From the Guidelines
The workup for hypoglycemia should begin with a thorough history and physical examination, followed by laboratory testing during a hypoglycemic episode using Whipple's triad (symptoms of hypoglycemia, low plasma glucose, and resolution of symptoms with glucose administration) as recommended by the most recent guidelines 1.
Initial Evaluation
The initial evaluation should include a review of the occurrence and risk for hypoglycemia at every encounter and investigated as indicated 1.
- A comprehensive metabolic panel
- Complete blood count
- Insulin level
- C-peptide
- Proinsulin
- Beta-hydroxybutyrate
- Sulfonylurea screen
- Antibodies against insulin
Diagnostic Testing
For suspected reactive hypoglycemia, a 5-hour oral glucose tolerance test may be appropriate, while for fasting hypoglycemia, a supervised 72-hour fast is the gold standard diagnostic test, with blood samples collected every 6 hours and more frequently when glucose levels drop below 60 mg/dL 2.
- Additional workup may include imaging studies such as CT, MRI, or endoscopic ultrasound if insulinoma is suspected
- For patients with adrenal insufficiency symptoms, an ACTH stimulation test should be performed
- In cases of suspected hereditary fructose intolerance or glycogen storage diseases, specific enzyme assays or genetic testing may be necessary
Classification of Hypoglycemia
Hypoglycemia can be classified into three levels:
- Level 1: a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L)
- Level 2: a blood glucose concentration <54 mg/dL (3.0 mmol/L)
- Level 3: a severe hypoglycemic event that requires immediate action to resolve 1
Treatment
The preferred treatment for hypoglycemia is glucose (approximately 15–20 g), although any form of carbohydrate that contains glucose may be used 1, 2.
- Fifteen minutes after treatment, if self-monitoring of blood glucose (SMBG) shows continued hypoglycemia, the treatment should be repeated
- Once the SMBG or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia
- Glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia so that it is available should it be needed 2
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Hypoglycemia Workup
- Hypoglycemia is a common complication in patients with diabetes, mainly in those treated with insulin, sulfonylurea, or glinide 3
- Episodes of hypoglycemia are associated with physical and psychological morbidity, and the fear of hypoglycemia constitutes a barrier that impairs the patient's ability to reach good glycemic control 3
- Impairments in counterregulatory responses and hypoglycemia unawareness constitute the main risk factors for severe hypoglycemia 3
Risk Factors for Hypoglycemia
- Therapies for diabetes that increase the risk of hypoglycemia include all insulins and insulin secretagogues, including the glinides and sulfonylureas 4
- Non-severe (self-treated) and severe (requiring assistance for recovery) hypoglycemia rates are higher in people with type 1 diabetes, but those with insulin-treated type 2 diabetes are also at risk 4
- Vulnerable patients with T2D at dual risk of severe hypoglycemia and cardiovascular outcomes show features of "frailty" 5
Prevention and Treatment of Hypoglycemia
- Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention, and treatment of hypoglycemia 4
- Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycemia, impaired hypoglycemia awareness, frequent nocturnal hypoglycemia, and with history of severe hypoglycemia 5
- Glucagon is an emergency medication that can save lives by quickly raising glucose in people who are unconscious or unable to consume glucose due to severe hypoglycemia 6
Management of Hypoglycemia
- A management protocol for hypoglycemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan 5
- A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycemic goals and promote new therapies to improve quality of life of patients 5
- Optimizing insulin doses and carbohydrate intake, in addition to a short warm-up before or after physical activity sessions, may help avoid hypoglycemia 5