• Whenever glucose falls < 3.9mmol/L (70mg/dL), brain does not get enough glucose and sends signals to raise glucose levels:
      • Glucagon, Epinephrine, Norepinephrine, Cortisol, Growth Hormone (liver to release glucose)
    • Symptoms: (Hyperadrenergic)
      • Initially: Sweating, Rapid HR, Anxiety, Hunger, Tremor
      • Eventually: Neuroglycopenic symptoms (somnolence, dizziness, slurred speech)
      • If continues to decr: Lose conscouslness, focal neurological signs (hemiparesis), seizures
    • Causes:
      • Hypoglycemic Drugs: Esp sulfonylureas, meglitanides + skip meals or HF/AKI
      • Prolongued Exercise (muscles lose glycogen), often delayed hrs after exercise.  Esp worse if they have alcohol.

    Patients with Diabetes

    • Severe Hypoglycemia
    • Documented Symptomatic Hypoglycemia
    • Asymptomatic Hypoglycemia - esp  those that are chronically low (Type I DM), body gets used to low glucose.
    • Relative Hypoglycemia - Get used to higher glucose levels, must lower gradually.


    Patients without Diabetes

    • Very rare, islet cells turn off insulin, and turn on glucagon
    • When hepatic glycogen stores exhausted (takes ~8hrs), liver manufactures (gluconeogenesis) glucose
    • Causes:  (+ glycogen stores depleted)
      • Extreme starvation
      • Hepatic dysfunction
      • Sepsis
      • Alcohol suppresses hepatic glucose production
      • Cortisol Deficient (Addisons)
    • If Hypoglycemic in non-fasting state
      • Insulinoma --> very rare
      • Exogenous Insulin (or sulfonylurea or meglitonide)



    • Must diagnose hypoglycemia WITH SYMPTOMS
    • Whipple's Triad exists
      • 1.  Hypoglycemic Symptoms
      • 2.  Low plasma glucose level (by lab!  Not glucometer - unreliable at low levels)
      • 3.  Symptoms resolve with glucose ingestion



    • Considering it is not caused by exogenous insulin. 
    • If suspecting excess insulin secretion must do workup 
    • Diagnostic Workup:  (ONLY worthwhile in fasting state)
      • Plasma glucose
      • Insulin + Pro-Insulin
      • C-Peitide
      • β-hydroxybutyrate
      • Sulfonylurea
    • These tests must be done during the episode of hypoglycemia (dong this after sugar was given is not helpful). 
    • Typically patients fast x72hrs, and the above labwork is done every 6hrs until finish (blood glucose < 3.0, or symptomatic)
    • Hypoglycemia-Investigations-ES.jpg


    • If positive, and suspect insulinoma: need CT for surgery!



    Postprandial Hypoglycemia

    • Extremely Rare, but frequently missed
    • Often seen in patients post bypass surgery
    • Report sleepy, shaky after a large meal (hypoglycemia)
    • Diagnosis:
      • Observe patient + measure plasma glucose when symptoms occur
      • Do not do OGTT --> can cause severe hypoglycemia
    • Treatment
      • Smaller, more frequent meals. (avoid simple carbs)
      • More complex carbs w/ protein (peanut butter, etc..)
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