Approach
All adult patients may require supportive care with glucose and/or glucagon while awaiting definitive therapy for the underlying condition, whether that is surgery, for example, for insulinoma and insulin-like growth factor (IGF)-II-secreting tumour; medical management of renal and liver failure; antibiotics, and supportive care for sepsis; or waiting for an inciting medicine to be cleared from the system.[17][18][46] Patients with reactive hypoglycaemia are often treated successfully with dietary changes.[44]
Exposure to medicine, toxin, or ethanol
Hypoglycaemia should resolve as toxin or medicine is metabolised. The patient may require inpatient monitoring and glucose infusion until the effects of the toxin, medicine, or exogenous insulin/sulfonylurea diminish, the time course for which is widely variable and may be further prolonged if there is concomitant hepatic and/or renal dysfunction.
If intentional overdosing of salicylates, ethanol, insulin, or sulfonylureas is suspected, the patient should be screened to determine whether referral to a psychiatric speciality is warranted. If suicidality is present, involuntary commitment may be necessary.
Bariatric surgery, anorexia, malnutrition, ackee fruit ingestion
In addition to correcting the glucose deficiency, referral or consultation with endocrinology, eating disorders, toxicology, or gastrointestinal disease specialists may be necessary in these patients.
Insulinoma
Surgical excision is indicated for insulinoma.
Until surgery the patient should be instructed to be alert for hypoglycaemic symptoms. Should such symptoms occur and the patient is unable to tolerate oral intake to raise glucose levels, he or she may be taught to self-administer glucagon injections.
If the patient continues to have hypoglycaemic events after surgery, then it is possible that a metastatic lesion was missed or the primary tumour was not fully excised. Consideration should be given to repeating surgery.[7]
Focal embolisation or chemotherapy may be required for metastatic disease in the presence of rare malignant insulinoma.[47]
Inoperable insulinoma
For patients who are not surgical candidates or in whom surgery was unsuccessful, pharmacological therapy may offer a degree of control over the hypoglycaemia. There is limited evidence to suggest superiority of one agent over another, and each carries significant risks:[47][48][49][50]
Diazoxide:
Can control hypoglycaemia by inhibition of insulin secretion
May cause oedema and hirsutism
Monitor for lowering of blood pressure if also taking calcium-channel blockers.
Octreotide:
High doses inhibit insulin secretion
Thyroid-stimulating hormone, growth hormone, and glucagon are also inhibited.
Streptozocin:
May destroy the tumour
Can lead to hyperglycaemia or diabetes mellitus because it will destroy normal islets as well.
IGF-II-secreting tumour
The patient with IGF-II hypersecretion should be referred to a surgeon for excision of the offending mass.
While awaiting surgery, glucose levels may need to be supported with intermittent glucose infusion or glucagon administration.
Therapies that reduce tumour burden (e.g., chemotherapy, radiotherapy) may help to relieve symptoms in some cases.[44]
Renal failure, liver failure, sepsis, or other endocrinopathy
Treatment should focus on management of underlying organ dysfunction. Support with glucose infusion may be necessary until the condition resolves, especially if the patient cannot tolerate oral intake.
Use of this content is subject to our disclaimer