Hypoglycemia

From Wikipedia, the free encyclopedia
Jump to navigation Jump to search

Hypoglycemia, also known as low blood sugar, is a fall in blood sugar to levels below normal.[1] This may result in a variety of symptoms, including clumsiness, trouble talking, confusion, loss of consciousness, seizures, or death.[1] Feelings of hunger, sweating, shakiness, or weakness may also be present.[1] Symptoms typically come on quickly.[1]

The most common cause of hypoglycemia is medications used to treat diabetes such as insulin and sulfonylureas.[2][3] Risk is greater in diabetics who have eaten less than usual, recently exercised,[4] or drunk alcohol.[1] Other causes of hypoglycemia include kidney failure, certain tumors (such as insulinoma), liver disease, hypothyroidism, starvation, inborn error of metabolism, severe infections, reactive hypoglycemia, and a number of drugs, including alcohol.[1][3] Low blood sugar may occur in otherwise healthy babies who have not eaten for a few hours.[5]

The glucose level that defines hypoglycemia is variable.[1] In people with diabetes, levels below 3.9 mmol/l (70 mg/dl) are diagnostic.[1] In adults without diabetes, symptoms related to low blood sugar, low blood sugar at the time of symptoms, and improvement when blood sugar is restored to normal confirm the diagnosis.[6] Otherwise, a level below 2.8 mmol/l (50 mg/dl) after not eating or following exercise may be used.[1] In newborns, a level below 2.2 mmol/l (40 mg/dl), or less than 3.3 mmol/l (60 mg/dl) if symptoms are present, indicates hypoglycemia.[5] Other tests that may be useful in determining the cause include insulin and C peptide levels in the blood.[3]

Hypoglycemia
Other namesHypoglycaemia, hypoglycæmia, low blood glucose, low blood sugar
Glucose test.JPG
Glucose meter
SpecialtyEndocrinology
SymptomsHeadache, blurred vision, shakiness, dizziness, weakness, tiredness, sweating, clamminess, fast heart rate, pounding heartbeat, nervousness or anxiety, hunger, nausea, pins and needles sensation, difficulty talking, confusion, loss of consciousness, unusual behavior, lightheadedness, pale skin color, seizures, death[1][6][7][8][9]
Usual onsetRapid[1]
CausesMedications (insulin, glinides and sulfonylureas), sepsis, kidney failure, certain tumors, liver disease[1][2][3]
Diagnostic methodWhipple's triad: Symptoms of hypoglycemia, serum blood glucose level <70 mg/dL (3.9 mmol/L), and resolution of symptoms when blood glucose returns to normal [6]
TreatmentEating foods high in simple sugars, dextrose, glucagon[1]
FrequencyIn type 1 diabetics, mild hypoglycemia occurs twice per week on average, and severe hypoglycemia occurs one per year.[7]
DeathsIn type 1 diabetics, 6-10% will die of hypoglycemia.[7]

Among people with diabetes, prevention is by matching the foods eaten with the amount of exercise and the medications used.[1] When people feel their blood sugar is low, testing with a glucose monitor is recommended.[1] Some people have few initial symptoms of low blood sugar, and frequent routine testing in this group is recommended.[1] Treatment of hypoglycemia is by eating foods high in simple sugars or taking dextrose.[1] If a person is not able to take food by mouth, glucagon by injection or in the nose may help.[1][10] The treatment of hypoglycemia unrelated to diabetes includes treating the underlying problem and a healthy diet.[1] The term "hypoglycemia" is sometimes incorrectly used to refer to idiopathic postprandial syndrome, a controversial condition with similar symptoms that occurs following eating, but with normal blood sugar levels.[11][12]

Definition[edit]

Blood sugar levels naturally fluctuate throughout the day, however hypoglycemia, also called low blood sugar or low blood glucose, is when blood sugar levels drop below 70 mg/dL (3.9 mmol/L).[7][9] People may have different blood sugar target levels based on their glucose meters or health conditions, and as a result it is important to consult a doctor on personalized blood sugar target levels.[9]

Plasma blood glucose levels are generally maintained between 70 and 110 mg/dL (3.9-6.1 mmol/L).[6][7] Although 70 mg/dL (3.9 mmol/L) is commonly cited as the lower limit of normal glucose, symptoms of hypoglycemia usually do not occur until 55 mg/dL (3.0 mmol/L) or lower.[6][7] The serum blood glucose threshold at which symptoms of hypoglycemia develop in someone with several prior episodes of hypoglycemia may be even lower.[6]

Whipple's triad[edit]

The symptoms of low blood sugar alone are not specific enough to characterize a hypoglycemic episode.[6] A single blood sugar reading below 70 mg/dL is also not specific enough characterize a hypoglycemic episode.[6] Whipple's triad is a set of three conditions that need to be met in order to accurately characterize a hypoglycemic episode.[6]

The three conditions are the following:

  1. The signs and symptoms of hypoglycemia are present (see section below on Signs and Symptoms)[6]
  2. A low blood glucose measurement is present, typically less than 70 mg/dL (3.9 mmol/L)[6]
  3. The signs and symptoms of hypoglycemia resolve after blood glucose levels have returned to normal[6]

Age[edit]

The most notable variation in blood glucose levels between the adult and pediatric population occurs within the first 48 hours of life, in newborns.[13] Following the first 48 hours of life, the Pediatric Endocrine Society cites that there is little variation in plasma glucose level and the physiology of glucose utilization.[13] During the 48 hour neonatal period, the neonate adjusts glucagon and epinephrine levels following birth, which may trigger transient hypoglycemia.[13] As a result, there has been controversy in developing guidelines on interpretation and treatment of low plasma glucose in neonates aged less than 48 hours.[13] The Pediatric Endocrine Society states that following data review, they suspect neonates aged less than 48 hours suppress insulin at serum glucose levels of approximately 55–65 mg/dL (3.0-3.6 mmol/L).[13] This is contrasted by the value in adults, children, and older infants, which is approximately 80–85 mg/dL (4.4-4.7 mmol/L).[13]

In children who are aged greater than 48 hours, serum glucose on average ranges from 70 to 100 mg/dL (3.9-5.5 mmol/L), similar to adults.[13] In children who are able to communicate their symptoms, Whipple's triad is used to identify hypoglycemia.[13]

Differential diagnosis[edit]

Other conditions that may present similarly to hypoglycemia include the following:

Signs and symptoms[edit]

Hypoglycemic symptoms are divided into two main categories, with the first category being symptoms caused by low glucose in the brain, called neuroglycopenic symptoms.[7] The second category of symptoms is caused by the body's reaction to low glucose in the brain, called adrenergic symptoms.[7]

Neuroglycopenic symptoms Adrenergic symptoms
  • Fast heart rate
  • Pounding heartbeat (also called Palpitations)
  • Sweating
  • Clamminess
  • Shakiness or tremulousness
  • Nervousness (also called Anxiety)
  • Hunger
  • Nausea
  • Pins and needles sensation
  • Pale skin color
References:[1][6][7][8][9]

Everyone experiences different symptoms of hypoglycemia, so someone with hypoglycemia may not show all of the symptoms listed above.[7][8][9] Symptoms also tend to have quick onset.[9] It is important to quickly obtain a blood glucose measurement in someone presenting with symptoms of hypoglycemia in order to properly identify the hypoglycemic episode.[6][9]

Causes[edit]

Hypoglycemia is most common in those who have a history diabetes treated with insulin, glinides, and sulfonylureas.[6][7] On the other hand, is quite rare in those without a history of diabetes, because there are a number of regulatory mechanisms in place to appropriately balance glucose, insulin, and glucagon.[6][7]

Diabetics[edit]

The most common cause of hypoglycemia in diabetics is medications used to treat diabetes mellitus such as insulin, sulfonylureas, and biguanides.[2][3][6][7] This is often due to excessive doses or poorly timed doses.[7] Sometimes diabetic patients may take insulin in anticipation of a meal or snack, which may be missed, leading to hypoglycemia due to increased insulin without the presence of glucose from the planned meal.[7] Fasting can also lead to hypoglycemia, whether it be a planned fast or overnight fast, as there is a long period of time without glucose intake.[1][7] Exercising more than usual can cause hypoglycemia due to more use of glucose, especially by the muscles.[1][7] Drinking alcohol may also lead to hypoglycemia especially when combined with diabetic medications, as alcohol inhibits glucose production.[1][7] Kidney disease can also be a cause hypoglycemia, as insulin clearance is decreased which leads to sustained levels of insulin in the circulation.[7]

Non-diabetics[edit]

Serious illness[edit]

Serious illness may result in low blood sugar.[1][6][7][16] Severe disease of many organ systems can cause hypoglycemia as a secondary problem.[6][7] Hypoglycemia is especially common in those in the intensive care unit or those in whom food and drink is withheld as a part of their treatment plan.[7][16]

Sepsis, a common cause of hypoglycemia in serious illness, can lead to hypoglycemia through a variety of ways.[7][16] In a state of sepsis, the body uses large amounts of glucose for energy.[7][16] Glucose utilization is further increased by cytokine production, where cytokines are a protein produced by the body in a state of stress, particularly when fighting an infection.[7] Cytokines may also inhibit glucose production, further decreasing the body's energy stores.[7] Finally, the liver and kidneys are sites of glucose production, and in a state of sepsis those organs may not receive enough oxygen, leading to decreased glucose production due to organ damage.[7]

Other causes of serious illness that may cause hypoglycemia include liver and kidney failure.[7][16] The liver is the main site of glucose production in the body, and any liver failure or damage will lead to decreased glucose production.[7][16] While the kidneys are also sites of glucose production, kidney failure leads to hypoglycemia through the inability to filter insulin properly.[7] The kidneys are responsible for removing insulin from the body, and when this function is impaired in kidney failure, the insulin stays in circulation longer, leading to hypoglycemia.[7]

Drugs[edit]

A number of medications have been identified which may induce hypoglycemia, through various mechanisms.[6][7][17] Moderate quality evidence implicates the non-steroidal anti-inflammatory drug indomethacin and the anti-malarial quinine.[6][7][17] Low quality evidence implicates lithium, used for bipolar disorder.[6][17] Finally, very low quality evidence implicates a number of hypertension medications including angiotensin converting enzyme inhibitors (also called ACE-inhibitors), angiotensin receptor blockers (also called ARBs), and β-adrenergic blockers (also called beta blockers).[6][7][17] Other medications with very low quality evidence include the antibiotics levofloxacin and trimethoprim-sulfamethoxazole, progesterone blocker mifepristone, anti-arrhythmic disopyramide, anti-coagulant heparin, and chemotherapeutic mercaptopurine.[6][17]

If a person without diabetes accidentally takes medications that are traditionally used to treat diabetes, this may also cause hypoglycemia.[6][7] These medications include insulin, glinides, and sulfonylureas.[6][7] This may occur through medical errors in a healthcare setting or through pharmacy errors, also called iatrogenic hypoglycemia.[7]

Surreptitious insulin use[edit]

When individuals take insulin without needing it to purposefully induce hypoglycemia, this is referred to as surreptitious insulin use or factitious hypoglycemia.[6][7][18] Some people may use insulin to induce weight loss, whereas for others this may a component of malingering or factitious disorder, which is a psychiatric disorder.[18] Demographics affected by factitious hypoglycemia include women aged 30–40, particularly those with diabetes, relatives with diabetes, healthcare workers, or those with history of a psychiatric disorder.[7][18] The classic way to identify surreptitious insulin use is through blood work revealing high insulin levels with low C-peptide and proinsulin.[7][18]

Alcohol misuse[edit]

The production of glucose is blocked by alcohol.[7] In those who misuse alcohol, hypoglycemia may be brought on by a several-day alcohol binge associated with little to no food intake.[1][7] The cause of hypoglycemia is multifactorial, where glycogen becomes depleted in a state of starvation, with glycogen stores unable to be repleted due to the lack of food intake, all compounded the inhibition of glucose production by alcohol.[7]

Hormone deficiency[edit]

Children with primary adrenal failure, also called Addison's disease, may experience hypoglycemia after long periods of fasting.[7] Addison's disease is associated with chronically low levels of the stress hormone cortisol, which leads to decreased glucose production.[7]

Hypopituitarism, leading to decreased growth hormone, is another cause of hypoglycemia in children, particularly with long periods of fasting or increased exercise.[7]

Inborn errors of metabolism[edit]

Briefly, inborn errors of metabolism are a group rare of genetic disorders that are associated with the improper breakdown or storage of proteins, carbohydrates, or fatty acids.[19] Inborn errors of metabolism may cause infant hypoglycemia, and much less commonly adult hypoglycemia.[19] Disorders that are related to the breakdown of glycogen, called glycogen storage diseases, may cause hypoglycemia.[7][19] Normally, breakdown of glycogen leads to increased glucose levels, particularly in a fasting state.[7] In glycogen storage diseases however, glycogen cannot be properly broken-down, leading to inappropriately decreased glucose levels in a fasting state, and thus hypoglycemia.[7] The glycogen storage diseases associated with hypoglycemia include type 0, type I, type III, and type IV, as well as Fanconi syndrome.[7]

Insulinomas[edit]

A primary β-cell tumor, such as an insulinoma, is associated with hypoglycemia.[7] This is a tumor located in the pancreas.[7] An insulinoma produces insulin, which in turn decreases glucose levels, causing hypoglycemia.[7] Normal regulatory mechanisms are not in place, which prevents insulin levels from falling during states of low blood glucose.[7] During an episode of hypoglycemia, plasma insulin, C-peptide, and proinsulin will be inappropriately high.[7]

Non-B cell tumors[edit]

Hypoglycemia may occur in people with non-B cell tumors such as hepatomas, adrenocorticoid carcinomas, and carcinoid tumors.[7] These tumors lead to a state of increased insulin, specifically increased insulin-like growth factor II, which in turn decreases glucose levels.[7]

Post-gastric bypass postprandial hypoglycemia[edit]

The Roux-en-Y gastric bypass, is a weight-loss surgery performed on the stomach, which has been associated with hypoglycemia, called post-gastric bypass postprandial hypoglycemia.[7] Although the entire mechanism of hypoglycemia following this surgery is not fully understood, it is hypothesized that meals cause very high levels of glucagon-like peptide-1 (also called GLP-1), which is a hormone that increases insulin, causing glucose levels to drop.[7]

Autoimmune hypoglycemia[edit]

Antibodies can be formed against insulin, leading to autoimmune hypoglycemia.[7][20] Antibodies are an immune cell produced by the body, which normally attack bacteria and viruses, but sometimes can attack normal human cells, leading to an autoimmune disorder.[21] In autoimmune hypoglycemia, there are two possible mechanisms.[7][20] In one instance, antibodies bind to insulin following its release associated with a meal, resulting in insulin being non-functional.[7][20] At a later time, the antibodies fall off of insulin, at which time insulin becomes functional again leading late hypoglycemia after a meal, called late postprandial hypoglycemia.[7][20] Another mechanism through which hypoglycemia occurs is due to antibodies formed against insulin receptors, called insulin receptor antibodies.[7][20] The antibodies attached to insulin receptors prevent insulin from being broken down, or degraded, leading to inappropriately high insulin levels and low glucose levels.[7][20]

Neonatal hypoglycemia[edit]

Low blood sugar may occur in healthy neonates aged less than 48 hours who have not eaten for a few hours.[13] During the 48 hour neonatal period, the neonate adjusts glucagon and epinephrine levels following birth, which may trigger transient hypoglycemia.[13] In children who are aged greater than 48 hours, serum glucose on average ranges from 70 to 100 mg/dL (3.9-5.5 mmol/L), similar to adults, with hypoglycemia being far less common.[13]

Pathophysiology[edit]

The importance of an adequate supply of glucose to the brain is apparent from the number of nervous, hormonal, and metabolic responses to a falling glucose level. Most of these are defensive or adaptive, tending to raise the blood sugar by glycogenolysis and gluconeogenesis or provide alternative fuels. If the blood sugar level falls too low, the liver converts a storage of glycogen into glucose and releases it into the bloodstream, to prevent the person going into a diabetic coma, for a short time.

Brief or mild hypoglycemia produces no lasting effects on the brain, though it can temporarily alter brain responses to additional hypoglycemia. Prolonged, severe hypoglycemia can produce lasting damage of a wide range. This can include impairment of cognitive function, motor control, or even consciousness. The likelihood of permanent brain damage from any given instance of severe hypoglycemia is difficult to estimate and depends on a multitude of factors such as age, recent blood and brain glucose experience, concurrent problems such as hypoxia, and availability of alternative fuels. Prior hypoglycemia also blunts the counter-regulatory response to future hypoglycemia.[22] While the mechanism leading to blunted counterregulation is unknown several have been proposed.[23]

Those type 1 diabetics found "dead in bed" in the morning after suspected severe hypoglycemia are often found to have had some underlying coronary pathology that led to an induced fatal heart attack.[24] In 2010, a case report was published demonstrating the first known case of an individual found "dead in bed" whilst wearing a continuous glucose monitor, which provided a history of glucose levels before the fatal event; the person had suffered a severe hypoglycemic incident, and while the authors described only a "minimal counter-regulatory response", they stated no "anatomic abnormalities" were observed during autopsy.[25]

The vast majority of symptomatic hypoglycemic episodes results in no detectable permanent harm.[26]

Diagnosic approach[edit]

The most reliable method of identifying hypoglycemia is through identifying Whipple's triad.[6][7] The components of Whipple's triad are a blood sugar level below 70 mg/dL (3.9 mmol/L), symptoms related to low blood sugar, and improvement of symptoms when blood sugar is restored to normal.[6][7] Identifying Whipple's triad in a patient helps to avoid unnecessary diagnostic testing and decrease healthcare costs.[6]

In those with a history of diabetes treated with insulin, glinides, or sulfonylurea, who demonstrate Whipple's triad, it is reasonable to assume the etiology of hypoglycemia is due to insulin, glinides, or sulfonylurea use.[6] In those without a history of diabetes with hypoglycemia, further diagnostic testing is necessary to identify the etiology.[6] Testing, during an episode of hypoglycemia, should include the following:

If necessary, a diagnostic hypoglycemic episode can be produced in an inpatient or outpatient setting.[7] This is called a diagnostic fast, in which a patient undergoes an observed fast to reproduce a hypoglyemic episode, allowing for the above labs to be drawn.[7] In some, the hypoglycemic episode may be reproduced simply after a mixed meal, whereas in others a fast may last up to 72 hours.[6][7]

In those with a suspected insulinoma, imaging is the most reliable diagnostic technique, including ultrasound, computed tomography imaging (also called CT imaging), and magnetic resonsance imaging (also called MRI).[6][7]

Sources of measurement errors[edit]

There are a number of factors that may affect blood glucose readings.[27][28][29] Sources of possible measurement errors include the following:

Treatment[edit]

After hypoglycemia in a person is identified, rapid treatment is necessary and can be life-saving.[1] The main goal of treatment is to raise blood glucose back to normal levels, which is done through various ways of administering glucose, depending on the severity of the hypoglycemia, what is on-hand to treat, and who is administering the treatment.[1][7] A general rule used by the American Diabetes Association is the "15-15 Rule," which suggests consuming or administering 15 grams of a carbohydrate, followed by a 15-minute wait and re-measurement of blood glucose level to assess if blood glucose has returned to normal levels or is still low, requiring repeated treatment.[9][31]

Self-treatment[edit]

If an individual recognizes the symptoms of hypoglycemia coming on, blood sugar should promptly be obtained, and a sugary food or drink should be consumed.[1] The person must be conscious and able to swallow.[1][7] The goal is to consume 10-20 grams of a carbohydrate to raise blood glucose levels to a minimum of 70 mg/dL (3.9 mmol/L).[6][7]

Examples of products to consume are:

  • Glucose tabs or gel (refer to instructions on packet)[1][6]
  • Juice containing sugar like apple, grape, or cranberry juice, 4 ounces or 1/2 cup[1][6]
  • Soda or a soft-drink, 4 ounces or 1/2 cup (not diet soda)[6]
  • Candy[6]
  • Table sugar or honey, 1 tablespoon[1]

Improvement in blood sugar levels and symptoms are expected to occur in 15–20 minutes, at which point blood sugar should be measured again.[6][7][31] If the repeat blood sugar level is not above 70 mg/dL (3.9 mmol/L), consume another 10-20 grams of a carbohydrate and remeasure blood sugar levels after 15–20 minutes.[6][7][31] Repeat until blood glucose levels have returned to normal levels.[6][7] The greatest improvements in blood glucose will be seen if the carbohydrate chewed or drunk, and then swallowed.[32] This results in the greatest bioavaliablity of glucose, meaning the greatest amount of glucose enters the body producing the best possible improvements in blood glucose levels.[32] The second best way to consume a carbohydrate it to allow it to dissolve under the tongue, also referred to as sublingual administration.[32] For example, a hard candy can be dissolved under the tongue, however the best improvements in blood glucose will occur if the hard candy is chewed and crushed, then swallowed.[32]

After correcting blood glucose levels, people may consume a full meal within one hour in order to replenish glucagon stores.[6]

Education[edit]

Family, friends, and co-workers of a person with diabetes diagnosis may provide life-saving treatment in the case of a hypoglycemic episode, as well as provide training with how to administer injectable or intra-nasal glucagon, or use a glucose meter.[1]

A glucagon kit used to treat severe hypoglycemia.

Treatment by family, friends, or co-workers[edit]

Family, friends, and co-workers of those with hypoglycemia are often first to identify hypoglycemic episodes, and may offer help.[7] Upon recognizing the signs and symptoms of hypoglycemia in an individual, a blood sugar level is determined using a glucose meter.[1] If blood glucose is below 70 mg/dL (3.9 mmol/L), treatment will depend on whether the person is conscious and can swallow safely.[6][7] If the person is conscious and able to swallow, the person consumes 10-20 grams of a carbohydrate to raise blood glucose levels to a minimum of 70 mg/dL (3.9 mmol/L).[6] Improvement in blood sugar levels and symptoms are expected to occur in 15–20 minutes, at which point blood sugar is measured again.[6][7][31] If the repeat blood sugar level is not above 70 mg/dL (3.9 mmol/L), the person consumes another 10-20 grams of a carbohydrate and remeasures blood sugar levels after 15–20 minutes.[6][7][31] Repeat until blood glucose levels have returned to normal levels.[6]

If the person is unconscious, a glucagon kit may be used to treat severe hypoglycemia, which delivers glucagon either by injection into a muscle or through nasal inhalation.[6][7][16] In the United States, glucacon kits are available by prescription for diabetic patients to carry in case of an episode of severe hypoglycemia.[33][34]

Treatment by medical professionals[edit]

In a healthcare setting, treatment depends on the severity of symptoms and intravenous access.[35] If a patient is conscious and able to swallow safely, food or drink may be administered, as well as glucose tabs or gel.[35] In those with intravenous access, 25 grams of 50% dextrose is commonly administered.[35] When there is no intravenous access, intramuscular or intra-nasal glucagon may be administered.[35]

Other treatments[edit]

While the treatment of hypoglycemia is typically managed with carbohydrate consumption, glucagon injection, or dextrose administration, there are some other treatments available.[7] Medications like diazoxide and octreotide decrease insulin levels, increasing blood glucose levels.[7] Dasiglucagon was approved for medical use in the United States in March 2021, to treat severe hypoglycemia.[36] Dasiglucagon (brand name Zegalogue) is unique because it is glucagon in a prefilled syringe or auto-injector pen, as opposed to traditional glucagon kits that require mixing powdered glucagon with a liquid.[36]

The soft drink Lucozade has been used for hypoglycemia in the United Kingdom, but it has recently replaced much of its glucose with artificial sweeteners, which do not treat hypoglycemia.[37]

Prevention[edit]

The prevention of hypoglycemia depends on the cause.[1][6][7] In those with diabetes treated by insulin, glinides, or sulfonylurea, the prevention of hypoglycemia has a large focus on patient education and medication adjustments.[1][6][7]

The risk of further episodes of diabetic hypoglycemia can often be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood-sugar balance during unusual hours, higher levels of exercise, or decreasing alcohol intake. Many of the inborn errors of metabolism require avoidance or shortening of fasting intervals, or extra carbohydrates. For the more severe disorders, such as type 1 glycogen storage disease, this may be supplied in the form of cornstarch every few hours or by continuous gastric infusion. Some forms of congenital hyperinsulinism respond to diazoxide or octreotide. Surgical removal of the overactive part of the pancreas is curative with minimal risk when hyperinsulinism is focal or due to a benign insulin-producing tumor of the pancreas. When congenital hyperinsulinism is diffuse and refractory to medications, near-total pancreatectomy may be the treatment of last resort, but is less consistently effective and fraught with more complications.

Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal insufficiency usually ceases when the appropriate hormone is replaced.

Hypoglycemia due to dumping syndrome and other postsurgical conditions is best dealt with by altering diet. Including fat and protein with carbohydrates may slow digestion and reduce early insulin secretion. Some forms of this respond to treatment with an alpha-glucosidase inhibitor, which slows starch digestion.

Idiopathic postprandial syndrome without demonstrably low glucose levels at the time of symptoms can be more of a management challenge. Many people find improvement by changing eating patterns (smaller meals, avoiding excessive sugar, mixed meals rather than carbohydrates by themselves), reducing intake of stimulants such as caffeine, or by making lifestyle changes to reduce stress.

Epidemiology[edit]

Hypoglycemia is common in people with type 1 diabetes, especially in those taking insulin, glinides, or sulfonylurea.[1][7] It is estimated that type 1 diabetics experience two mild, symptomatic episodes of hypoglycemia per week.[7] Additionally, type 1 diabetics suffer from at one severe hypoglyemic episode per year, requiring treatment assistance.[7] In terms of mortality, hypoglycemia causes death in 6-10% of type 1 diabetics.[7]

In those with type 2 diabetes, hypoglycemia is less common compared to type 1 diabetics, because medications that treat type 2 diabetes like metformin, glitazones, alpha-glucosidase inhibitors, glucagon-like peptide 1 agonists, and dipeptidyl peptidase IV inhibitors, do not cause hypoglycemia.[1][7] Hypoglycemia is common in type 2 diabetics who take insulin, glinides, or sulfonylurea.[1][7] Insulin use remains a key risk factor in developing hypoglycemia, regardless of diabetes type.[1][7]

History[edit]

Hypoglycemia was first discovered by James Collip when he was working with Frederick Banting on purifying insulin in 1922. Collip was asked to develop an assay to measure the activity of insulin. He first injected insulin into a rabbit, and then measured the reduction in blood-glucose levels. Measuring blood glucose was a time-consuming step. Collip observed that if he injected rabbits with a too large a dose of insulin, the rabbits began convulsing, went into a coma, and then died. This observation simplified his assay. He defined one unit of insulin as the amount necessary to induce this convulsing hypoglycemic reaction in a rabbit. Collip later found he could save money, and rabbits, by injecting them with glucose once they were convulsing.[38]

Etymology[edit]

The word hypoglycemia is also spelled hypoglycaemia or hypoglycæmia. The term means 'low blood sugar' from Greek ὑπογλυκαιμία, from ὑπο- hypo- 'under' + γλυκύς glykys 'sweet' + αἷμᾰ haima 'blood'.

See also[edit]

References[edit]

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an "Low Blood Glucose (Hypoglycemia) | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 12 January 2022.
  2. ^ a b c Yanai H, Adachi H, Katsuyama H, Moriyama S, Hamasaki H, Sako A (February 2015). "Causative anti-diabetic drugs and the underlying clinical factors for hypoglycemia in patients with diabetes". World Journal of Diabetes. 6 (1): 30–36. doi:10.4239/wjd.v6.i1.30. PMC 4317315. PMID 25685276.
  3. ^ a b c d e Schrier RW (2007). The internal medicine casebook real patients, real answers (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 119. ISBN 978-0-7817-6529-9.
  4. ^ Ertl AC, Davis SN (March 2004). "Evidence for a vicious cycle of exercise and hypoglycemia in type 1 diabetes mellitus". Diabetes/Metabolism Research and Reviews. 20 (2): 124–130. doi:10.1002/dmrr.450. PMID 15037987. S2CID 19186376.
  5. ^ a b Perkin RM (2008). Pediatric hospital medicine : textbook of inpatient management (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 105. ISBN 978-0-7817-7032-3.
  6. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az ba bb bc bd be bf bg bh bi bj bk bl Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ (March 2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology and Metabolism. 94 (3): 709–728. doi:10.1210/jc.2008-1410. PMID 19088155.
  7. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az ba bb bc bd be bf bg bh bi bj bk bl bm bn bo bp bq br bs bt bu bv bw bx by bz ca cb cc cd ce cf cg ch ci cj ck cl cm cn co cp cq cr cs ct Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J (2018). Harrison's principles of internal medicine (20th ed.). New York. ISBN 978-1-259-64403-0. OCLC 1029074059.
  8. ^ a b c Young VB (2016). Blueprints medicine. William A. Kormos, Davoren A. Chick (6th ed.). Philadelphia. ISBN 978-1-4698-6415-0. OCLC 909025539.
  9. ^ a b c d e f g h "Hypoglycemia (Low Blood Glucose) | ADA". www.diabetes.org. Retrieved 12 January 2022.
  10. ^ "FDA approves first treatment for severe hypoglycemia that can be administered without an injection". FDA. 11 September 2019. Retrieved 11 November 2019.
  11. ^ Talreja RS (2005). The internal medicine peripheral brain. Philadelphia, Pa.: Lippincott Williams & Wilkins. p. 176. ISBN 978-0-7817-2806-5.
  12. ^ Dorland's illustrated medical dictionary (32nd ed.). Philadelphia: Elsevier/Saunders. 2012. p. 1834. ISBN 978-1-4557-0985-4.
  13. ^ a b c d e f g h i j k Thornton PS, Stanley CA, De Leon DD, Harris D, Haymond MW, Hussain K, et al. (August 2015). "Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children". The Journal of Pediatrics. 167 (2): 238–245. doi:10.1016/j.jpeds.2015.03.057. PMID 25957977.
  14. ^ Kahn CR, et al., eds. (2005). Joslin's diabetes mellitus (14th ed.). Philadelphia: Lippincott Williams & Willkins. p. 1154. ISBN 978-0-7817-2796-9.
  15. ^ a b c d e f g h i j Vella A. "Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes". www.uptodate.com. Retrieved 14 January 2022.{{cite web}}: CS1 maint: url-status (link)
  16. ^ a b c d e f g Mathew P, Thoppil D (2022). "Hypoglycemia". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30521262. Retrieved 24 January 2022.
  17. ^ a b c d e Murad MH, Coto-Yglesias F, Wang AT, Sheidaee N, Mullan RJ, Elamin MB, et al. (March 2009). "Clinical review: Drug-induced hypoglycemia: a systematic review". The Journal of Clinical Endocrinology and Metabolism. 94 (3): 741–745. doi:10.1210/jc.2008-1416. PMID 19088166.
  18. ^ a b c d Awad DH, Gokarakonda SB, Ilahi M (2022). "Factitious Hypoglycemia". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 31194450. Retrieved 21 January 2022.
  19. ^ a b c Jeanmonod R, Asuka E, Jeanmonod D (2022). "Inborn Errors Of Metabolism". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 29083820. Retrieved 24 January 2022.
  20. ^ a b c d e f Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P (May 2009). "Autoimmune forms of hypoglycemia". Medicine. 88 (3): 141–153. doi:10.1097/MD.0b013e3181a5b42e. PMID 19440117.
  21. ^ "Antibody". Genome.gov. Retrieved 24 January 2022.
  22. ^ Davis SN, Shavers C, Mosqueda-Garcia R, Costa F (August 1997). "Effects of differing antecedent hypoglycemia on subsequent counterregulation in normal humans". Diabetes. 46 (8): 1328–1335. doi:10.2337/diab.46.8.1328. PMID 9231658. S2CID 27050655.
  23. ^ Martín-Timón I, Del Cañizo-Gómez FJ (July 2015). "Mechanisms of hypoglycemia unawareness and implications in diabetic patients". World Journal of Diabetes. 6 (7): 912–926. doi:10.4239/wjd.v6.i7.912. PMC 4499525. PMID 26185599.
  24. ^ Secrest AM, Becker DJ, Kelsey SF, Laporte RE, Orchard TJ (March 2011). "Characterizing sudden death and dead-in-bed syndrome in Type 1 diabetes: analysis from two childhood-onset Type 1 diabetes registries". Diabetic Medicine. 28 (3): 293–300. doi:10.1111/j.1464-5491.2010.03154.x. PMC 3045678. PMID 21309837.
  25. ^ Tanenberg RJ, Newton CA, Drake AJ (2010). "Confirmation of hypoglycemia in the "dead-in-bed" syndrome, as captured by a retrospective continuous glucose monitoring system". Endocrine Practice. 16 (2): 244–248. doi:10.4158/EP09260.CR. PMID 19833577.
  26. ^ Arieff AI, Griggs RC, eds. (1992). Metabolic brain dysfunction in systemic disorders. Boston: Little, Brown. ISBN 978-0-316-05067-8. OCLC 24912204.
  27. ^ a b c d e f Erbach M, Freckmann G, Hinzmann R, Kulzer B, Ziegler R, Heinemann L, Schnell O (September 2016). "Interferences and Limitations in Blood Glucose Self-Testing: An Overview of the Current Knowledge". Journal of Diabetes Science and Technology. 10 (5): 1161–1168. doi:10.1177/1932296816641433. PMC 5032951. PMID 27044519.
  28. ^ a b c d e f Ginsberg BH (July 2009). "Factors affecting blood glucose monitoring: sources of errors in measurement". Journal of Diabetes Science and Technology. 3 (4): 903–913. doi:10.1177/193229680900300438. PMC 2769960. PMID 20144340.
  29. ^ a b Baumstark A, Pleus S, Schmid C, Link M, Haug C, Freckmann G (September 2012). "Lot-to-lot variability of test strips and accuracy assessment of systems for self-monitoring of blood glucose according to ISO 15197". Journal of Diabetes Science and Technology. 6 (5): 1076–1086. doi:10.1177/193229681200600511. PMC 3570841. PMID 23063033.
  30. ^ Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al. (June 2011). "Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus". Diabetes Care. 34 (6): e61–e99. doi:10.2337/dc11-9998. PMC 3114322. PMID 21617108.
  31. ^ a b c d e "Diabetes and Hypoglycemia". Diabetes.co.uk. Archived from the original on 13 March 2012. Retrieved 10 March 2012.
  32. ^ a b c d De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djärv T (April 2019). "First aid glucose administration routes for symptomatic hypoglycaemia". The Cochrane Database of Systematic Reviews. 4: CD013283. doi:10.1002/14651858.cd013283.pub2. PMC 6459163. PMID 30973639.
  33. ^ "Severe Low Blood Sugar (Hypoglycemia) Treatment | Lilly GLUCAGON". www.lillyglucagon.com. Retrieved 24 January 2022.
  34. ^ "Glucacon Emergency Kit". Glucagon Emergency Kit. Retrieved 24 January 2022.
  35. ^ a b c d Pasala S, Dendy JA, Chockalingam V, Meadows RY (2013). "An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety". The Ochsner Journal. 13 (3): 407–412. PMC 3776519. PMID 24052773.
  36. ^ a b "HIGHLIGHTS OF PRESCRIBING INFORMATION. These highlights do not include all the information needed to use ZEGALOGUE® safely and effectively. See full prescribing information for ZEGALOGUE. ZEGALOGUE (dasiglucagon) injection, for subcutaneous use" (PDF). Accessdate.fsa.gov. Retrieved 10 November 2021.
  37. ^ Harrold A. "Diabetic patients should be warned about changes to Lucozade glucose content". Nursing in Practice. Retrieved 27 February 2019.
  38. ^ "Collip discovers hypoglycemia". Treating Diabetes. Archived from the original on 8 September 2017. Retrieved 18 June 2017.

External links[edit]