Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Hypoglycemia Differential Diagnoses

  • Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 05, 2016
 
 

Diagnostic Considerations

Because 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. Patients with no previous history of hypoglycemia require a complete workup to find a potentially treatable disease.

Careful consideration should be given to all diabetic patients presenting with hypoglycemia. New medications, activity changes, and infection should be considered. Early in the course of non–insulin-dependent diabetes, patients may experience episodes of hypoglycemia several hours after meals. The symptoms generally are brief and respond spontaneously.

Conditions such as Jamaican vomiting sickness, ingestion of ethanol-containing mouthwash or cologne (children), gastric surgery, potassium administration during periodic attacks of paralysis, excessive muscular activity, diarrhea (childhood) can also cause hypoglycemia.

The following should also be considered when evaluating a patient with hypoglycemia:

  • Hepatic disease: (eg, hepatic failure, cirrhosis, galactose intolerance, fructose intolerance, glycogen storage diseases)
  • Transient ischemic attacks
  • Cardiac dysrhythmia
  • Endocrine disorders (eg, pheochromocytoma, Addison disease, glucagon deficiency, carcinomas, extrahepatic tumors)
  • Substance abuse (eg, cocaine, ethanol, salicylates, beta-blockers, pentamidine)
  • Hypoglycemic agents (eg, insulin, oral hypoglycemic agents)
  • Nutritional disorders (eg, prolonged starvation before anesthesia, protein calorie malnutrition, L-leucine-sensitive hypoglycemic defect in children, low-calorie ketogenic diet, renal disease)
  • Autoimmune disorders (eg, Graves disease)
  • Central nervous system (CNS) disorders
  • Psychogenic

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Osama Hamdy, MD, PhD Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Program, Joslin Diabetes Center; Assistant Professor of Medicine, Harvard Medical School

Osama Hamdy, MD, PhD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association

Disclosure: Received consulting fee from Merck Inc for speaking and teaching; Received consulting fee from Abbott Nutrition for consulting; Received grant/research funds from Metagenics for research support; Received grant/research funds from Neurometrix for research support.

Coauthor(s)

Kenneth J Snow, MD Associate Chief, Adult Diabetes, Joslin Clinic

Kenneth J Snow, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Vellore A R Srinivasan, MSc, PhD Professor of Biochemistry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, India

Disclosure: Received salary from Sri Balaji Vidyapeeth University, Mahatma Gandhi Medical College and Research Institute campus , Pondicherry ( Puducherry ) , India . P.C. 607 402 for employment.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Vasudevan A Raghavan, MBBS, MD, MRCP(UK) Director, Cardiometabolic and Lipid (CAMEL) Clinic Services, Division of Endocrinology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine

Vasudevan A Raghavan, MBBS, MD, MRCP(UK) is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Heart Association, Endocrine Society, National Lipid Association, and Royal College of Physicians

Disclosure: Nothing to disclose.

David S Schade, MD Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Pugh SK, Doherty DA, Magann EF, et al. Does hypoglycemia following a glucose challenge test identify a high risk pregnancy?. Reprod Health. 2009 Jul 14. 6:10. [Medline]. [Full Text].

  2. Hughes S. Pain Med Linked to Hypoglycemia. Medscape Medical News. Dec 11 2014. [Full Text].

  3. Fournier JP, Azoulay L, Yin H, et al. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Intern Med. 2014 Dec 8. [Medline].

  4. Eriksson JW, Bodegard J, Nathanson D, Thuresson M, Nystrom T, Norhammar A. Sulphonylurea compared to DPP-4 inhibitors in combination with metformin carries increased risk of severe hypoglycemia, cardiovascular events, and all-cause mortality. Diabetes Res Clin Pract. 2016 Jul. 117:39-47. [Medline].

  5. Gautier JF, Monguillon P, Verier-Mine O, et al. Which oral antidiabetic drug to combine with metformin to minimize the risk of hypoglycemia when initiating basal insulin?: A randomized controlled trial of a DPP4 inhibitor versus insulin secretagogues. Diabetes Res Clin Pract. 2016 Jun. 116:26-8. [Medline].

  6. Hill NR, Thompson B, Bruce J, et al. Glycaemic risk assessment in children and young people with Type 1 diabetes mellitus. Diabet Med. 2009 Jul. 26(7):740-3. [Medline].

  7. Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia. 2009 Aug 5. [Medline].

  8. Prolonged Nocturnal Hypoglycemia Is Common During 12 Months Of Continuous Glucose Monitoring In Children And Adults With Type 1 Diabetes. Diabetes Care. 2010 Mar 3. [Medline]. [Full Text].

  9. Swinnen SG, Dain MP, Aronson R, et al. A 24-week, randomized, treat-to-target trial comparing initiation of insulin glargine once-daily with insulin detemir twice-daily in patients with type 2 diabetes inadequately controlled on oral glucose-lowering drugs. Diabetes Care. 2010 Mar 3. [Medline].

  10. Ito T, Otsuki M, Igarashi H, et al. Epidemiological Study of Pancreatic Diabetes in Japan in 2005: A Nationwide Study. Pancreas. 2010 Feb 22. [Medline].

  11. Chen L. A literature review of intensive insulin therapy and mortality in critically ill patients. Clin Nurse Spec. 2010 Mar-Apr. 24(2):80-6. [Medline].

  12. Garza H. Minimizing the risk of hypoglycemia in older adults: a focus on long-term care. Consult Pharm. 2009 Jun. 24 Suppl B:18-24. [Medline].

  13. Boucai L, Southern WN, Zonszein J. Hypoglycemia-associated Mortality Is Not Drug-associated but Linked to Comorbidities. Am J Med. 2011 Nov. 124(11):1028-35. [Medline]. [Full Text].

  14. Feil DG, Rajan M, Soroka O, et al. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc. 2011 Dec. 59(12):2263-72. [Medline].

  15. Lin YY, Hsu CW, Sheu WH, Chu SJ, Wu CP, Tsai SH. Use of therapeutic responses to glucose replacement to predict glucose patterns in diabetic patients presenting with severe hypoglycaemia. Int J Clin Pract. 2009 Aug. 63(8):1161-6. [Medline].

  16. Egi M, Bellomo R, Stachowski E, et al. Hypoglycemia and outcome in critically ill patients. Mayo Clin Proc. 2010 Mar. 85(3):217-24. [Medline]. [Full Text].

  17. New Guidelines Stress Hypoglycemia Affects All Diabetics. Medscape Medical News. Available at http://www.medscape.com/viewarticle/802949?nlid=30763_1621. Accessed: May 2, 2013.

  18. 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 May. 36(5):1384-95. [Medline]. [Full Text].

  19. Goh HK, Chew DE, Miranda IG, Tan L, Lim GH. 24-Hour observational ward management of diabetic patients presenting with hypoglycaemia: a prospective observational study. Emerg Med J. 2009 Oct. 26(10):719-23. [Medline].

  20. Goto A, Arah OA, Goto M, Terauchi Y, Noda M. Severe hypoglycaemia and cardiovascular disease: systematic review and meta-analysis with bias analysis. BMJ. 2013 Jul 29. 347:f4533. [Medline].

  21. Lowry F. Severe Hypoglycemia Boosts CVD Risk in Type 2 Diabetes. Medscape Medical News. Available at http://www.medscape.com/viewarticle/808863. Accessed: August 12, 2013.

  22. McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C. A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia. JPEN J Parenter Enteral Nutr. 2013 Jan. 37(1):23-36. [Medline].

  23. Sinert R, Su M, Secko M, Zehtabchi S. The utility of routine laboratory testing in hypoglycaemic emergency department patients. Emerg Med J. 2009 Jan. 26(1):28-31. [Medline].

  24. Kong AP, Chan JC. Hypoglycemia and Comorbidities in Type 2 Diabetes. Curr Diab Rep. 2015 Oct. 15 (10):646. [Medline].

 
Previous
Next
 
Diagnostic algorithm. A systematic approach is often required to establish the true cause of hypoglycemia, using an algorithmic approach.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.