What conditions can cause hypertensive urgency and hypoglycemia (low blood sugar) with altered mental status?

From the Guidelines

Hypertensive urgency and hypoglycemia with altered mental status can develop in several clinical conditions, including medication-related causes, endocrine disorders, acute kidney injury, liver failure, and sepsis, and management requires immediate glucose administration and careful control of blood pressure with titratable agents.

Conditions Causing Hypertensive Urgency and Hypoglycemia

The conditions that can cause hypertensive urgency and hypoglycemia with altered mental status include:

• Medication-related causes, such as excessive antihypertensive therapy (especially with beta-blockers like propranolol or clonidine withdrawal), insulin overdose, or sulfonylurea medications (like glipizide or glyburide) 1
• Endocrine disorders, such as pheochromocytoma crisis with reactive hypoglycemia, adrenal insufficiency, or severe hypothyroidism
• Acute kidney injury, which can cause hypertension while impairing insulin clearance or gluconeogenesis
• Liver failure, which can present with both conditions due to impaired glucose regulation and altered vascular tone
• Sepsis, which can initially present with hypertension before progressing to hypotension, alongside metabolic derangements including hypoglycemia

Management

Management of hypertensive urgency and hypoglycemia with altered mental status requires:

• Immediate glucose administration (D50W 25-50mL IV for adults) for hypoglycemia 1
• Careful control of blood pressure with titratable agents like labetalol (10-20mg IV) or nicardipine (5mg/hr IV infusion) 1
• Identification and treatment of the underlying cause, as both conditions can lead to permanent neurological damage if not addressed quickly
• Close monitoring of vital signs, mental status, glucose levels, and end-organ function during treatment

Diagnosis

Diagnosis of the underlying cause of hypertensive urgency and hypoglycemia with altered mental status is crucial, and may involve:

• Laboratory tests, such as blood glucose levels, electrolyte panels, and renal function tests
• Imaging studies, such as chest radiography, electrocardiogram, and computed tomography (CT) scans
• Physical examination and medical history, to identify potential causes and guide further evaluation and treatment 1

From the FDA Drug Label

5.1 Substantial Increase in Blood Pressure in Patients with Pheochromocytoma 5.2 Hypoglycemia in Patients with Insulinoma 5.8 Hypoglycemia in Patients with Glucagonoma

The conditions that can cause hypertensive urgency and hypoglycemia (low blood sugar) with altered mental status are:

• Pheochromocytoma: can cause a substantial increase in blood pressure, potentially leading to hypertensive urgency.
• Insulinoma: can cause hypoglycemia.
• Glucagonoma: can cause hypoglycemia. These conditions may lead to altered mental status due to the severe hypoglycemia or hypertensive urgency they can cause 2.

From the Research

Conditions Causing Hypertensive Urgency and Hypoglycemia

• Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease 3
• Hypertensive emergencies are best managed with parenteral drugs and careful intraarterial blood pressure monitoring, while hypertensive urgencies can usually be managed with oral agents 3
• Hypoglycemia (low blood sugar) can occur in patients with altered mental status, and it is recommended to use venous blood to analyze blood glucose in these patients before dextrose administration is considered 4

Management of Hypertensive Emergencies and Urgencies

• The management of hypertensive emergencies and urgencies depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities 5
• For emergencies, a maximum BP reduction of 20-25% within the first hour and then to 160/110-100 over the next 2-6 hours is considered appropriate 5
• In the case of hypertensive urgencies, a gradual lowering of BP over 24-48 hours with an oral medication is the best approach, and an aggressive BP lowering should be avoided 5

Relationship Between Hypertension and Hypoglycemia

• There is no direct relationship between hypertensive urgency and hypoglycemia mentioned in the studies, but both conditions can cause altered mental status 3, 4
• Patients with severely elevated BP level but without symptoms have asymptomatic severe hypertension, and management of this condition starts with long-acting antihypertensive drugs 6