Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline

Abstract

We recommend evaluation and management of hypoglycemia only in patients in whom Whipple's triad--symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised--is documented. In patients with hypoglycemia without diabetes mellitus, we recommend the following strategy. First, pursue clinical clues to potential hypoglycemic etiologies--drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies. Insulin or insulin secretagogue treatment of diabetes mellitus is the most common cause of hypoglycemia. We recommend the practice of hypoglycemia risk factor reduction--addressing the issue of hypoglycemia, applying the principles of intensive glycemic therapy, and considering both the conventional risk factors and those indicative of compromised defenses against falling plasma glucose concentrations--in persons with diabetes.

A 76-Year-Old Woman with Diaphoresis and Anxiety

“…Whipple's Triad for the diagnosis of hypoglycemia includes symptoms and/or signs of hypoglycemia, documented hypoglycemia, and resolution of symptoms and/or signs with the administration of glucose. 20 2. Hypoglycemia has a wide differential diagnosis, including medications, factitious hyperinsulinemia, inherited metabolic diseases, critical illness, infection, alcohol use, nesidioblastosis (islet cell hypertrophy), insulin producing tumors, and insulin-like growth factor producing tumors among others.…”

Applicability of Adipose-Derived Stem Cells in Type 1 Diabetes Mellitus

“…Among these patients, 10% have type 1 diabetes mellitus (T1DM). At present, exogenous insulin injections, hormone substitution, and oral hypoglycemic agents are the main treatment options; however, these methods only deal with the symptoms or condition of the patient and cannot be considered a cure for diabetes (26,58). Once diagnosed with diabetes, most patients require continuous medication or insulin to control the syndrome and prevent deterioration of the condition (75).…”

Hiperinsulinismo endógeno: revisão e seguimento de 24 casos

“…A hipoglicemia pode ser dividida em pós-prandial (até 5h após a refeição) e de jejum e seu diagnóstico se baseia na presença da tríade de Whipple (glicose plasmática baixa, sintomas compatíveis com hipoglicemia e melhora dos sintomas após o aumento nas concentrações de glicose), cuja presença deve impelir à análise de suas potenciais causas, sendo essa investigação fortemente recomendada (2,3). Entretanto, o diagnóstico é praticamente inequívoco mesmo na ausên cia de sintomas se os valores de glicose plasmática estiverem abaixo de: 50 mg/dL na idade adulta e na adolescência (4,5), 40 mg/dL na criança pré-púbere (6), 30 mg/dL no neonato a termo e 20 mg/dL no neonato prematuro e/ou pequeno para a idade gestacional (7).…”

“…Entretanto, o diagnóstico é praticamente inequívoco mesmo na ausên cia de sintomas se os valores de glicose plasmática estiverem abaixo de: 50 mg/dL na idade adulta e na adolescência (4,5), 40 mg/dL na criança pré-púbere (6), 30 mg/dL no neonato a termo e 20 mg/dL no neonato prematuro e/ou pequeno para a idade gestacional (7). En-tretanto, vale considerar que 10% dos indivíduos normais têm valores de glicose plasmática menores que 50 mg/dL durante uma prova de tolerância oral à glicose de 5 horas (8) e que mulheres aparentemente normais podem ter valores de glicose plasmática menores de 40 mg/dL durante o jejum prolongado (3,9,10).…”

“…A hipoglicemia, em decorrência de hiperinsulinismo endógeno (HHE), é diagnosticada em um indivíduo com níveis baixos de glicose plasmática, concomitante a valores de insulina plasmática > 3 uU/ml e peptídeo-C > 0,6 ng/ml, segundo recentes diretrizes da Endocrine Society (3). Entre as causas de HHE, estão as doenças das células-b das ilhotas pancreáticas (adenomas solitários e múltiplos, hiperplasia e carcinoma), uso de secretagogos das células-b (sulfonilureias) e a hipoglicemia autoimune (anticorpos contra insulina e seus receptores).…”