Hypoglycemia
Hypoglycemia, also spelled hypoglycaemia or hypoglycæmia, sometimes called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL. Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose below 70 mg/dL, symptoms associated with hypoglycemia, and resolution of symptoms when blood sugar returns to normal. Hypoglycemia may result in headache, tiredness, clumsiness, trouble talking, confusion, fast heart rate, sweating, shakiness, nervousness, hunger, loss of consciousness, seizures, or death. Symptoms typically come on quickly. Symptoms can persist after blood-glucose levels are restored to normal.
The most common cause of hypoglycemia is medications used to treat diabetes such as insulin, sulfonylureas, and biguanides. Risk is greater in diabetics who have eaten less than usual, recently exercised, or consumed alcohol. Other causes of hypoglycemia include severe illness, sepsis, kidney failure, liver disease, hormone deficiency, tumors such as insulinomas or non-B cell tumors, inborn errors of metabolism, and several medications. Low blood sugar may occur in otherwise healthy newborns who have not eaten for a few hours.
Hypoglycemia is treated by eating a sugary food or drink, for example glucose tablets or gel, apple juice, soft drink, or lollipops. The person must be conscious and able to swallow. The goal is to consume 10–20 grams of a carbohydrate to raise blood glucose levels to a minimum of 70 mg/dL. If a person is not able to take food by mouth, glucagon by injection or insufflation may help. The treatment of hypoglycemia unrelated to diabetes includes treating the underlying problem.
Among people with diabetes, prevention starts with learning the signs and symptoms of hypoglycemia. Diabetes medications, like insulin, sulfonylureas, and biguanides can also be adjusted or stopped to prevent hypoglycemia. Frequent and routine blood glucose testing is recommended. Some may find continuous glucose monitors with insulin pumps to be helpful in the management of diabetes and prevention of hypoglycemia.
Definition
Hypoglycemia, also called low blood sugar or low blood glucose, is a blood-sugar level below 70 mg/dL.Blood-sugar levels naturally fluctuate throughout the day, the body normally maintaining levels between 70 and 110 mg/dL. Although 70 mg/dL is the lower limit of normal glucose, symptoms of hypoglycemia usually do not occur until blood sugar has fallen to 55 mg/dL or lower. The blood-glucose level at which symptoms of hypoglycemia develop in someone with several prior episodes of hypoglycemia may be even lower.
Whipple's triad
The symptoms of low blood sugar alone are not specific enough to characterize a hypoglycemic episode. A single blood sugar reading below 70 mg/dL is also not specific enough to characterize a hypoglycemic episode. Whipple's triad is a set of three conditions that need to be met to accurately characterize a hypoglycemic episode.The three conditions are the following:
- The signs and symptoms of hypoglycemia are present
- A low blood glucose measurement is present, typically less than 70 mg/dL
- The signs and symptoms of hypoglycemia resolve after blood glucose levels have returned to normal
Age
In children who are aged greater than 48 hours, serum glucose on average ranges from 70 to 100 mg/dL, similar to adults. Elderly patients and patients who take diabetes pills such as sulfonylureas are more likely to suffer from a severe hypoglycemic episode. Whipple's triad is used to identify hypoglycemia in children who can communicate their symptoms.
Signs and symptoms
Hypoglycemic symptoms are divided into two main categories. The first category is symptoms caused by low glucose in the brain, called neuroglycopenic symptoms. The second category of symptoms is caused by the body's reaction to low glucose in the blood, called adrenergic symptoms.Everyone experiences different symptoms of hypoglycemia, so someone with hypoglycemia may not have all of the symptoms listed above. Symptoms also tend to have quick onset. It is important to quickly obtain a blood glucose measurement in someone presenting with symptoms of hypoglycemia to properly identify the hypoglycemic episode.
Causes
Hypoglycemia is most common in those with diabetes treated by insulin, glinides, and sulfonylureas. Hypoglycemia is rare in those without diabetes, because there are many regulatory mechanisms in place to appropriately balance glucose, insulin, and glucagon.Diabetic
Medications
The most common cause of hypoglycemia in diabetics is medications used to treat diabetes such as insulin, sulfonylureas, and biguanides. This is often due to excessive doses or poorly timed doses. Sometimes diabetics may take insulin in anticipation of a meal or snack; then forgetting or missing eating that meal or snack can lead to hypoglycemia. This is due to increased insulin without the presence of glucose from the planned meal.Hypoglycemic unawareness
Recurrent episodes of hypoglycemia can lead to hypoglycemic unawareness, or the decreased ability to recognize hypoglycemia. As diabetics experience more episodes of hypoglycemia, the blood glucose level which triggers symptoms of hypoglycemia decreases. In other words, people without hypoglycemic unawareness experience symptoms of hypoglycemia at a blood glucose of about 55 mg/dL. Those with hypoglycemic unawareness experience the symptoms of hypoglycemia at far lower levels of blood glucose. This is dangerous for a number of reasons. The hypoglycemic person not only gains awareness of hypoglycemia at very low blood glucose levels, but they also require high levels of carbohydrates or glucagon to recover their blood glucose to normal levels. These individuals are also at far greater risk of severe hypoglycemia.While the exact cause of hypoglycemic unawareness is still under research, it is thought that these individuals progressively begin to develop fewer adrenergic-type symptoms, resulting in the loss of neuroglycopenic-type symptoms. Neuroglycopenic symptoms are caused by low glucose in the brain, and can result in tiredness, confusion, difficulty with speech, seizures, and loss of consciousness. Adrenergic symptoms are caused by the body's reaction to low glucose in the brain, and can result in fast heart rate, sweating, nervousness, and hunger. See section above on Signs and Symptoms for further explanation of neuroglycopenic symptoms and adrenergic symptoms.
In terms of epidemiology, hypoglycemic unawareness occurs in 20–40% of type 1 diabetics.
Other causes
Other causes of hypoglycemia in diabetics include the following:- Fasting, whether it be a planned fast or overnight fast, as there is a long period of time without glucose intake
- Exercising more than usual as it leads to more use of glucose, especially by the muscles
- Drinking alcohol, especially when combined with diabetic medications, as alcohol inhibits glucose production
- Kidney disease, as insulin cannot be cleared out of circulation well
Non-diabetic
Serious illness
Serious illness may result in low blood sugar. Severe disease of many organ systems can cause hypoglycemia as a secondary problem. Hypoglycemia is especially common in those in the intensive care unit or those in whom food and drink is withheld as a part of their treatment plan.Sepsis, a common cause of hypoglycemia in serious illness, can lead to hypoglycemia through many ways. In a state of sepsis, the body uses large amounts of glucose for energy. Glucose use is further increased by cytokine production. Cytokines are a protein produced by the body in a state of stress, particularly when fighting an infection. Cytokines may inhibit glucose production, further decreasing the body's energy stores. Finally, the liver and kidneys are sites of glucose production, and in a state of sepsis those organs may not receive enough oxygen, leading to decreased glucose production due to organ damage.
Other causes of serious illness that may cause hypoglycemia include liver failure and kidney failure. The liver is the main site of glucose production in the body, and any liver failure or damage will lead to decreased glucose production. While the kidneys are also sites of glucose production, their failure of glucose production is not significant enough to cause hypoglycemia. Instead, the kidneys are responsible for removing insulin from the body, and when this function is impaired in kidney failure, the insulin stays in circulation longer, leading to hypoglycemia.
Drugs
A number of medications have been identified which may cause hypoglycemia, through a variety of ways. Moderate quality evidence implicates the non-steroidal anti-inflammatory drug indomethacin and the anti-malarial quinine. Low quality evidence implicates lithium, used for bipolar disorder. Finally, very low quality evidence implicates a number of hypertension medications including angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and β-adrenergic blockers. Other medications with very low quality evidence include the antibiotics levofloxacin and trimethoprim-sulfamethoxazole, progesterone blocker mifepristone, anti-arrhythmic disopyramide, anti-coagulant heparin, and chemotherapeutic mercaptopurine.If a person without diabetes accidentally takes medications that are traditionally used to treat diabetes, this may also cause hypoglycemia. These medications include insulin, glinides, and sulfonylureas. This may occur through medical errors in a healthcare setting or through pharmacy errors, also called iatrogenic hypoglycemia.