Evaluation and Management of Adult Hypoglycemic Disorders
Guideline Status
Recommendations
Workup for a hypoglycemic disorder
Evaluation and management of hypoglycemia in persons without diabetes mellitus
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Review the history, physical findings, and all available laboratory data seeking clues to specific disorders—drugs, critical illnesses, hormone deficiencies, nonislet cell tumors.
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When the cause of the hypoglycemic disorder is not evident, i.e. in a seemingly well individual, measure plasma glucose, insulin, C-peptide, proinsulin, and β-hydroxybutyrate concentrations and screen for oral hypoglycemic agents, during an episode of spontaneous hypoglycemia, and observe the plasma glucose response to iv injection of 1.0 mg glucagon. These steps will distinguish hypoglycemia caused by endogenous (or exogenous) insulin from that caused by other mechanisms. Also, measure insulin antibodies.
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When a spontaneous hypoglycemic episode cannot be observed, formally recreate the circumstances in which symptomatic hypoglycemia is likely to occur, i.e. during a fast of up to 72 h or after a mixed meal. The findings of symptoms, signs, or both with plasma concentrations of glucose less than 55 mg/dl (3.0 mmol/liter), insulin of at least 3.0 μU/ml (18 pmol/liter), C-peptide of at least 0.6 ng/ml (0.2 nmol/liter), and proinsulin of at least 5.0 pmol/liter document endogenous hyperinsulinism; β-hydroxybutyrate levels of 2.7 mmol/liter or less and an increase in plasma glucose of at least 25 mg/dl (1.4 mmol/liter) after iv glucagon indicate mediation of the hypoglycemia by insulin (or by an IGF).
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In a patient with documented fasting or postprandial endogenous hyperinsulinemic hypoglycemia, negative screening for oral hypoglycemic agents, and no circulating insulin antibodies, conduct procedures for localizing an insulinoma. These may include computed tomography or magnetic resonance imaging (MRI), transabdominal and endoscopic ultrasonography, and, if necessary, selective pancreatic arterial calcium injections with measurements of hepatic venous insulin levels.
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Tailor treatment to the specific hypoglycemic disorder, taking into account the burden of hypoglycemia on patient well-being and patient preferences.
Evaluation and management of hypoglycemia in persons with diabetes mellitus
Recommendation Grading
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Overview
Title
Evaluation and Management of Adult Hypoglycemic Disorders
Authoring Organization
Endocrine Society
Publication Month/Year
March 1, 2009
Last Updated Month/Year
March 16, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D007003 - Hypoglycemia
Keywords
diabetes, hypoglycemia, hypoglycemic
Source Citation
Philip E. Cryer, Lloyd Axelrod, Ashley B. Grossman, Simon R. Heller, Victor M. Montori, Elizabeth R. Seaquist, F. John Service, Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 94, Issue 3, 1 March 2009, Pages 709–728, https://doi.org/10.1210/jc.2008-1410