Hypoglycemia
Hypoglycemia is common in insulin, sulfonylurea, or glinide-treated diabetes where it is typically the result of the interplay of therapeutic insulin excess and compromised physiological and behavioral defenses against falling glucose levels. It is uncomm
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Hypoglycemia Philip E. Cryer
Précis 1. Clinical setting—A patient with some combination of neurogenic symptoms (sweating, hunger, tremor, palpitations), neuroglycopenic manifestations (confusion, aberrant behavior, seizure, coma), and signs of sympathoadrenal activation (pallor, diaphoresis) [1, 2]. 2. Diagnosis (a) Important findings include a history of hypoglycemic or hyperglycemic episodes, a confirmed diagnosis of diabetes, medications used to treat hypoglycemia, alcohol abuse, liver, kidney, and pituitary disease, and a history of bariatric surgery. (b) Physical examination—vital signs (tachycardia) mental status (delirium, obtundation) and the “gag” reflex should be assessed. (c) Laboratory findings—the key laboratory measurement is a capillary blood plasma glucose of less than 55 mg/dL. 3. Treatment (a) In the medical setting (office or hospital): intravenous glucose is the standard initial treatment regardless of cause. An initial dose of 25 g of glucose as an intravenous bolus is recommended [5]. This should be followed by an intravenous infusion of glucose at a rate of 20 mg/kg/min until hypoglycemia is corrected [8]. In sulfonylurea-induced hypoglycemia infusion of the somatostatin analogue octreotide can be used to suppress insulin secretion [9].
P.E. Cryer, M.D. (*) Barnes-Jewish Hospital, Campus Box 8127, 660 South Euclid Avenue, St. Louis, MO 63110, USA e-mail: [email protected]
L. Loriaux (ed.), Endocrine Emergencies: Recognition and Treatment, Contemporary Endocrinology 74, DOI 10.1007/978-1-62703-697-9_3, © Springer Science+Business Media New York 2014
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(b) In the home setting, most episodes of hypoglycemia can be treated with oral carbohydrate in the form of glucose tablets, juices, soft drinks, candy, or food. An initial dose of 20 g carbohydrate is recommended. The carbohydrate must be swallowed: Glucose applied to the buccal mucosa is not absorbed [6]. This dose of carbohydrate should be repeated if the plasma glucose is not increased 15–20 min after administration. (c) If the patient cannot take oral carbohydrate: A subcutaneous or intramuscular injection of 1 mg glucagon is very effective [7]. Because glucagon works by stimulating insulin secretion and glycogenolysis, it will be less effective in type 2 compared to type 1 diabetes and will be ineffective in glycogendepleted individuals such as the aftermath of an alcoholic binge, or in patients with end stage liver disease. After successful treatment of an episode of hypoglycemia, measures that will prevent its recurrence are required. An understanding of the pathogenesis of the initial hypoglycemic episode and a rational approach to its treatment are essential components of successful management.
Frequency and Impact of Hypoglycemia Hypoglycemia is the limiting factor in the glycemic management of diabetes [1]. Iatrogenic hypoglycemia—triggered by treatment with a sulfonylurea, a glinide, or insulin—causes recurrent morbidity in most people with type 1 diabetes and many with advanced type 2 diabetes and is sometimes
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