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Let's go on to another case. A 74-year-old woman comes to the emergency department with confusion.
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One of her grandchildren recently had a gastrointestinal infection. The patient developed anorexia
3 days ago and vomiting 2 days ago. She has been unable to tolerate any liquid or solid food for
the last 24 hours. Medical history is significant for type 2 diabetes, hypertension, hyperlipidemia,
and hypothyroidism. Medications include aspirin, lisinopril, glimepiride, levothyroxine, and
atorvastatin. Her last dose of medication was 48 hours ago. On physical exam, her temperature
is 37.5°C, blood pressure 115/65, pulse rate 95 beats/minute. She is arousable but confused.
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Her mucous membranes are dry. She has mild tenderness to palpation throughout the abdomen. There are
no focal or neurologic deficits. Lab studies are pending. What is the most likely diagnosis? This
patient most likely has a diagnosis of hypoglycemia. This hypoglycemia is due to the presence
of glimepiride which has a long half-life in association with her fasting and volume loss induced
by her recent gastrointestinal infection. Hypoglycemia in patients with diabetes is a common
complication of intensive therapeutic regimens in patients with diabetes. Avoidance of hypoglycemia
prior to focusing on a patient's hemoglobin A1c goal is of the outmost importance because of
the significant morbidity and mortality associated with low plasma glucose levels. The American
Diabetes Association Standard for Medical Care refer to serious clinically significant hypoglycemia
as a glucose level of less than 54 mg/dL whereas the glucose alert value is defined as less than
70 mg/dL. Insulin ceases when the glucose level falls below 80 mg/dL. Hypoadrenergic symptoms begin
to alert the patient to hypoglycemia. These include tachycardia, sweating, tremor, hunger, and
anxiety. Typically, the body responds to hypoglycemia by secreting glucagon, epinephrine,
norepinephrine, cortisol, and growth hormone. Progression is based on the escalating degree
of hypoglycemia. As hypoglycemia worsens, the cognitive function begins to decline. This can lead to
a loss of consciousness, seizures, and even death. The treatment of hypoglycemia involves the
immediate correction of blood glucose. If the patient is conscious, 15-20 grams of glucose tablets
or glucose gel should be provided. Check the blood glucose after 15 minutes. The consumption
of 15-20 grams of glucose should occur again if the hypoglycemia does not improve to greater
than 70 mg/dL. When oral consumption of glucose is not possible or safe, parenteral glucagon
should be provided. To prevent future events, a meal or snack after glucose has been corrected
should be used to avoid continued hypoglycemia as under the underlying course may still be
present. In the particular case, the long half-life of the glimepiride may persist for many hours
after the patient has left the emergency room. Consequently, alerting the patient to the symptoms of
hypoglycemia will be important and encouraging her to take snacks until the drug has left her
system. The long-term management of hypoglycemia involves relaxing glycemic target goals especially
for hemoglobin A1c in diabetics. Reducing the doses of therapeutic agents may be needed and review
of the patient's diabetes self-management plan may also be helpful to identify recurring factors
that lead to the presence of hypoglycemia.