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| PRACTICE GUIDELINES |
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| Year : 2017 | Volume
: 15
| Issue : 3 | Page : 211-215 |
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Management of hypoglycemia
Nitin Kapoor1, Jubbin Jagan2, Nihal Thomas3
1 Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India; Non communicable Diseases Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
2 Department of Endocrinology, Christian Medical College, Ludhiana, India
3 Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India
| Date of Web Publication | 7-Aug-2017 |
Correspondence Address:
Nitin Kapoor
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore - 632 004, Tamil Nadu, India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_66_17
Hypoglycemia is a condition characterized by an abnormally low level of blood glucose and has significant clinical consequences if left untreated. It is a potential adverse event in the treatment of diabetes mellitus. Causes of hypoglycemia are varied, but in diabetic patients, it is most often iatrogenic. Medication changes or overdoses, infection, dietary changes, and changes in activity levels are some of the important reasons for a person to develop hypoglycemia. Prompt diagnosis and treatment of hypoglycemia is an essential component of the management of diabetes. Evaluation of the cause is important, especially if there are recurrent episodes of hypoglycemia.
Keywords: Adrenergic symptoms, hypoglycemia, management of hypoglycemia, neuroglycopenic symptoms
How to cite this article:
Kapoor N, Jagan J, Thomas N. Management of hypoglycemia. Curr Med Issues 2017;15:211-5 |
| Introduction | |  |
Hypoglycemia is a condition characterized by an abnormally low level of blood glucose and has significant clinical consequences if left untreated. There are several reasons why a person on treatment could develop hypoglycemia, but in most cases, the cause is iatrogenic. Prompt treatment and evaluation of the cause are essential in the management strategy. This article provides evidence-based guidelines for the diagnosis, evaluation, and management of hypoglycemia, which are practically applicable in an inpatient or emergency department situation.
| Definition and Classification | | |
Hypoglycemia as defined by both the American Diabetes Association and European Association for the Study of Diabetes is when blood glucose level is <70 mg/dL.[1]
However, this level is neither an indication for treatment nor necessitates the presence of symptoms but may just suggest a trend toward low sugars and warrant further exploration. Treatment to correct blood glucose levels must be considered if the individual is symptomatic or if there is a previous risk factor for hypoglycemia (see discussion below).
It has been shown in an epidemiological study in South India that 23% of normal controls have a postprandial blood glucose level (70 mg/dL) less than the fasting level.[2] This 70 mg/dL is the lower limit of normal postprandial range and is the level at which counter-regulatory hormones get activated in a nondiabetic person. In addition, antecedent blood glucose levels of ≤70 mg/dL reduce sympathoadrenal responses to subsequent hypoglycemia and therefore this criterion sets the conservative lower limit for individuals with diabetes.
An alternative definition of hypoglycemia is a decrease in the blood glucose level or its tissue utilization that results in demonstrable signs or symptoms. These signs or symptoms usually include altered mental status and/or sympathetic nervous system stimulation. The glucose level at which an individual becomes symptomatic is highly variable. The aim of the physician is to strike a balance between either end of the spectrum wherein at one end there are microvascular complications related to hyperglycemia and on the other end there is increased morbidity due to hypoglycemia.
| Clinical Classification of Hypoglycemia | | |
Hypoglycemia in diabetes may be classified into the following categories [Table 1]:[1],[3]
| Pathophysiology | | |
[Table 2] summarizes the various physiologic responses to falling plasma glucose concentrations.
| Causes | | |
Causes of hypoglycemia are varied, but in diabetic patients, it is most often iatrogenic. Early in the course of type 2 diabetes, patients may experience episodes of hypoglycemia several hours after meals. The symptoms generally are brief and respond spontaneously.
Some of the important causes and those who are at higher risk of developing hypoglycemia are summarized in [Table 3] and [Table 4].
| Symptoms and Signs of Hypoglycemia | | |
The adrenergic symptoms and neuroglycopenic symptoms are summarized in [Table 5].
| Clinical Recognition of Hypoglycemia | | |
History
- A history of insulin usage or ingestion of an oral hypoglycemic agent may be known, and possible toxic ingestion should be considered. Inquire if the patient is taking any new medications. Obtaining an accurate medical history may be difficult if the patient's mental status is altered
- The medical history may include diabetes mellitus, renal insufficiency/failure, alcoholism, hepatic cirrhosis/failure, other endocrine diseases, or recent surgery
- Review systems for weight reduction, fatigue, somnolence, nausea and vomiting, and headache
- Look for other symptoms suggesting infection.
Physical examination
Physical findings are nonspecific in hypoglycemia and generally are related to the central and autonomic nervous systems.
- Assess vital signs for hypothermia, tachypnea, tachycardia, hypertension, and bradycardia (neonates)
- Cardiovascular disturbances may include tachycardia (bradycardia in children), hypertension or hypotension, and dysrhythmias. Respiratory disturbances may include dyspnea, tachypnea, and acute pulmonary edema
- Gastrointestinal disturbances may include nausea and vomiting, dyspepsia, and abdominal cramping
- Skin may be diaphoretic and warm or show signs of dehydration with decrease in turgor
- Neurologic conditions include coma, confusion, fatigue, loss of coordination, combative or agitated disposition, stroke syndrome, tremors, convulsions, and diplopia.
| Laboratory Studies | | |
- Serum glucose: Treatment and disposition of hypoglycemia are guided by the history and the clinical picture. Serum glucose should be measured frequently and used to guide treatment, because clinical appearance alone may not reflect the seriousness of the situation.
- If the cause of hypoglycemia is other than oral hypoglycemic agents or insulin in a diabetic patient, other laboratory tests may be necessary. Check liver function tests, cortisol and thyroid levels (if clinically indicated)
- Search for a source of infection. Studies should be considered to rule out the possibility of a concurrent occult infection contributing to the new hypoglycemic episode.
- Blood counts and chest radiograph (if indicated)
- Urinalysis and renal function tests
- Continuous glucose monitoring system: It is useful in identifying asymptomatic or subtle hypoglycemia as depicted in [Figure 1].
 | Figure 1: Somogyi effect: Early morning hypoglycemia (solid arrows) leading to fasting hyperglycemia (empty arrows) in an asymptomatic patient, detected on flash glucometer monitoring system - A new concept in glucose monitoring providing much more information at an affordable cost.
Click here to view |
| Consequences of Untreated Hypoglycemia | | |
Delay in treatment can result in profound sequelae, including death, though uncommon.[5]
- Acute sequelae include coma, cardiac dysrhythmia, and death
- The risk of permanent neurological deficits increases with prolonged hypoglycemia; such deficits can include hemiparesis, memory impairment, diminished language skills, decreased abstract thinking capabilities, and ataxia
- Since the consequences of hypoglycemia can be devastating and an antidote is readily available, diagnosis and treatment must be rapid in any patient with suspected hypoglycemia, regardless of the cause
- In patients with cardiac autonomic neuropathy, repetitive hypoglycemia may lead to unresponsiveness and ultimately death which is known as death in bed syndrome. Cardiac autonomic neuropathy is more seen in patients with fibrocalcific pancreatic diabetes [6]
- Recurrent hypoglycemia in children can cause intellectual impairment as they have relaxed glycemic targets. They also require additional care during adolescence due to the higher incidence in this age group. This is often due to lack of motivation, busy educational responsibilities, changing physical activities, and poor dietary habits.
The approach to the management of hypoglycemia is depicted in [Figure 2]. Treatment should not be withheld while waiting for a laboratory glucose value; since the brain uses glucose as its primary energy source, neuronal damage may occur if treatment of hypoglycemia is delayed. A hyperglycemic patient with an altered mental status may receive a bolus of glucose. This procedure is unlikely to harm the patient with high glucose; however, the delay in giving glucose to the hypoglycemic patient may be detrimental. The mainstay of therapy for hypoglycemia is glucose/carbohydrates.
Monitoring and admission
The following patients require admission and 10% dextrose infusion after initial hypoglycemia is corrected because of the risk of further hypoglycemia
- No obvious cause of hypoglycemia
- Those on oral hypoglycemic agent
- Those on long-acting insulin
- Persistent neurologic deficits.
Ten percent glucose intravenous infusion should ideally be given by a central venous line at a rate of 100 ml/h to avoid venous sclerosis that may occur with a peripheral infusion. Blood glucose must be measured every 4–6 h until levels are stable.
Education/prevention
Patients must be counseled as to the causes and the early signs and symptoms of hypoglycemia. General outpatient diabetic education or inpatient diabetic teaching is indicated.[7]
The young adolescent age group is an especially vulnerable population due to various reasons such as loss of parental supervision of diabetes care with the transition to self-care, decreased attendance to specialty care, busy schedules (work and school), lack of diabetes knowledge, lack of motivation, alcohol consumption, changing physical activity levels, alterations in normal routine (school and work stress), and poor dietary choices. To counter these problems, it is essential to utilize options such as support groups, repeated counseling, and development of transition clinics.
Recurrent hypoglycemia
The protocol in [Figure 3] is suggested in individuals with recurrent hypoglycemia in whom overdosage of medications and lifestyle change alone cannot explain hypoglycemia. Though rare, if all the mentioned causes are excluded, then rarely patients may require evaluation and imaging for insulinoma.[8]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Standards of medical care in diabetes-2017: Summary of revisions. Diabetes Care 2017;40 Suppl 1:S4-5.  |
| 2. | Vasan SK, Ramachandran P, Mathew M, Natraj CV, Antonisamy B, Thomas N, et al. Post-absorptive glucose lowering in normal healthy individuals: An epidemiological observation. Diabetes Res Clin Pract 2014;104:e5-7. |
| 3. | Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia and diabetes: A report of a workgroup of the American diabetes association and the endocrine society. Diabetes Care 2013;36:1384-95. |
| 4. | Vasan SK, Karol R, Mahendri NV, Arulappan N, Jacob JJ, Thomas N, et al. A prospective assessment of dietary patterns in Muslim subjects with type 2 diabetes who undertake fasting during Ramadan. Indian J Endocrinol Metab 2012;16:552-7. |
| 5. | Vasan SK, Pittard AE, Abraham J, Samuel P, Seshadri MS, Thomas N, et al. Cause-specific mortality in diabetes: Retrospective hospital based data from South India. J Diabetes 2012;4:47-54. |
| 6. | Nanaiah A, Chowdhury SD, Jeyaraman K, Thomas N. Prevalence of cardiac autonomic neuropathy in Asian Indian patients with fibrocalculous pancreatic diabetes. Indian J Endocrinol Metab 2012;16:749-53. |
| 7. | Esterson YB, Carey M, Piette JD, Thomas N, Hawkins M. A systematic review of innovative diabetes care models in low-and middle-income countries (LMICs). J Health Care Poor Underserved 2014;25:72-93. |
| 8. | Joseph AJ, Kapoor N, Simon EG, Chacko A, Thomas EM, Eapen A, et al. Endoscopic ultrasonography – A sensitive tool in the preoperative localization of insulinoma. Endocr Pract 2013;19:602-8. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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