hypoglycemia



OVERVIEW

What is hypoglycemia?

Definition of Hypoglycemia

Hypoglycemia is a clinical syndrome in which plasma glucose levels are lowered by a variety of causes, resulting in symptoms and signs that subside when plasma glucose levels rise.

For non-diabetic patients, the diagnostic criterion for hypoglycemia is a blood glucose level of less than 2.8 mmol/L (millimoles per liter), while diabetic patients with a blood glucose level of ≤3.9 mmol/L fall into the category of hypoglycemia.

Typing

Hypoglycemia in diabetic patients: It may be related to the improper use of glucose-lowering medication and eating too little in diabetic patients.

Hypoglycemia in non-diabetic patients: can be caused by insulinoma, dumping syndrome, liver failure, severe diarrhea, etc.

Mild hypoglycemia: only hunger pangs, transient sweating, palpitations, which can be relieved by oneself.

Moderate hypoglycemia: palpitations, sweating, obvious hunger, hand shaking, dizziness, need to supplement sugary food to correct.

Severe hypoglycemia: on the basis of moderate hypoglycemia, there are manifestations of insufficient supply of energy to the central system, such as drowsiness, impaired consciousness, or even coma and death.

Morbidity

Hypoglycemia can occur in non-diabetic as well as diabetic patients.

Hypoglycemia is one of the dangerous complications of diabetes mellitus, with approximately 9 to 120 episodes per 100 patients per year.

Questions you may be concerned about

What are the dangers of hypoglycemia?

Hypoglycemic episodes may affect the patient’s consciousness and increase the incidence of accidents such as fractures and falls. Hypoglycemic episodes in the elderly are prone to induce angina pectoris, myocardial infarction, transient ischemic attack, and cerebral infarction.

Severe prolonged hypoglycemia may lead to permanent brain cell damage. If a hypoglycemic coma lasts for more than 6 hours, brain cells will be severely damaged and can lead to dementia or even death.

How can I tell if I have hypoglycemia?

To determine if you are hypoglycemic, you can use a combination of symptoms and blood glucose measurements.

In hypoglycemia, symptoms such as sweating, hunger, trembling, palpitations, and pallor may occur, and these symptoms can be relieved quickly after sugar supply.

At the same time, blood glucose values can be measured. Blood glucose <2.8 mmol/L in non-diabetic adults and ≤3.9 mmol/L in diabetic patients can assist in diagnosis.

Sometimes insulin, C-peptide measurement, abdominal CT, abdominal magnetic resonance imaging (MRI), and other tests are also needed to help clarify the cause of hypoglycemia under the guidance of a doctor.

What are the dietary precautions for hypoglycemia?

People with a history of hypoglycemia and those with diabetes must eat all three meals on time and carry some high-sugar foods, such as candies and chocolates, with them on weekdays. If symptoms of hypoglycemia such as panic, shaking hands, and hunger occur, promptly replenish candies, etc. For those who are unconscious, do not feed them to avoid choking.

Is low blood sugar a precursor to diabetes?

Hypoglycemia may be a precursor to diabetes, but the presence of hypoglycemia does not necessarily indicate diabetes.

In pre-diabetes, hypoglycemia may occur, manifested as preprandial hunger, palpitations, sweating, this is because pre-diabetes is mostly dominated by insulin resistance, that is, the sensitivity of their own insulin decreases, in order to better control blood glucose, the pancreatic islet cells “desperately” produce insulin, so that when blood glucose reaches the highest point in the descent process, it encounters the secretion of insulin, which is the most important part of blood glucose. When the blood glucose reaches the highest point, the insulin secretion peaks, and preprandial hypoglycemia may occur.

Causes

Causes

Hypoglycemia in diabetics

The following factors have been associated with the development of hypoglycemia in diabetics.

Inappropriate use of glucose-lowering medications, such as overdose of insulin and oral hypoglycemic agents.

Not eating on time or eating too little.

Exercising without eating, or increased exercise.

Consumption of alcohol, especially on an empty stomach.

Hypoglycemia in non-diabetics

The following factors have been associated with the development of hypoglycemia in diabetics.

Quinolones, pentamidine, quinine, beta-blockers, angiotensin-converting enzyme inhibitors, etc.

Serious illness: liver failure, renal failure, heart failure, sepsis, or malnutrition.

Other diseases: insulinoma, islet cell hyperplasia, insulin autoimmune hypoglycemia.

Common disorders in infants: persistent hyperinsulinemic hypoglycemia in infants, congenital hyperinsulinemia.

Dumping syndrome occurs after gastrectomy, causing hypoglycemia.

Starvation, weight loss, heavy drinking on an empty stomach, heavy diarrhea, and excessive exercise.

Pathogenesis

The central aspect of the pathogenesis of hypoglycemia is that the sources of blood glucose are less than the destination, including both a decrease in the body’s glucose intake, a decrease in hepatic glycogenolysis and gluconeogenesis, and/or an increase in the body’s tissues consuming and utilizing glucose.

Decreased sources of blood glucose

Inadequate glucose intake: inability to meet the body’s needs, e.g., starvation, poor digestion and absorption, etc.

Insufficient gluconeogenesis: insufficient hepatic glycogen synthesis reserve, decreased glycogenolysis, impaired gluconeogenesis, etc., e.g. occurrence of cirrhosis, liver cancer, etc.

Increase in blood sugar going

Increased sugar consumption: excessive sugar consumption without timely supplementation, such as strenuous exercise, severe diarrhea, nephrogenic urinary glucose, malignant tumors, etc.

Excessive sugar conversion: excessive insulin, sugar in the body is converted or consumed, resulting in a drop in blood sugar, such as insulinoma.

Symptoms

Symptoms of hypoglycemia are varied, and the severity is related to the etiology, the rate of blood glucose drop, the frequency of onset, and individual differences. Autonomic and central nervous symptoms may be present.

Autonomic symptoms

Symptoms are mostly due to the overproduction of epinephrine or norepinephrine.

For example, panic, trembling, sweating, fatigue, hunger, transient blackouts, abnormal sensation, pallor, anxiety, abnormal sensation of face, hands and feet, cold and clammy skin, nausea and vomiting.

Central nervous system symptoms

Symptoms caused by central nervous system dysfunction, and prolonged and aggravated with the duration of hypoglycemia.

Initially: lack of mental concentration, slow thinking and speech, dizziness, drowsiness, unsteady gait, blurred vision, hallucinations, agitation, irritability, strange behavior.

Further development: inhibition of subcortical functions: restlessness, even tonic convulsions.

Further development: coma, various reflexes disappear.

Hypoglycemia continues to be uncorrected, the symptoms continue to be irreversible or even death.

Special manifestations

Undetected hypoglycemia syndrome

It is a more dangerous complication of type 1 diabetes mellitus, with no autonomic symptoms and rapid onset of convulsions or coma.

It tends to occur in patients who have had type 1 diabetes for 5 to 10 years or more, who use insulin to tightly control their blood glucose levels, who are overworked, who consume large amounts of alcohol, and who use certain medications for treating high blood pressure or diabetes.

Hypoglycemia

is a relatively common problem in the treatment of type 1 diabetes and is associated with insulin overdose.

It usually strikes during morning sleep, and upon awakening, hyperglycemia occurs due to the effects of glucagon, which can be attributed to underuse of insulin.

Severe hypoglycemia, or even coma, occurs with increased insulin doses.

Coma after hypoglycemia

Blood glucose levels return to normal and remain unconscious for more than 30 minutes.

Atypical presentation

Fasting hypoglycemia in children, the elderly, and patients with other systemic diseases, especially those with prolonged episodes, can present with a very atypical cross-cutting pattern.

Infants: may present with hypersomnia, excessive sweating, or even acute respiratory failure.

Elderly: often with personality changes, insomnia, hypersomnia, nightmares or sinus bradycardia.

Consultation

Department of Medicine

Endocrinology

If the following symptoms occur, it is recommended to consult a doctor promptly.

Blood glucose ≤2.8mmol/L in non-diabetic patients and ≤3.9mmol/L in diabetic patients.

Repeated symptoms such as hunger, dizziness, panic, trembling, and pallor.

Emergency Department

In case of emergencies such as unconsciousness, unresponsiveness, drowsiness, coma, etc., it is recommended to consult the doctor immediately.

Preparation for medical treatment

Information on how to get to the clinic: registration, preparation of documents, and frequently asked questions

Tips for medical treatment

It is recommended to record the time of blood glucose measurement and blood glucose value for the doctor’s reference.

It is recommended to carry hard candy bars and chocolates with you to avoid hypoglycemia during the visit.

Preparation Checklist

When did you first notice the blood sugar abnormality? What is the blood glucose value?

Do you have palpitations, trembling, sweating and hunger from time to time?

Has there been any change in weight in the last six months?

Do any of your blood relatives have a history of diabetes?

Are there any allergies to drugs, food or other substances?

Is there a history of heavy alcohol consumption?

Are there any diseases such as diabetes, cirrhosis of the liver, kidney failure, hypertension, etc.?

Laboratory tests: blood glucose, glycosylated hemoglobin, glycosylated plasma albumin, glucose tolerance test, insulin autoantibodies, insulin, C-peptide assay, urinalysis, urinary protein assay, liver and kidney function, arterial blood gas analysis.

Imaging tests: ultrasound of both lower limbs, ultrasound of liver, gallbladder, pancreas, spleen and kidneys, abdominal CT, abdominal magnetic resonance examination.

Other tests: electrocardiogram, funduscopic examination, electromyography

Metformin: Metformin, Phenformin

Sulfonylureas: glibenclamide, glimepiride, gliclazide, glipizide, gliquinone

Glargine: Repaglinide, Naglinide, Miglinide

Thiazolidinediones: rosiglitazone, pioglitazone

α-glucosidase inhibitors: acarbose, voglibose, miglitol

Dipeptidyl peptidase IV inhibitors: selegiline, saxagliptin, vigliptin

Sodium-glucose cotransporter protein 2 inhibitors: dagliflozin, empagliflozin, cagliflozin

Insulin: Glucagon, Deguelin, Mentholatum 30/50 Injection, Mentholatum Injection, Arginin Biosynthetic Human Insulin Injection 30R/50R

Glucagon-like peptide-1 receptor agonist: liraglutide

Others: glucose, hydrocortisone, prednisone acetate, methylprednisolone, dexamethasone

Diagnosis

Diagnosis based on

Medical history

Providing a detailed medical history is helpful for the doctor to make a diagnosis, such as history of diabetes mellitus, history of diabetes mellitus treatment, exercise, meal intake, and medication use.

Clinical manifestations

Hypoglycemic symptoms, such as sweating, hunger, abnormal sensation, trembling, anxiety, palpitation, pallor, etc.

Hypoglycemic symptoms resolve rapidly after sugar supply.

Laboratory Tests

The amount of blood glucose in the blood can be measured.

It is the most basic test to confirm the diagnosis of hypoglycemia. The diagnosis can be confirmed by blood glucose ≤ 2.8 mmol/L in non-diabetic adults and ≤ 3.9 mmol/L in diabetic patients.

Measurement of serum insulin and C-peptide levels.

Insulin measurement can confirm the presence or absence of abnormal insulin secretion; serum C-peptide measurement combined with insulin measurement can assist in determining the source of insulin. It helps to clarify the etiology.

Measure plasma glucose, serum insulin, C-peptide, and insulinogen after 72 hours of fasting.

Can be used to determine the presence of insulinoma.

CAUTION: Certain medications should be discontinued during the test as prescribed by the physician.

Imaging

Examines abdominal organs such as the pancreas.

Test results may be abnormal in the case of insulinoma.

Precautions:

Differential Diagnosis.

Hypoglycemia needs to be differentiated from transient ischemic attack and anemia. Coma occurring with hypoglycemia needs to be differentiated from diabetic ketoacidosis and diabetic nonketotic hyperosmolar coma.

Transient ischemic attack

Similarities: Dizziness, blackouts, tremors, headache, and seizures may be present.

Differences: Hypoglycemia has no cerebrovascular abnormalities and transient ischemic attack has no hypoglycemia on blood glucose testing. Diseases can be checked by blood glucose test, MRI of the head, etc.

Anemia

Similarities: Both may have symptoms such as pallor, blackouts, dizziness, etc.

Differences: Anemia can be detected by routine blood test with low hemoglobin content, while hypoglycemia usually has no hemoglobin reduction. It can be differentiated by routine blood test and blood glucose test.

Diabetic ketoacidosis

Similarity: Coma.

Difference: Diabetic ketoacidosis has ketone odor (rotten apple smell), low blood pressure and high urine output, blood glucose >11mmol/L, and arterial blood gas can have acidosis. Hypoglycemia is characterized by low blood glucose. It can be identified by blood biochemistry, etc.

Diabetic non-ketotic hyperosmolar coma

Similarity: coma.

Difference: hyperosmolar hyperglycemic state. Checking blood glucose may reveal hyperglycemia. It can be differentiated by blood biochemistry.

Treatment

Principles of treatment

Hypoglycemic episodes require rapid glucose supplementation and prompt search for the cause and treatment of the cause.

Treatment method

Emergency treatment

Prompt replenishment of candies, sugary drinks, and eating high carbohydrates (bread, buns, etc.) can correct the situation.

However, care should be taken to avoid fructose-containing foods, which cannot be used to correct hypoglycemia.

Monitor blood glucose after 15 minutes, if the blood glucose has not risen to normal (3.9 mmol/L for diabetic patients, 2.8 mmol/L for non-diabetic patients), or the symptoms are not relieved to continue to supplement sugar, if hypoglycemia symptoms recurring in time to go to the emergency room for medical attention.

The occurrence of unconsciousness, coma need to go to the emergency room immediately, intravenous injection of 50% glucose solution, most patients quickly awake.

Hydrocortisone and glucagon can also be added to take intramuscular or intravenous injection.

It is important to note that feeding is contraindicated in order to avoid choking in confused patients.

Treatment of etiology

Drug-induced hypoglycemia requires discontinuation of the drug in question.

Insulinoma-induced hypoglycemia: Surgical resection of the tumor is preferred. If the tumor cannot be resected, growth-suppressor analogues, such as octreotide and lanreotide, can be used to control hypoglycemia by inhibiting insulin secretion.

Prognosis

Cure

Hypoglycemia can usually be corrected by timely glucose supplementation, and most of them can be relieved after 15 minutes.

Drug-induced hypoglycemia can be relieved by prompt discontinuation of the drug in question.

Most insulinoma-induced hypoglycemia has a good prognosis after tumor resection, with a 10-year survival rate of 85%.

There are numerous causes of hypoglycemia, and hypoglycemia caused by certain incurable diseases can recur, such as malignant tumors and congenital enzyme defects.

Hypoglycemic episodes in the elderly predispose to angina pectoris, myocardial infarction, transient ischemic attack and cerebral infarction.

Hypoglycemia can affect consciousness and can increase the incidence of accidents such as fractures and falls.

Severe prolonged hypoglycemia can lead to permanent brain cell damage. If a hypoglycemic coma lasts for more than six hours, brain cells will be severely damaged, which can lead to dementia or even death, and brain tissue will not return to normal even after treatment.

Daily

Daily Management

Dietary management

Always eat on time, especially breakfast.

Those with a history of hypoglycemia or those with diabetes should carry some high-sugar foods with them, such as fruit candies, milk candies and chocolates.

Lifestyle Management

Avoid dieting and excessive weight loss.

Learn to recognize the symptoms of hypoglycemia and take sugar supplements immediately if there is discomfort.

Avoid heavy exercise on an empty stomach.

Blood Glucose Monitoring

People with frequent hypoglycemia should pay attention to blood glucose monitoring, and can choose regular manufacturers of home blood glucose meter monitoring.

Specific use should be carried out in accordance with the instructions, generally wash your hands before blood collection, and disinfect your fingers for blood collection, and press to stop bleeding after measurement.

Prevention

General population prevention

Eat regularly, three meals a day, especially avoid skipping breakfast.

Do not go on a long-term diet to lose weight.

Avoid strenuous exercise on an empty stomach, such as running or climbing mountains.

Have regular medical checkups and keep an eye on your blood sugar to check for any abnormalities.

Prevention for special groups

When going out, always carry candies or sugary drinks with you, and replenish sugar in time if you experience palpitations, hunger and other symptoms.

Be fully aware of the glucose-lowering drugs you are using, and do not change them and their dosages at will.

When activity increases, reduce the amount of insulin and add meals in time.

For patients who are prone to hypoglycemia in the second half of the night and early morning, add more staple food or food with higher protein content to dinner as appropriate.

Meals should be taken promptly after rapid-acting or short-acting insulin injection.

Monitor blood glucose regularly to keep abreast of blood glucose control.

Avoid alcohol intake, especially drinking on an empty stomach.

Avoid exercise immediately after insulin injection or taking hypoglycemic drugs.

Gastric surgery patients: after the operation can be eaten by mouth, the diet should be small and frequent meals, less soups and low sugar foods, and increase fat and protein foods appropriately.

Pregnant women: fasting should be avoided.

Newborns: breastfeed promptly within 30 minutes after delivery.

Others: If you have thyroid insufficiency or liver disease, treat it promptly and take medication on time.