From the Guidelines
The appropriate workup for a patient presenting with hypoglycemia should begin with immediate stabilization by administering oral or intravenous glucose, followed by a comprehensive evaluation to determine the underlying cause, as recommended by the most recent guidelines 1.
Initial Assessment and Treatment
The initial step in managing hypoglycemia is to ensure the patient's immediate safety and stabilize their blood glucose levels. This can be achieved by administering glucose (approximately 15–20 g) orally or intravenously, depending on the patient's consciousness level and ability to swallow safely. If the patient is conscious and able to swallow, any form of carbohydrate that contains glucose may be used as an alternative 1.
Comprehensive Evaluation
Following initial stabilization, a comprehensive evaluation is necessary to determine the underlying cause of hypoglycemia. This evaluation should include:
- Initial laboratory tests: basic metabolic panel, complete blood count, liver function tests, and measurement of insulin, C-peptide, and proinsulin levels during a hypoglycemic episode (glucose <55 mg/dL) 1.
- Additional testing: cortisol levels, growth hormone, thyroid function tests, and screening for medications that can cause hypoglycemia, such as insulin, sulfonylureas, and meglitinides.
- Detailed medication history: essential for identifying potential causes of hypoglycemia, including medications and their dosages.
- Assessment for underlying conditions: alcohol use, critical illness, sepsis, liver disease, kidney disease, and adrenal insufficiency, which can contribute to hypoglycemia.
Specialized Testing for Suspected Conditions
For patients with suspected insulinoma or other pancreatic disorders, imaging studies like CT, MRI, or endoscopic ultrasound may be necessary to visualize the pancreas and identify any abnormalities. A supervised 72-hour fast may be required to document spontaneous hypoglycemia in patients with suspected endogenous hyperinsulinism, helping to differentiate between different causes of hypoglycemia 1.
Importance of Recent Guidelines
The most recent guidelines from 2021 1 emphasize the importance of reviewing the occurrence and risk for hypoglycemia at every encounter and investigating as indicated. They also recommend glucagon prescription for individuals at increased risk of level 2 or 3 hypoglycemia and highlight the need for hypoglycemia avoidance education in cases of hypoglycemia unawareness or episodes of level 3 hypoglycemia.
By following this comprehensive approach, healthcare providers can effectively manage hypoglycemia, reduce the risk of future episodes, and improve patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Hypoglycemia Workup
The appropriate workup for a patient presenting with hypoglycemia involves several steps, including:
- Identifying the underlying cause of hypoglycemia, which can be due to various factors such as hyperinsulinemia, hypoglucagonemia, or adrenal insufficiency 2
- Measuring blood glucose levels to confirm hypoglycemia
- Administering treatment, such as glucagon or glucose, to raise blood glucose levels
Treatment Options
Treatment options for hypoglycemia include:
- Intranasal glucagon, which has been shown to be effective in the prehospital treatment of hypoglycemia 3
- Intramuscular glucagon, which is a safe and reliable alternative to intravenous glucose infusion 4
- Intravenous glucose, which can provide rapid recovery from hypoglycemia, but may be associated with a fluctuating glycemia pattern 4
Diagnostic Tests
Diagnostic tests, such as the glucagon stimulation test, can help identify the underlying cause of hypoglycemia and guide treatment decisions 5
- The glucagon stimulation test involves administering glucagon and measuring the subsequent rise in blood glucose levels
- This test can help distinguish between different causes of hypoglycemia, such as insulin-mediated hypoglycemia or hypoglycemia due to poor hepatic glycogen reserve/liver failure 5
Special Considerations
Special considerations in the workup and treatment of hypoglycemia include: