulin syndrome occurs most frequently in Japanese patients and is often associated with other autoimmune diseases such as Graves' disease, rheumatoid arthritis, systemic lupus erythematosus, and type I diabetes mellitus.

21. When is hypoglycemia associated with another pathology?
Often, patients have multiple mechanisms for developing hypoglycemia, including renal failure, liver disease, drug therapy, and malnutrition. Liver failure leads to hypoglycemia due to the role of the liver in gluconeogenesis. Hypoglycemia in congestive heart failure, sepsis, and lactic acidosis is also associated with hepatic mechanisms. Hypoglycemia occurs, although not often, in adrenal insufficiency. Fasting conditions such as anorexia nervosa and insufficient protein intake also cause hypoglycemia.

22. What endocrine conditions are associated with hypoglycemia?
In addition to disorders of the islet cell tissue, hypoglycemia can occur with insufficiency of the anterior pituitary gland, in which the secretion of growth hormone, ACTH and thyroid-stimulating hormone is insufficient. In addition, primary adrenal insufficiency and primary hypothyroidism may be associated with reactive or fasting hypoglycemia.

23. When is hypoglycemia associated with renal failure?
The clinical picture of renal failure includes malnutrition with anorexia, vomiting, and poor absorption of dietary food. A decrease in renal mass may be a predisposing condition for hypoglycemia, since the kidney is involved in approximately 1/3 of all gluconeogenesis during hypoglycemic stress. Renal failure leads to changes in drug metabolism, which may contribute to the development of hypoglycemia. Liver failure may coexist with advanced renal failure. Sepsis in patients with renal insufficiency further contributes to hypoglycemia. In some cases, dialysis has been associated with hypoglycemia, as the kidney is an important site for extrahepatic insulin breakdown. With the loss of kidney mass in patients with diabetes, it is necessary to reduce the dose of insulin.

24. What conditions cause reactive hypoglycemia?
In the vast majority of patients, it is idiopathic in nature, since they have not had a concomitant disease of the gastrointestinal tract (alimentary reactive hypoglycemia), hormonal insufficiency, or diabetic reactive hypoglycemia. In most patients with idiopathic reactive hypoglycemia, there is a delayed release of insulin (disinsulinism), which is inadequate in time and is combined with a drop in plasma glucose; some of them noted hyperinsulinemia after eating. Sometimes a patient with insulinoma may have hypoglycemia, which seems reactive, as it develops after a meal. In patients with insulin autoantibodies, insulin-antibody dissociation may occur after meals. Reactive hypoglycemia has been noted in patients who drink a cocktail - gin and tonic - and in some patients taking lithium as prescribed by a doctor.

25. What conditions should be taken into account in a patient who has diagnosed himself with reactive hypoglycemia?
Most patients who complain of seizures after meals do not have reactive hypoglycemia; instead, they may have any of a number of conditions that present as vague, episodic symptoms, usually of an adrenergic nature.

Differential diagnosis of seizures

Cardiovascular diseases Arrhythmias (sinus node depression, cardiac arrest, tachycardia, atrial fibrillation-flutter, tachybradycardiac syndromes, including sick sinus syndrome, atrioventricular dissociation, and Adams-Stokes syndrome) Emboli and/or microemboli of the pulmonary artery Syndromes of orthostatic hypotension Neurocirculatory dystonia (p-adrenergic- hyperreactive state) Mitral valve dysfunction Congestive heart failure	Endocrine-metabolic disorders Hyperthyroidism Hypothyroidism Reactive hypoglycemia Fasting hypoglycemia Pheochromocytoma Carcinoid syndrome hereditary angioedema Urticaria pigmentosa Hyperbradykinesia Addison's disease hypopituitarism Hypothalamic-pituitary dysfunction Menopause Diabetes diabetes insipidus
Psychoneurological diseases epileptiform disorders Insufficiency of the autonomic nervous system Diencephalic epilepsy (autonomous epilepsy) Hyperventilation Syndrome Catalepsy Anxiety neurosis Hysteria Migraine Syncope Psychophysiological reaction conversion hysteria	Miscellaneous diseases Sepsis Anemia Cachexia Hypovolemia (dehydration) Diuretic abuse Clonidine withdrawal syndrome Monoamine oxidase inhibitors plus tyramine (cheese, wine) Asthma Postprandial Idiopathic Syndrome
Gastrointestinal diseases Dumping syndrome after gastrointestinal surgery Physiological dumping syndrome after eating without prior gastrointestinal surgery Chinese Restaurant Syndrome irritable bowel syndrome food intolerance

26. How is reactive hypoglycemia diagnosed and treated?
Reactive hypoglycemia is a diagnosis made by exclusion after most of the conditions that cause "attacks" have been ruled out. In true reactive hypoglycemia, the patient's condition is diet related, most likely the patient is taking in excess refined carbohydrates or high glycemic foods Low blood glucose levels are due to postprandial hyperinsulinism or impaired insulin secretion Oral glucose tolerance test detects sensitivity to refined carbohydrates Excess intake of refined carbohydrates or foods with a high glycemic index can be detected by asking the patient about his diet Limiting the intake of refined carbohydrates to 8 -10% of total food intake eliminates syndrome in patients with present illness Often underlying neuropsychiatric illness, fear, or situational stress responses are the actual culprits episodic episodes that the patient characterizes or diagnoses as reactive hypoglycemia True reactive hypoglycemia is rare.