Hypoglycemia

Aka: Hypoglycemia

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II. Definitions

  1. Hypoglycemia
    1. Plasma Glucose <54 mg/dl (3.0 mmol/L)
  2. Severe Hypoglycemia
    1. Hypoglycemia event in which patient requires another person's assistance for management

III. Causes: Adults

  1. Subtypes
    1. Postprandial Hypoglycemia (Reactive Hypoglycemia)
    2. Fasting Hypoglycemia
  2. Endocrine disorders
    1. Diabetes Mellitus on Insulin or Insulin Secretagogue
    2. Adrenal Insufficiency
    3. Pheochromocytoma
    4. Hyperthyroidism
  3. Substance Abuse or Overdose
    1. Alcoholism with Alcohol Intoxication
    2. Cocaine
    3. Salicylate Toxicity
    4. Beta Blocker Overdose
  4. Nutritional
    1. Nutritional Deficiency
    2. Eating Disorder
    3. Liver disease (e.g. Cirrhosis)
  5. Medications
    1. See Sulfonylurea Drug Interactions Causing Hypoglycemia
    2. Insulin
    3. Insulin Secretagogue
    4. Quinolones (esp. Gatifloxacin and esp. with Sulfonylureas)
    5. Methadone
    6. Tramadol
    7. Pentamidine
    8. Quinine
  6. Miscellaneous
    1. Sepsis

IV. Causes: Children

  1. Sepsis
  2. Inborn Errors of Metabolism
  3. Poor oral intake or decreased absorption (e.g. Diarrhea)
  4. Hypothyroidism
  5. Hypopituitarism
  6. Large malignancy (e.g. Wilms Tumor)
  7. Toxin Ingestion
    1. Beta Blocker Overdose
    2. Alcohol Toxicity
    3. Salicylate Toxicity
    4. Sulfonylurea Overdose

V. Findings

  1. Sensitivity to hypoglycemic episodes decreases with recurrent hypoglycemic episodes
    1. Higher risk for severe Hypoglycemia
  2. Sympathetic response
    1. Sweating
    2. Tremor
    3. Tachycardia
    4. Anxiety
    5. Hunger
  3. Neurologic symptoms
    1. Dizziness
    2. Visual disturbance
    3. Confusion or Delirium
    4. Loss of consciousness
    5. Seizures
    6. Syncope

VI. Diagnosis: Whipple's Triad

  1. Low Plasma Glucose
    1. Men < 2.8 mmol/L (50 mg/dl)
    2. Women < 2.2 mmol/L (40 mg/dl)
  2. Hypoglycemic Symptoms
    1. May be masked by certain conditions or medications
      1. Autonomic Neuropathy
      2. Beta Blockers
  3. Symptoms improve with plasma Glucose correction

VII. Management

  1. See Hypoglycemia Management
  2. Manage underlying cause
    1. See Insulin Shock
    2. See Adrenal Insufficiency
    3. See Salicylate Toxicity
    4. See Beta Blocker Overdose
    5. See Sulfonylurea Toxicity
    6. See Inborn Errors of Metabolism
    7. See Sepsis

VIII. Prevention

  1. See Diabetes Mellitus Glucose Management
  2. See Diabetes Sick Day Management
  3. General Dietary Measures
    1. Avoid Fasting
    2. Small, frequent meals
  4. Prepare Emergency Kit that is always available
    1. Medical alert bracelet
    2. Glucagon
    3. Emergency Glucose Replacement
    4. Glucometer
  5. Prepare for a hypoglycemic event (and teach family and friends)
    1. Recognize signs of Hypoglycemia (e.g. Altered Level of Consciousness or confusion, sweating, Dizziness)
    2. Test Blood Glucose for Hypoglycemia symptoms (but do not delay replacement)
    3. Treat Hypoglycemia if Blood Glucose <70 mg/dl (or <80-90mg/dl in elderly)
      1. See Hypoglycemia Management
      2. Deliver Glucagon in an unconscious or altered patient
        1. Temporize briefly until Glucose can be absorbed
      3. Deliver Emergency Glucose Replacement (15-20 grams Carbohydrate)
    4. Glucose monitoring
      1. Monitor Blood Glucose every 15 minutes until >100 mg/dl
      2. Redose Glucose replacement per above every 15 min as needed
    5. Eat a small meal once Blood Glucose has returned to a normal level
  6. Adjust diabetes Blood Sugar goals
    1. Indicated in those with multiple comorbid conditions, elderly or other risks of severe Hypoglycemia
    2. Allow Hemoglobin A1C to rise to around 8%
  7. Adjust diabetes medications to lower risk of Hypoglycemia
    1. Avoid Glyburide (use other Sulfonylureas such as Glipizide or Glimepiride instead)
    2. Exercise particular care in the Nursing Home elderly who frequently have unrecognized Hypoglycemia (weekly)
      1. Bouillet (2021) Age Ageing 50(6):2088-93 +PMID: 34324624 [PubMed]
    3. Consider replacing Sulfonylurea with alternative
      1. Gliptin (e.g. Januvia)
      2. GLP-1-Agonist (e.g. Byetta)
      3. Pioglitazone (Actos)
    4. Avoid Sulfonylurea with Insulin (especially with short-acting or Bolus Insulin such as Lispro/Humalog, Novolog)
      1. Sulfonylureas may be used with long-acting or Basal insulin (e.g. Lantus, Levemir) in patients at lower risk of Hypoglycemia
    5. Convert older Insulin preparations to newer agents with better predictable onset and duration
      1. Convert NPH Insulin to newer long-acting or Basal insulin (e.g. Lantus, Levemir)
      2. Convert Regular Insulin to newer short-acting or Bolus Insulin (e.g. Lispro/Humalog, Novolog)

IX. References

  1. Inzucchi (2012) Diabetes Care 35(6):1364-79 [PubMed]

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Related Studies

Ontology: Blood glucose decreased (C0595883)

Concepts Finding (T033)
SnomedCT 44621000009101
English BLOOD SUGAR DECREASED, Glucose blood decreased, Blood sugar decreased, Decreased blood sugar, Sugar blood decreased, blood decreasing sugar, blood glucose decreased, Blood glucose decreased below normal, Blood glucose level below normal (finding), Hypoglycemia, Blood glucose level below normal, Blood glucose decreased
Dutch glucose bloed verlaagd, suiker bloed verlaagd, bloed suiker verlaagd, verlaagd bloed suiker, bloed glucose verlaagd
French Glucose sanguin diminué, DIMINUTION DE LA GLYCEMIE, Glycémie diminuée
German Blutzucker erniedrigt, Blutzucker erniedigt, erniedrigter Blutzucker, BLUTZUCKER ERNIEDRIGT, Glukose im Blut erniedrigt
Portuguese Açúcar no sangue diminuído, BAIXA DA GLICEMIA, Glicemia diminuída
Spanish Azúcar disminuida en sangre, Azucar disminuida en sangre, AZUCAR EN SANGRE, DISMINUIDO, Glucosa disminuida en sangre
Japanese 血中ブドウ糖減少, 血糖減少, ｹｯﾁｭｳﾌﾞﾄﾞｳﾄｳｹﾞﾝｼｮｳ, ｹｯﾄｳｹﾞﾝｼｮｳ
Czech Glykemie snížená, Hladina cukru v krvi snížená, Snížená hladina krevního cukru, Hodnoty glykemie snížené, Hladina krevního cukru snížená
Italian Zuccheri ematici diminuiti, Glucosio ematico diminuito
Hungarian Glükóz vérszint csökkent, Vércukor csökkent, Vércukorszint csökkent
Derived from the NIH UMLS (Unified Medical Language System)

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