Hypoglycemia is usually a complication of treatment of diabetics with insulin or sulfonylureas (chlorpropamide, glyburide, glipizide). Hypoglycemia is an unusual reaction from treatment with the glitizones (rosiglitazone, pioglitazone), glinides (repaglinide, nateglinide), alpha-glucosidase inhibitors (acarbose, miglitol), or the biguanide metformin. Patients with diabetes, alcoholism, sepsis, adrenal insufficiency, hypothyroidism, or malnutrition are at risk for severe hypoglycemia.
Typical symptoms of hypoglycemia include sweating, shakiness, anxiety, nausea, dizziness, confusion, slurred speech, blurred vision, headache, lethargy, and coma. Focal neurologic findings may include cranial nerve palsies, hemiplegia, seizures, and decerebrate posturing.
Diagnosis and Differential
A blood glucose level alone does not define hypoglycemia. The diagnosis is based on the glucose level in conjunction with typical symptoms that resolve with treatment. Hypoglycemia can easily be misdiagnosed as a primary neurologic or psychiatric condition (Table 129-1).
Table 129-1 Differential Diagnosis of Hypoglycemia |Favorite Table|Download (.pdf)
Table 129-1 Differential Diagnosis of Hypoglycemia
|Transient ischemic attack|
|Traumatic head injury|
|Sympathomimetic drug ingestion|
|Altered sleep patterns and nightmares|
Emergency Department Care and Disposition
Treat hypoglycemic patients with altered mental status with 50% dextrose 50 mL IV. A continuous infusion of 10% dextrose solution may be required to maintain the blood glucose above 100 milligrams/dL. Provide a carbohydrate meal if the patient can tolerate po.
If there is no IV access, administer glucagon 1 milligram IM or SC.
Refractory hypoglycemia secondary to the sulfonylureas may respond to octreotide 50 to 100 micrograms SC. A continuous infusion of 125 micrograms/h may be required.
Monitor for rebound hypoglycemia by determining blood glucose every 30 min initially.
Disposition is determined by the patient's response to treatment, cause of hypoglycemia, comorbid conditions, and social situation. Most insulin reactions respond rapidly. Patients can be discharged with instructions to continue oral intake of carbohydrates and closely monitor their finger stick glucose. Patients with hypoglycemia due to the sulfonylureas or long acting insulins should be admitted due to the risk of recurrence from these agents. See Table 129-2 for admission guidelines.
Table 129-2 Disposition/Guidelines for Hospital Admission |Favorite Table|Download (.pdf)
Table 129-2 Disposition/Guidelines for Hospital Admission
|Inpatient care for type 2 diabetes mellitus is generally appropriate for the following clinical situations:|
| Life-threatening metabolic decompensation such as diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic state|
| Severe chronic complications of diabetes, acute comorbidities, or inadequate social situation|
| Hyperglycemia (>400 milligrams/dL) associated with severe volume depletion or refractory to appropriate interventions|
| Hypoglycemia with neuroglycopenia (altered level of consciousness, altered behavior, coma, seizure) that does not rapidly resolve with correction of hypoglycemia|
| Hypoglycemia resulting from long-acting oral hypoglycemic agents|
| Fever without an obvious source in patients with poorly controlled diabetes|