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Hypoglycemia Treatment & Management

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

Approach Considerations

The mainstay of therapy for hypoglycemia is glucose. Other medications may be administered based on the underlying cause or the accompanying symptoms (not discussed here).

Fasting hypoglycemia

Dietary therapy may be effective for improving symptoms in patients with fasting hypoglycemia. Frequent meals/snacks are preferred, especially at night, with complex carbohydrates.

If dietary therapy is inadequate, medical care for patients with fasting hypoglycemia may include intravenous (IV) glucose infusion. However, IV octreotide is effective for suppressing endogenous insulin secretion. Reactive hypoglycemia does not require medical care.

Because exercise burns carbohydrates and increases sensitivity to insulin, patients with fasting hypoglycemia should avoid significant activity. However, patients with reactive hypoglycemia often find that their symptoms improve after embarking on a routine exercise program.

Definitive treatment for fasting hypoglycemia caused by a tumor is surgical resection. The success rate is good for benign islet-cell adenomas, and the success rate for malignant islet-cell tumors can be as high as 50%.

Reactive hypoglycemia

For patients with reactive hypoglycemia, initiate a restriction of refined carbohydrates. Patients should avoid simple sugars, increase the frequency of their meals, and reduce the size of their meals. Patients may require 6 small meals and 2-3 snacks per day. Increased protein and fiber in the meal may be beneficial. In many patients, use of alpha-glucosidase inhibitors (acarbose and miglitol) may help. These medications cause reversible inhibition of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase enzymes. This enzyme inhibition results in delayed glucose absorption and a lowering of postprandial hyperglycemia and thus may prevent reactive hypoglycemia.

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Complications

Hypoglycemia occurring as a complication of therapy for diabetes is common[8, 9, 10, 11] ; in fact, mild hypoglycemia occurs in more than half of all patients with diabetes who are in therapy. Unrecognized infection causing hypoglycemia in patients with diabetes may result in recurrent hypoglycemic spells or progression of the infection.

Acute sequelae of hypoglycemia can include coma, cardiac dysrhythmia, and death. The risk of permanent neurologic deficits increases with prolonged hypoglycemia; such deficits can include hemiparesis, memory impairment, diminished language skills, decreased abstract thinking capabilities, and ataxia.

Untreated fasting hypoglycemia can lead to severe neuroglycopenia and, possibly, death.

In an Australian study, Egi et al reported that in critically ill patients, hypoglycemia was found to be an independent risk factor for death, cardiovascular death, and infectious disease–related death.[16] In addition, there was a significant association between patient mortality rates and the severity of hypoglycemia.[16]

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Long-Term Monitoring

Diabetic patients with episodes of hypoglycemia need education in nutrition, checking glucose levels at home, and early signs and symptoms of hypoglycemia. Recognition of early symptoms is paramount for self-treatment.

Guidelines from a workgroup of the American Diabetes Association (ADA) and the Endocrine Society address the dangers of hypoglycemia in diabetic patients. The workgroup developed 2 tools for clinicians treating those with diabetes:a patient questionnaire and a provider checklist.[17, 18]

The Hypoglycemia Patient Questionnaire includes the following questions:

  • How well can you recognize the symptoms of low blood glucose?
  • How often do you have hypoglycemic episodes?
  • Have you needed assistance in the past during a hypoglycemic episode?
  • Do you check your glucose level before driving?
  • Do those close to you know how to administer glucagon?

The Hypoglycemia Provider Checklist is designed to verify that the clinician has asked the appropriate questions of the patient and has made the appropriate recommendations for managing low blood sugar.[17, 18]

If the patient has fasting hypoglycemia and the cause is treatable, long-term follow-up usually is not needed. If the cause cannot be treated definitively (eg, inoperable pancreatic insulinoma), diazoxide can be used to elevate blood glucose levels and chemotherapy that specifically targets the beta cell (ie, using cytotoxic agents such as streptozotocin) should be considered.

If the patient has reactive hypoglycemia, periodic outpatient monitoring is warranted to assess the continued presence of symptoms.

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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: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: on advisory panel of Novo-Nordisk Inc, Astra-Zeneca Inc., Metagenics Inc<br/>Received research grant from: Metagenics Inc, USDA Dairy Council <br/>Have a 5% or greater equity interest in: HealthyMation LLC<br/>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

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Diagnostic algorithm. A systematic approach is often required to establish the true cause of hypoglycemia, using an algorithmic approach.
 
 
 
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