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. Using resistant-starch bars, which provide steady-state glucose over an extended period, may also be beneficial.
Complications
Hypoglycemia occurring as a complication of therapy for diabetes is common; [14, 15, 16, 17] 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.
A study by Middleton et al suggested that sulfonylurea-related hypoglycemia can result in harmful cardiovascular effects. The study included 30 persons with sulfonylurea-treated type 2 diabetes, nine of whom were found to have hypoglycemia. The investigators found that five of the nine patients demonstrated hypoglycemia-associated QTc prolongation; additionally, the hypoglycemic individuals showed higher QT dynamicity relative to the other patients, even after the hypoglycemic events had passed. [24]
Another study, by Mezquita-Raya et al, involving patients with type 1 or type 2 diabetes, also found a relationship between hypoglycemia and QTc prolongation, with the phenomenon occurring primarily in cases of type 1 diabetes. However, the results did not demonstrate a link between hypoglycemia and clinical arrhythmias in patients with type 1 or type 2 diabetes with high cardiovascular risk. [25]
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. [26] In addition, there was a significant association between patient mortality rates and the severity of hypoglycemia. [26]
A Japanese study, by Ohashi et al, indicated that in persons with type 1 or 2 diabetes being treated with insulin, nonsevere hypoglycemic events (NSHEs) can negatively affect diabetes management, daily activities, work, sleep, and the patient’s emotional state. Subjects in the study were aged 20 years or older. [27]
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. [28, 29]
The Hypoglycemia Patient Questionnaire includes the following questions:
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How well can you recognize the symptoms of low blood glucose?
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How often do you have hypoglycemic episodes?
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Have you needed assistance in the past during a hypoglycemic episode?
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Do you check your glucose level before driving?
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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. [28, 29]
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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Diagnostic algorithm. A systematic approach is often required to establish the true cause of hypoglycemia, using an algorithmic approach.
