Hypoglycemia


Article Author:
Philip Mathew


Article Editor:
Deepu Thoppil


Editors In Chief:
Ann Anderson Berry
Mark Hudak
Sumesh Parat


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/1/2019 9:37:49 AM

Introduction

Hypoglycemia is often defined by a plasma glucose concentration below 70 mg/dL; however, signs and symptoms may not occur until plasma glucose concentrations drop below 55 mg/dL. The symptoms of Whipple's triad have been used to describe hypoglycemia since 1938.  For Whipple's triad, the practitioner must first recognize symptoms of hypoglycemia, then obtain low blood glucose, and finally, demonstrate immediate relief of symptoms by the correction of the low blood glucose.  Glucose is the primary metabolic fuel for the brain under physiologic conditions. Unlike other tissues of the body, the brain is very limited in supplying its glucose. Expectedly, the brain requires a steady supply of arterial glucose for adequate metabolic function. Potential complications can arise from an interruption in the glucose supply. As such, protective mechanisms to guard against low serum blood glucose (hypoglycemia) have evolved in the body. 

During fasting states, serum glucose levels are maintained via gluconeogenesis and glycogenolysis in the liver. Gluconeogenesis is the pathway in which glucose is generated from non-carbohydrate sources.  These non-carbohydrate sources could be protein, lipids, pyruvate or lactate. In contrast, glycogenolysis is the breakdown of glycogen into glucose product. Much of glycogenolysis occurs in hepatocytes (liver) and myocytes (muscle).

Hypoglycemia is most often seen in patients suffering from diabetes who are undergoing pharmacologic intervention. Amongst this group, patients with type 1 diabetes are 3 times as likely to experience hypoglycemia as compared to patients with type 2 diabetes when receiving treatment.

Etiology

In patients who do not have diabetes, hypoglycemia is uncommon, but when it occurs, there are a few major causes of hypoglycemia: pharmacologic, alcohol, critical illness, counter-regulatory hormone deficiencies, and non-islet cell tumors.

Most cases of hypoglycemia occur in diabetic patients who are undergoing therapeutic intervention with meglitinides, sulfonylureas, or insulin. Drugs are the most common cause of hypoglycemia.[1] Metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose co-transporter 2 inhibitors (SGLT-2), and dipeptidyl peptidase-4 (DPP-4) inhibitor use does not lead to hypoglycemia.Non-diabetic patients with intact hepatic function will rarely experience fasting hypoglycemia because of preventative counter-regulatory measures. Episode of true hypoglycemia in a non-diabetic patient is likely due to iatrogenic causes such as the surreptitious use of insulin. Other potential causes of hypoglycemia are critical illness, alcohol, cortisol deficiency, or malnourishment.

Alcohol inhibits gluconeogenesis in the body, but does not affect glycogenolysis. Thus, hypoglycemia occurs after several days of alcohol consumption and after glycogen stores are depleted.

In critical illness states, for example, end-stage liver disease, sepsis, starvation, or renal failure, glucose utilization exceeds glucose intake, glycogenolysis and/or gluconeogenesis. The result of this imbalance is hypoglycemia. Counter-regulatory hormone deficiencies can occur as in states of adrenal insufficiency. Hypoglycemia associated with such deficiencies are rare. Non-islet cell tumors may also be a cause of hypoglycemia through increased secretion of insulin-like growth factor 2 (IGF-2).[2] IGF-2 increases glucose utilization, which can lead to hypoglycemia.

Insulinomas are hyperfunctioning islet cell tumors associated with increased insulin secretion. They can be life-threatening and primarily manifest with postprandial hypoglycemia. Although these tumors are rare, MEN1 should be a consideration in the workup of suspected cases.

Epidemiology

Hypoglycemia is common with type 1 diabetes, particularly in those patients receiving intensive insulin therapy. Severe hypoglycemic events have been reported to be anywhere between 62 to 320 episodes per 100 patient-years in type 1 diabetes.[3] As opposed to patients who have type I diabetes and require insulin therapy exclusively, patients with type II diabetes experience hypoglycemia relatively less frequently compared to patients with type I diabetes. This can be due, in part, to pharmacotherapies that do not induce hypoglycemia like metformin. The incidence of hypoglycemia in patients with type II diabetes has been reported to be approximately 35 episodes for 100 patient-years.[4] There are no reported disparities in incidents based on gender.

Pathophysiology

The body has inherent counter-regulatory mechanisms to prevent hypoglycemic episodes. All of these counter-regulatory mechanisms include an interplay of hormones and neural signals to regulate the release of endogenous insulin, to increase hepatic glucose output, and to alter peripheral glucose utilization. Among the counter-regulatory mechanisms, the regulation of insulin production plays a major role.  Decreases in insulin production as a response to low serum glucose is the bodies first line of defense against hypoglycemia. For endogenous glucose production to take place, particularly hepatic glycogenolysis, low insulin levels are necessary. As plasma glucose levels decline, beta cell secretion of insulin also decreases, thus leading to increased hepatic/renal gluconeogenesis and hepatic glycogenolysis. Glycogenolysis maintains serum glucose levels over 8 to 12 hours until glycogen stores are depleted. Over time, hepatic gluconeogenesis contributes more to maintaining euglycemia when required.

The decrease in insulin production occurs while the glucose level is in the low-normal range. This serves as a distinctive feature compared to other counter-regulatory measures. Additional counter-regulatory measures typically occur once the serum glucose levels decrease beyond physiologic range. Among the additional counter-regulatory mechanisms, pancreatic alpha cell secretion of glucagon is the next line of defense against hypoglycemia. Should increased glucagon fail to achieve euglycemia, adrenomedullary epinephrine is secreted [5]. All three counter-regulatory measures occur in the acute stage of hypoglycemia.

The previously mentioned counter-regulatory mechanisms may fail to resolve the hypoglycemia. Further counter-regulatory measures are employed in the form of growth hormone and cortisol. Both the release of growth hormone and cortisol are seen in prolonged hypoglycemic states.

History and Physical

The clinical manifestations of hypoglycemia can be classified as either neuroglycopenic or neurogenic. Neuroglycopenic signs and symptoms are signs and symptoms that result from direct central nervous system (CNS) deprivation of glucose. These include behavioral changes, confusion, fatigue, seizure, coma, and potential death if not immediately corrected. Neurogenic signs and symptoms can either be adrenergic (tremor, palpitations, anxiety) or cholinergic (hunger, diaphoresis, paresthesias). Neurogenic symptoms and signs arise from sympathoadrenal involvement (either norepinephrine or acetylcholine release) in response to perceived hypoglycemia. 

A detailed history is essential in evaluating hypoglycemia. Pertinent issues that should be addressed while taking a patient's history include 

  • A detailed medication history
  • History of alcohol and/or drug use
  • History of psychiatric disorders
  • Personal or family history of diabetes mellitus or multiple endocrine neoplasia syndromes (MEN)
  • Unintentional weight changes
  • Changes in medication
  • Consideration of acute kidney injury or renal failure
  • Symptoms of other hormone deficiencies.
  • It is also important to note the context of the hypoglycemic episode relative to meals or exercise.

There is no agreed-upon lab value that defines hypoglycemia. Hypoglycemia is said to be present when the patient has symptoms consistent with hypoglycemia in addition to a low serum glucose measurement (less than  70 mg/dL). This perspective reflects the idea that hypoglycemia is a clinical presentation coupled with a lab finding of low serum glucose rather than a pure chemistry finding. Typically neurogenic and neuroglycopenic symptoms of hypoglycemia occur at a glucose level of or below 50 to 55 mg/dL, but this threshold can vary from individual to individual.

Patients who have diabetes can present with symptoms of hypoglycemia at relatively higher serum glucose levels. The chronic hyperglycemia alters the "set point" in which neuroglycopenic/neurogenic symptoms become apparent. This phenomenon is referred to as "pseudohypoglycemia" because the serum glucose may be within normal range despite symptom presentation.

Evaluation

As previously mentioned, documentation of Whipple’s triad is a potential indicator of hypoglycemia, and any initial laboratory evaluation should confirm hypoglycemia. Other pertinent labs to consider include insulin, proinsulin, and C-peptide levels during any episode of suspected hypoglycemia. If C-peptide levels are low in the presence of high insulin levels, the patient has received exogenous insulin. The pro-form of insulin created within the body is attached to C peptide. The body then cleaves C peptide from the pro form of the molecule to create active insulin. Elevated C-peptide levels and insulin levels can be seen with secretagogue agents such as sulfonylureas or insulin secretagogues since both classes of agents stimulate endogenous insulin secretion.

Once the use of exogenous insulin administration is ruled out, sources of endogenous hyperinsulinemia need to be considered. Localization is usually performed via abdominal computed tomography (CT) with MRI.

Treatment / Management

Identification of a hypoglycemic patient is critical due to potential adverse effects including coma and/or death. Severe hypoglycemia can be treated with intravenous (IV) dextrose followed by infusion of glucose. For conscious patients able to take oral (PO) medications, readily absorbable carbohydrate sources (such as fruit juice) should be given. For patients unable to take oral agents, a 1-mg intramuscular (IM) injection of glucagon can be administered. Once the patient is more awake, a complex carbohydrate food source should be given to the patient to achieve sustained euglycemia. More frequent blood glucose monitoring should occur to rule out further drops in blood sugar.

Nonpharmacological management of recurrent hypoglycemia involves patient education and lifestyle changes. Some patients are unaware of the serious ramifications of persistent hypoglycemia. As such, patients should be educated on the importance of routine blood glucose monitoring as well as on the identification of the individual's symptoms of hypoglycemia.  If lifestyle changes are not effective in preventing further episodes, then pharmacologic intervention should be modified. Patients should be advised to wear a medical alert bracelet and to carry a glucose source like gel, candy or tablets on their person in case symptoms arise. In the outpatient setting, reviewing blood sugar logs as well as food logs may be helpful in identifying problem areas for the patient.

Glycemic control has been an important aspect of medical management due to the association between glycated hemoglobin levels and cardiovascular events in diabetes mellitus type 2 patients. In the 2008 ACCORD trial, it was determined that intensive therapy (defined as a goal hemoglobin A1C less than 6.0%) did not significantly reduce major cardiovascular events and was associated with increased mortality and risk for hypoglycemia.[6] It should be noted, however, that the intensive therapy group had proportionally more participants using rosiglitazone compared to the standard therapy group (91.2% versus 57.5%), thus possibly contributing to an increased incidence of cardiovascular events in the intensive therapy group.

The 2009 VADT study additionally studied the effect of intensive blood glucose control in a sample of 1791 veterans with poorly controlled diabetes mellitus type 2. More rigid glycemic control did not appear to have a significant effect on cardiovascular outcomes, although it did improve microalbuminuria compared to the standard therapy arm.[7]  The results, however, cannot be extrapolated to females since 97% of the study participants were male. Besides, there was a significant dropout (approximately 15%), limiting statistical power.

Regarding endogenous sources of insulin, insulinomas are often managed surgically. Evidence of an insulinoma should prompt workup or investigative effort into potential multiple endocrine neoplasia (MEN) disorders.

Differential Diagnosis

If hypoglycemia is confirmed, the focus should be on correcting the hypoglycemia and identifying an underlying cause. In the workup of hypoglycemia, history should include medication and dietary adherence, changes in medication, suspicion for acute kidney injury or intentional/unintentional over the administration of medications.

Complications

Complications of untreated hypoglycemia can lead to serious neurologic consequences, the most serious being death.

Consultations

Most cases of hypoglycemia can be managed conservatively. Recurrent episodes of hypoglycemia with no apparent or obvious cause may warrant specialty consultation with an endocrinologist. Consultation with a diabetic educator may also be beneficial for the long-term management of diabetes and hypoglycemia.

Deterrence and Patient Education

Patient education remains a pivotal component in the prevention of hypoglycemic episodes. Focus on preventing hypoglycemia should include patient education on signs and symptoms that constitute hypoglycemia and early recognition of these signs and symptoms.

Pearls and Other Issues

Hypoglycemia in non-diabetic patients is uncommon.  When it does occur, a critical illness, sustained alcohol use, malnutrition, and exogenous medications should be considered. Tumors may be a cause of hypoglycemia but are rare.

Hypoglycemia is relatively common in neonates, particularly in mothers with uncontrolled diabetes. A 2017 study performed in Israel showed that 559 neonates out of 3595 neonates were observed to have a glucose level of less than 47 mg/dL.[8] Gestational glucose intolerance in the mother is usually attributed to the presence of human placental lactogen. Pregnant women with impaired glucose tolerance not responsive to diet or exercise can be started on insulin. Insulin does not cross the placenta although the fetus will be exposed to maternal hyperglycemia. Since the fetal pancreatic islet cells produce insulin starting at 10 weeks gestation, the fetal pancreas is capable of responding to hyperglycemia. Upon delivery, the newborn pancreas continues to secrete insulin although maternal hyperglycemia is withdrawn. Subsequently, the neonate’s glucose will decrease, resulting in an insulin-glucose imbalance and hypoglycemia.

Enhancing Healthcare Team Outcomes

An interprofessional approach to hypoglycemia is recommended.

Adequate measures to minimize hypoglycemic events involve participation and effective communication between the primary care physician, endocrinologists, diabetes educators, pharmacist, diabetic nurse, the patient's family, and the patient. The cornerstone of this management is the patient.

Patient education should address the importance of relatively detailed documentation regarding blood glucose levels, timing, units of insulin administered, and any pertinent notes such as increased/decreased food intake or exercise relative to blood glucose measurements. Such documentation allows a primary care physician or endocrinologist to make appropriate adjustments to diabetic medication therapy to best optimize blood glucose levels. Stability of blood glucose levels can be obtained with consistent dietary and exercise habits in addition to the appropriate timing of insulin therapy to avoid drastic spikes and dips in blood glucose levels. Hospitalized patients with newly diagnosed diabetes can be taught insulin administration and self-injections while in the hospital. Discussions with the patient will help decide the best medications to achieve safe glycemic control. Group education classes and local event planning can help diabetic patients learn and grow their knowledge between themselves as well as others in the household.

Non-adherence to medication or diet are the most common cause of treatment failure. Patients should monitor for signs or symptoms of hypoglycemia and have sources of glucose (for example, hard candy, fruit juice) immediately available. Developing programs to educate healthcare staff has also shown to provide better outcomes. Teaming up with local pharmacies or grocery stores can help some of the barriers often encountered by diabetic patients.

Patients should be advised to have fairly consistent exercise and dietary habits to avoid drastic spikes and dips in hour-to-hour blood glucose measurements.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Hypoglycemia - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is an incorrect statement?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements is true about hypoglycemia in diabetes mellitus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Do beta-blockers prevent patients from noticing the signs and symptoms of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female is convinced she has hypoglycemia. She complains of shakiness, nausea, and irritability 3 hours after meals. In the morning she feels fine, even though she has not eaten since 7 PM the previous evening. Which of the following is true about this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not associated with postprandial hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following would not be appropriate treatment for postprandial hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents with episodes of palpitations, dizziness, tremors, and feeling faint. She says these symptoms generally occur if she does not eat breakfast. Which of the following is most appropriate for the evaluation of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 43-year-old female with a past medical history of diabetes mellitus and hypertension comes into your clinic for a routine visit. She reports compliance with her diabetic and hypertensive medications but notes that she sometimes feels "sweaty" and fatigued in the mornings. She checks her blood pressure during the time and notes that her SBP is > 100 mmHg. When she performs a sugar check, she notes that her blood glucose is in the 60's. She reports that drinking orange juice helps resolve her symptoms. Her diabetic medications include metformin 500 mg BID and glimepiride once daily. You suspect hypoglycemic episodes. What is the likely cause and what will be the expected c-peptide level?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which chemical imbalance induces histological changes in neurons closely mimicking hypoxia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What blood glucose level is considered hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a common presenting initial feature of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is NOT a clinical feature of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is least likely to be found in a hypoglycemic patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following tests can be performed to help diagnose the cause of hypoglycemic episodes?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 7-year-old child feels nausea and palpitations six hours post NPH insulin injection. What is the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 2.0 kg infant born at 37 weeks of gestation had APGAR scores of 7 and 9. At 14 hours of age, the respiratory rate is 80 and the heart rate is 185. The infant is hypotonic and lethargic. Select the next step in management.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the best initial management of hypoglycemia in a diabetic patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is NOT a sign of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not a sign or symptom of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a symptom of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
During home therapy, a patient with diabetes mellitus reports that she is not well and starts sweating, shaking, and has a rapid pulse. Therapy is stopped. What is the next step?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is receiving moist heat to the thigh for pain subsequent to a fall. The patient has a history of diabetes mellitus type 1 and had just taken her insulin. After the treatment, the patient is lethargic and unsteady on her feet. What is the most likely etiology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not a cause of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is an atypical symptom of mild hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a treatment for mild and moderate cases of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the time interval suggested before rechecking glucose levels after providing glucose in cases of mild hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the ideal combination of snack food to provide after the glucose rises following the oral glucose in a case of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is an accurate consideration when providing glucose for hypoglycemia in school age children?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true of diabetic hypoglycemia and insulin shock?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not associated with hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is not seen in hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which medication is not indicated in treatment of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which patient with hypoglycemia needs hospitalization for the hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cause of movements mimicking seizure activity?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How is diagnosis the of fasting hypoglycemia determined?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following needs to be addressed in an insulin dependent patient with severe hypoglycemia upon awakening?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents at 20 weeks of gestation. She complains of a headache, nausea, and visual blurring. The patient is tremulous and diaphoretic. Which of the following questions is most important?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is given 15 units of insulin isophane at 7 AM before breakfast. At 3 PM the patient is slightly confused and diaphoretic. Which of the following would be appropriate management after checking the blood sugar?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A previously healthy 4-month-old with unremarkable birth history is brought to the emergency department with a tonic-clonic seizure. A glucose check was recorded to be 10 mg/dL. D50 was administered and the patient was admitted for overnight observation. A repeat glucose check 3 hours later reveals a value of 15 mg/dL. Laboratories show elevated serum insulin, low insulin-like growth factor binding protein-1, and non-detectable C-peptide levels. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An infant is born of a healthy mother at 30 weeks gestation and small for gestational age. Serum glucose is 22 mg/dL at one hour. What is the most likely cause of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is not a common sign of hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is the first step in the treatment of mild hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following medications does not affect serum glucose level?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 53-year-old male who takes insulin glargine 35 units daily and insulin aspart 12 units TID AC to manage his type 2 diabetes mellitus. He checks his blood glucose 2 hours after a small lunch, and it is 53 mg/dL. He feels shaky, is sweating despite appropriate air conditioning in his office, and is dizzy. He can talk to you and eat food but is slightly confused. How should the patient be treated?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Patients with diabetes mellitus are at risk for hypoglycemia. Which of the following are signs of hypoglycemia? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A community health nurse is educating a group of individuals with diabetes mellitus on the signs and symptoms of hypoglycemia and treatment recommendations according to the American Diabetes Association (ADA). What does the nurse need to include in the teaching session? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is brought to the emergency department with mental confusion and lethargy. The triage nurse obtains a blood glucose and determines the patient is hypoglycemic. The primary healthcare provider is notified. What are the general admission criteria for this group of patients that a provider would consider in the decision-making process to admit or discharge? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old white male with a past medical history of depression presents to the emergency department after being found on the kitchen floor by his mother. He reports no loss of consciousness, but the mom reported that her son was slurring his words and appeared somnolent and diaphoretic. Head CT without contrast was unremarkable, and pertinent labs show glucose of 45 mg/dL. Urine toxicology screen is negative. A C-peptide is elevated at 3.8 ng/mL. The patient is administered intravenous dextrose and monitored with noted improvement. He later admits that he was feeling suicidal and decided to overdose on his father's diabetic medications. Which of the following is the likely agent responsible for the patient's hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old white female is being treated for type 1 diabetes mellitus with diabetic ketoacidosis (DKA) secondary to infection and insulin nonadherence. The treatments provided so far include fluid therapy, insulin, and electrolyte replacement. The anion gap remains elevated at 28 mmol/L although it is trending downward with the insulin therapy. The last glucose check was 136 mg/dL. The patient is otherwise stable other than mild tachycardia with a heart rate in the 110’s. What is the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 35-year-old white female with a history of gestational diabetes delivers a 9 lb baby boy via non-emergent c-section. Due to initially uncontrolled gestational hyperglycemia, she was placed on subcutaneous insulin throughout her pregnancy with questionable compliance. A heel stick reveals neonatal blood glucose of 39 mg/dL. What is the likely underlying cause of the baby’s neonatal hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 46-year-old male with a past medical history of alcohol use disorder, coronary artery disease, and hyperlipidemia presents as an inpatient on your hospital rounds. Labs for the day show mildly elevated liver transaminases and a blood glucose consistently in the 60 to 70 mg/dL range. Other pertinent labs include a sodium of 137 mmol/L and potassium of 3.8 mmol/L. The CBC shows a hemoglobin of 12 mg/dL, hematocrit of 39%, and platelet count of 288,000/microliter. What is the most likely explanation for the patient’s persistently low glucose levels?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 47-year-old male with a past medical history of insulin-dependent diabetes mellitus type 2, hypertension, and coronary artery disease presents to the clinic. His weight is 120 kg. He is injecting 30 units of long-acting insulin in the morning and 12 units of short-acting insulin before breakfast, 12 units before lunch, and 12 units before dinner. In addition to insulin, he is taking metformin, which he is tolerating well. At the next visit, he reports his blood glucose to be in the 70s and 80s throughout the day but lower in the morning. Occasionally he is symptomatic. What is the underlying cause of this patient’s hypoglycemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Hypoglycemia - References

References

Marks V,Teale JD, Drug-induced hypoglycemia. Endocrinology and metabolism clinics of North America. 1999 Sep     [PubMed]
Daughaday WH, Hypoglycemia due to paraneoplastic secretion of insulin-like growth factor-I. The Journal of clinical endocrinology and metabolism. 2007 May     [PubMed]
Bromiker R,Perry A,Kasirer Y,Einav S,Klinger G,Levy-Khademi F, Early neonatal hypoglycemia: incidence of and risk factors. A cohort study using universal point of care screening. The journal of maternal-fetal     [PubMed]
Duckworth W,Abraira C,Moritz T,Reda D,Emanuele N,Reaven PD,Zieve FJ,Marks J,Davis SN,Hayward R,Warren SR,Goldman S,McCarren M,Vitek ME,Henderson WG,Huang GD, Glucose control and vascular complications in veterans with type 2 diabetes. The New England journal of medicine. 2009 Jan 8     [PubMed]
Gerstein HC,Miller ME,Byington RP,Goff DC Jr,Bigger JT,Buse JB,Cushman WC,Genuth S,Ismail-Beigi F,Grimm RH Jr,Probstfield JL,Simons-Morton DG,Friedewald WT, Effects of intensive glucose lowering in type 2 diabetes. The New England journal of medicine. 2008 Jun 12     [PubMed]
Cryer PE, Hypoglycemia in type 1 diabetes mellitus. Endocrinology and metabolism clinics of North America. 2010 Sep     [PubMed]
Donnelly LA,Morris AD,Frier BM,Ellis JD,Donnan PT,Durrant R,Band MM,Reekie G,Leese GP, Frequency and predictors of hypoglycaemia in Type 1 and insulin-treated Type 2 diabetes: a population-based study. Diabetic medicine : a journal of the British Diabetic Association. 2005 Jun     [PubMed]
Cryer PE, Hypoglycemia in diabetes: pathophysiological mechanisms and diurnal variation. Progress in brain research. 2006     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric-Neonatal/Perinatal. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric-Neonatal/Perinatal, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric-Neonatal/Perinatal, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric-Neonatal/Perinatal. When it is time for the Pediatric-Neonatal/Perinatal board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric-Neonatal/Perinatal.