Approach To Patient

Hypoglycemia in Adults - Approach to the Patient Without Diabetes

Editors: Paul M. Copeland MD, MPhil; Heather A. Ferris MD, Phd; Allen Shaughnessy PharmD, M Med Ed, FCCP; Alan Ehrlich MD, FAAFP

American College of PhysiciansProduced in collaboration with American College of Physicians
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General Information

Description

  • hypoglycemia in persons without diabetes is a rare clinical syndrome defined as plasma glucose low enough to cause autonomic and/or neuroglycopenic signs or symptoms, including impaired brain function
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    ,
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  • hypoglycemia is confirmed when Whipple triad is present
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    ,
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    • symptoms or signs consistent with hypoglycemia
    • plasma glucose < 55 mg/dL (measured with a precise method such as a venous blood sample)
    • resolution of symptoms after increasing plasma glucose level
  • the causes and pathophysiology of hypoglycemia differ in patients with and without diabetes; the diagnosis and management strategies differ as well
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  • for more information on hypoglycemia in diabetes, see Hypoglycemia in Diabetes

Definitions

  • hypoglycemia - plasma glucose low enough to cause autonomic and/or neuroglycopenic signs or symptoms, including impaired brain function
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  • postprandial hyperinsulinemic hypoglycemia - development of hypoglycemia within a few hours of meal ingestion
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  • factitious hypoglycemia - hypoglycemia that is voluntarily self-induced
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  • pseudohypoglycemia - an artifact of continued glucose metabolism by elements of the blood after the sample is drawn; occurs in the setting of erythrocytosis, leukocytosis, or thrombocytosis
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Classifications

  • historical classification fasting (postabsorptive) vs. postprandial (reactive) hypoglycemia
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    • no longer considered useful
    • patients with some disorders (for example insulinoma) usually experience postabsorptive hypoglycemia, but may also have postprandial hypoglycemia, while other conditions (for example postgastric bypass) who typically have postprandial hypoglycemia, may have symptoms when fasting
    • other disorders (for example, factitious hypoglycemia) are not easily classified as either postabsorptive or postprandial
  • preferred approach is to classify patient as
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    • seemingly well
      • endogenous hyperinsulinism
        • insulinoma
        • noninsulinoma pancreatogenous hypoglycemia
        • postgastric bypass hypoglycemia
        • insulin autoimmunity
          • antibody to insulin
          • antibody to insulin receptor
      • exogenous hyperinsulinism
        • accidental
        • factitious
    • having a concurrent illness
      • critical illness
        • hepatic, renal, cardiac failure
        • sepsis
        • inanition
      • hormone deficiency
        • cortisol
        • growth hormone
        • glucagon
      • nonbeta cell tumors
    • taking a medication or toxin that causes hypoglycemia
      • insulin or insulin secretagogue
      • alcohol

Incidence and Prevalence

  • hypoglycemia is rare in persons who do not have drug-treated diabetes mellitus
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  • postgastric bypass hypoglycemia
    • reported to be < 1%, but may be underreported (Clin Endocrinol (Oxf) 2016 Jul;85(1):3)
    • 0.36% prevalence of symptomatic postgastric bypass hypoglycemia in 3,082 patients who had Roux-en-Y gastric bypass in cohort study (Surg Obes Relat Dis 2008 Jul-Aug;4(4):492)
    • 0.1% prevalence of self-reported hypoglycemia following Roux-en-Y gastric bypass in 145,582 patients from Bariatric Outcomes Longitudinal Database cohort (Obes Surg 2014 Jul;24(7):1120)
    • 34.2% prevalence of symptoms of postbariatric hypoglycemia and 11.6% prevalence of severe symptoms of postbariatric hypoglycemia self-reported by 450 patients with Roux-en-Y gastric bypass (79%) or vertical sleeve gastrectomy (21%) in questionnaire-based cohort study (Obesity (Silver Spring) 2015 May;23(5):1079)
    • STUDY SUMMARY
      prevalence of hospitalization for hypoglycemia following Roux-en-Y gastric bypass 0.2% in Sweden
      COHORT STUDY: Diabetologia 2010 Nov;53(11):2307

  • hypoglycemia in critical care patients
    • STUDY SUMMARY
      ≥ 1 episode of hypoglycemia may occur in about 5% of patients in intensive care unit
      COHORT STUDY: Crit Care Med 2010 Jun;38(6):1430

    • STUDY SUMMARY
      prevalence of hypoglycemia (≥ 1 episode) about 25% among children in intensive care unit after burn injury
      COHORT STUDY: Crit Care Med 2014 May;42(5):1221

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