Hypoglycaemia is defined as blood glucose <3.0 mmol/L; however, blood glucose <2.5 mmol/L is considered pathological and requires investigation.
The diagnosis of hypoglycaemia rests on three criteria (Whipple's triad):
- Plasma hypoglycaemia.
- Symptoms attributable to a low blood sugar level.
- Resolution of symptoms with correction of the hypoglycaemia.
There are many causes of hypoglycaemia but it is most commonly the result of an excess of either insulin or oral hypoglycaemic medications combined with reduced sugar intake or increased activity. Hypoglycaemia adversely affects quality of life in patients with diabetes.
Hypoglycaemia is uncommon in people without diabetes.
- Alcohol is the most common non-iatrogenic (non-physician) cause of hypoglycaemia in adults.
- People with diabetes treated with insulin or sulfonylureas:
- Recurrent hypoglycaemia often responds to changes in diet or treatment but referral for structured education may be required (eg, to a Diabetes Specialist Nurse or a local education programme).
- People with diabetes may develop impaired awareness of hypoglycaemia.
- Daytime non-severe hypoglycaemic episodes may have a significant adverse effect on day-to-day functioning.
- People with diabetes with poor glycaemic control may experience hypoglycaemic symptoms with normal glucose concentrations ('false hypoglycaemia').
- Ketotic hypoglycaemia (see under 'Presentation', below).
- Other drugs and toxins including pentamidine, quinine, paracetamol and toadstools.
- Rare causes (if insulin and C-peptide levels are elevated, an endogenous insulin source is the cause):
- Pancreatic endocrine tumours - eg, insulinoma.
- Extrapancreatic IGF-II-secreting neoplasms - eg, adrenal tumours.
- Autoimmune hypoglycaemia (endogenous antibodies reacting with insulin or the insulin receptors).
- Reactive hypoglycaemia: may be caused by upper gastrointestinal surgery or congenital enzyme deficiencies such as hereditary fructose intolerance, galactosaemia or leucine sensitivity of childhood.
- Hormone deficiencies - eg, hypoadrenalism, hypopituitarism.
- Factitious hypoglycaemia or self-induced hypoglycaemia.
- Insulinomas usually cause semiautonomous release of insulin, resulting in fasting hypoglycaemia.
- In response to meals these tumours usually respond subnormally, so that postprandial glucose levels are normal or even mildly elevated, although postprandial hypoglycaemia can occur.
- Insulinomas may be too small to be seen on CT scans and further investigation with endoscopic ultrasound should be considered, if no other cause for the hypoglycaemia is apparent.
- Glucagon should be used with caution in insulinoma.
There is poor correlation between blood glucose and symptoms, especially in patients with diabetes. Patients can often recognise the symptoms themselves and this state responds to sugar in water or a few lumps of sugar. Children may not have such prominent changes but may appear unduly lethargic.
- Shaking and trembling.
- Sweating, pins and needles in the lips and tongue.
- Hunger, palpitations.
- Headache (occasionally), double vision, difficulty in concentrating.
- Slurring of speech, confusion, change of behaviour, truculence.
- Stupor, coma.
- Also known as hypoglycaemia unawareness.
- This is seen in people with diabetes treated with insulin who may show reduction in spontaneous movements and speech, somnolence, poor thinking and work performance, changes in personality and amnesia.
- It may also present with transient hemiplegia, hypothermia or hyperthermia, convulsions, diplopia and strabismus. If untreated, it can progress to stupor, coma and, exceptionally, death.
- Chronic - a rare presentation with insidious changes in personality, defects in memory, paranoia and apparent dementia. Can also appear as neuropathy mistaken for motor neurone disease.
- Most often affects young children aged between 18 months and 5 years.
- Ketotic hypoglycaemia in young children usually resolves over time and only rarely persists over the age of 9 years.
- Ketotic hypoglycaemia presents with symptoms of hypoglycaemia (eg sweating, irritable, confused) and also nausea and vomiting.
- Severe hypoglycaemia may cause fainting, seizures and loss of consciousness.
- The underlying problem is the inability to tolerate prolonged periods without food.
- Therefore, management includes regular meals/snacks and a snack before bed (and sometimes also during the night).
Consider possible underlying causes and take a thorough medical and drug history.
- True hypoglycaemia should be confirmed by documentation of Whipple's triad: symptoms or signs of hypoglycaemia, a low plasma glucose concentration, and resolution of symptoms or signs after plasma glucose returns to normal.
- Assessment of glucose control for people with diabetes, including HbA1c.
- Other initial investigations include LFTs and TFTs.
- Insulin radioimmunoassay if an islet cell tumour is suspected (elevated insulin levels). Inappropriately high insulin concentrations are seen in hyperinsulinaemic hypoglycaemia.
- A 72-hour fast is the gold standard for the diagnosis of insulinoma. The fast only rarely needs to be extended beyond 16 hours.
- Plasma concentrations of C-peptide are above the reference range in endogenous hyperinsulinaemia but low in exogenous hyperinsulinaemia. Exogenous insulin-induced hypoglycaemia can be detected by an insulin to C-peptide ratio greater than 1.0.
- Proinsulin should be measured because some insulinomas secrete much, or sometimes all, of their insulin in the unaltered proinsulin form and such tumours will go undetected if only insulin is measured. Proinsulin is usually less than 20% of total immunoreactive insulin. In patients with islet cell tumours, proinsulin may contribute as much as 70% of insulin immunoreactivity.
- A low level of glucose in a patient with confirmed endogenous hyperinsulinaemia should raise suspicion of sulfonylurea-induced hypoglycaemia.
- Blood and urine assays for sulfonylureas will detect factitious hypoglycaemia caused by these drugs.
- Further investigations for possible underlying endocrine cause - eg, pituitary function tests, adrenal function tests. See separate Adrenal Insufficiency and Addison's Disease article.
See separate Emergency Management of Hypoglycaemia article.
Treatment of any underlying cause
This may involve management of alcohol abuse, review and changes to prescribed medications or removal of an insulin-secreting tumour.
- Advise a diet with restriction of refined carbohydrates; the patient should avoid simple sugars.
- They should increase the frequency of their meals and reduce the size of meals (may need to have six small meals and two to three snacks each day).
- It may be beneficial to increase protein and fibre in the meal.
Diazoxide, administered by mouth, is useful in the management of chronic intractable hypoglycaemia caused by excess endogenous insulin secretion, either from an islet cell tumour or islet cell hyperplasia.
- Diazoxide has no place in the management of acute hypoglycaemia.
- Sodium and water retention induced by diazoxide may be reduced by concurrent use of a diuretic.
- Chlorothiazide 3-5 mg/kg twice-daily has the added benefit of potentiating the glycaemic effect of diazoxide.
- If diazoxide and chlorothiazide fail to suppress excessive glucose requirements then octreotide or nifedipine may be added. There is limited experience for this indication.
- Octreotide may suppress growth hormone secretion but there is little evidence that this has any long-term adverse effect on growth.
Further reading and references
Marks V in Oxford Textbook of Medicine, 4th Edition; Eds Warrell DA et al, OUP 2003.
; Non-Diabetic Hypoglycemia. Endotext, March 2016.
; How hypoglycaemia can affect the life of a person with diabetes. Diabetes Metab Res Rev. 2008 Feb24(2):87-92.
; Hypoglycaemia in nondiabetic patients - an evidence. Aust Fam Physician. 2010 Jun39(6):399-404.
; Hypoglycaemia. BMJ. 2011 Feb 16342:d567. doi: 10.1136/bmj.d567.
; Prevalence of impaired awareness of hypoglycaemia and frequency of hypoglycaemia in insulin-treated type 2 diabetes. Diabetes Res Clin Pract. 2010 Jan87(1):64-8. doi: 10.1016/j.diabres.2009.10.013. Epub 2009 Nov 24.
; The impact of non-severe hypoglycemic events on daytime function and diabetes management among adults with type 1 and type 2 diabetes. J Med Econ. 201215(5):869-77. doi: 10.3111/13696998.2012.686465. Epub 2012 May 17.
; Symptoms of hypoglycaemia in people with diabetes. Diabet Med. 2001 Sep18(9):690-705.
; The effects of glucose fluctuation on cognitive function and QOL: the functional costs of hypoglycaemia and hyperglycaemia among adults with type 1 or type 2 diabetes. Int J Clin Pract Suppl. 2002 Jul(129):20-6.
; Recognition, assessment and management of hypoglycaemia in childhood. Arch Dis Child. 2016 Jun101(6):575-80. doi: 10.1136/archdischild-2015-308337. Epub 2015 Dec 30.
; The Diagnosis and Management of Hyperinsulinaemic Hypoglycaemia. J Clin Res Pediatr Endocrinol. 2015 Jun7(2):86-97. doi: 10.4274/jcrpe.1891.
; Approach to the patient with spontaneous hypoglycemia. Eur J Intern Med. 2014 Jun25(5):415-21. doi: 10.1016/j.ejim.2014.02.011. Epub 2014 Mar 16.
; Recurrent hypoglycaemia in a young man without diabetes. BMJ. 2013 Feb 28346:f1182. doi: 10.1136/bmj.f1182.
; NICE Evidence Services (UK access only)
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