Hypoglycemia laboratory findings: Difference between revisions

Jump to navigation Jump to search
Line 15: Line 15:
The strategy is to seek [[Whipple's triad]] under conditions in which hypoglycemia would be expected:
The strategy is to seek [[Whipple's triad]] under conditions in which hypoglycemia would be expected:
* If the symptoms occur in the [[Fasting plasma glucose|fasting state]], that evaluation should be performed during fasting.
* If the symptoms occur in the [[Fasting plasma glucose|fasting state]], that evaluation should be performed during fasting.
* If there is a compelling history of postprandial symptoms, it is reasonable to seek [[Whipple's triad]] with frequent, timed plasma [[Blood glucose monitoring|glucose measurements]] and recording of any symptoms after a mixed meal.  
* If there is a compelling history of [[postprandial]] symptoms, it is reasonable to seek [[Whipple's triad]] with frequent, timed plasma [[Blood glucose monitoring|glucose measurements]] and recording of any symptoms after a mixed meal.  
* All of the following should be measured:  
* All of the following should be measured:  
**[[Glucose]]: plasma glucose is usually <55-70 mg/dL.
**[[Glucose]]: plasma glucose is usually <55-70 mg/dL.

Revision as of 17:49, 20 October 2017

Hypoglycemia Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hypoglycemia from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic criteria

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Hypoglycemia laboratory findings On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Hypoglycemia laboratory findings

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Hypoglycemia laboratory findings

CDC on Hypoglycemia laboratory findings

Hypoglycemia laboratory findings in the news

Blogs on Hypoglycemia laboratory findings

Directions to Hospitals Treating Hypoglycemia

Risk calculators and risk factors for Hypoglycemia laboratory findings

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

Laboratory investigations of hypoglycemia depend on many tests: plasma glucose is usually <55-70 mg/dL, insulin, c-peptide, proinsulin, sulfonylurea screen, beta-hydroxybutyrate, 24-hour fasting glucose level and identifying the cause after that.

Laboratory Findings

Defining Hypoglycemia

Hypoglycemia can't be diagnosed only by measuring blood glucose level because it is misleading maneuver with high false positive results. The measurement should be repeated using a collection tube that contains an inhibitor of glycolysis and processing should not be delayed.

So, the following 3 characteristics should be present to diagnose hypoglycemia, which is called Whipple's triad and includes:[1]

The strategy is to seek Whipple's triad under conditions in which hypoglycemia would be expected:

Fasting evaluation[3][4] Mixed-meal evaluation[5]
  • If prolonged fasting may result in an episode of symptomatic hypoglycemia, plasma glucose should be measured repeatedly during fasting.
  • If symptoms occur and hypoglycemia is documented, the other tests mentioned above should be performed.
  • If the results are equivocal so the patient needs another confirmatory test such as the 72-hour fast.
  • If symptoms appear within 5 hours after meals, we should suspect postprandial hypoglycemia.[6]
  • Recurrent sampling before and after meals for the following 5 hours will help diagnosis; If severe symptoms occur, the samples for glucose should be analyzed.
  • If Whipple's triad is demonstrated, sulfonylureas, meglitinides, and antibodies to insulin should also be measured.

24-hour fasting

  • The fasting is ended when: [9]
    • Seventy-two hours have passed
    • Plasma glucose concentration is ≤45 mg/dL
    • Patient has symptoms or signs of hypoglycemia
  • The precise level of glucose considered low enough to define hypoglycemia is dependent on:[10][11]
    • Measurement method
    • Age of the person
    • Presence or absence of effects
    • The purpose of the definition

Identifying the cause

After confirmation of hypoglycemia. Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia:

Plasma insulin[12] C-peptide[12] proinsulin Sulfonylurea in plasma insulin or insulin receptor antibodies Postprandial symptoms Fasting symptoms
Insulinoma high high high - - - +
Oral hypoglycemics[13] high high high + - - -
Autoimmune hypoglycemia[14] high high high - + - -
NIPHS* high high high - - + -
Exogenous insulin high low low - - - -
Non-islet cell tumors low low low - - - -

*(NIPHS) non-insulinoma pancreatogenous hypoglycemia syndrome

Neonatal hypoglycemia:

Most of the neonatal hypoglycemias are transient but suspected cases as following should be investigated for metabolic diseases:

What to measure?

Surveys of healthy children and adults show that plasma glucose below 60 mg/dL or above 100 mg/dL are found in less than 5% of samples after an overnight fast.[15]

In infants and young children, up to 10% have been found to be below 60 mg/dL after an overnight fast. As the duration of fasting is extended, plasma glucose levels can fall further, even in healthy people.

In other words, many healthy people can occasionally have glucose levels in the hypoglycemic range without symptoms or disease.

References

  1. Guettier JM, Gorden P (2006). "Hypoglycemia". Endocrinol Metab Clin North Am. 35 (4): 753–66, viii–ix. doi:10.1016/j.ecl.2006.09.005. PMID 17127144.
  2. Service FJ, O'Brien PC (2005). "Increasing serum betahydroxybutyrate concentrations during the 72-hour fast: evidence against hyperinsulinemic hypoglycemia". J Clin Endocrinol Metab. 90 (8): 4555–8. doi:10.1210/jc.2005-0033. PMID 15886243.
  3. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
  4. Service FJ, Natt N (2000). "The prolonged fast". J Clin Endocrinol Metab. 85 (11): 3973–4. doi:10.1210/jcem.85.11.6934. PMID 11095416.
  5. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L; et al. (2013). "Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society". Diabetes Care. 36 (5): 1384–95. doi:10.2337/dc12-2480. PMC 3631867. PMID 23589542.
  6. Service FJ (1999). "Diagnostic approach to adults with hypoglycemic disorders". Endocrinol Metab Clin North Am. 28 (3): 519–32, vi. PMID 10500929.
  7. Landau BR, Wahren J, Chandramouli V, Schumann WC, Ekberg K, Kalhan SC (1996). "Contributions of gluconeogenesis to glucose production in the fasted state". J Clin Invest. 98 (2): 378–85. doi:10.1172/JCI118803. PMC 507441. PMID 8755648.
  8. Hogan MJ, Service FJ, Sharbrough FW, Gerich JE (1983). "Oral glucose tolerance test compared with a mixed meal in the diagnosis of reactive hypoglycemia. A caveat on stimulation". Mayo Clin Proc. 58 (8): 491–6. PMID 6876881.
  9. Service FJ (1999). "Diagnostic approach to adults with hypoglycemic disorders". Endocrinol Metab Clin North Am. 28 (3): 519–32, vi. PMID 10500929.
  10. Cornblath M, Schwartz R, Aynsley-Green A, Lloyd JK (1990). "Hypoglycemia in infancy: the need for a rational definition. A Ciba Foundation discussion meeting". Pediatrics. 85 (5): 834–7. PMID 2330247.
  11. Cornblath M, Hawdon JM, Williams AF, Aynsley-Green A, Ward-Platt MP, Schwartz R, Kalhan SC (2000). "Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds". Pediatrics. 105 (5): 1141–5. PMID 10790476.
  12. 12.0 12.1 Vezzosi D, Bennet A, Fauvel J, Caron P (2007). "Insulin, C-peptide and proinsulin for the biochemical diagnosis of hypoglycaemia related to endogenous hyperinsulinism". Eur J Endocrinol. 157 (1): 75–83. doi:10.1530/EJE-07-0109. PMID 17609405.
  13. Perros P, Henderson AK, Carter DC, Toft AD (1997). "Lesson of the week. Are spontaneous hypoglycaemia, raised plasma insulin and C peptide concentrations, and abnormal pancreatic images enough to diagnose insulinoma?". BMJ. 314 (7079): 496–7. PMC 2125998. PMID 9056803.
  14. Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P (2009). "Autoimmune forms of hypoglycemia". Medicine (Baltimore). 88 (3): 141–53. doi:10.1097/MD.0b013e3181a5b42e. PMID 19440117.
  15. Samuel Meites, editor-in-chief; contributing editors, Gregory J. Buffone... [et al.] (1989). Pediatric clinical chemistry: reference (normal) values. Washington, D.C: AACC Press. ISBN 0-915274-47-7.