Hypoglycemia

Definition:
Hypoglycemia is the clinical syndrome that results from low blood sugar. The symptoms of hypoglycemia can vary from person to person, as can the severity. Classically, hypoglycemia is diagnosed by a low blood sugar with symptoms that resolve when the sugar level returns to the normal range….CLICK & SEE

Risk Factor:
While patients who do not have any metabolic problems can complain of symptoms suggestive of low blood sugar, true hypoglycemia usually occurs in patients being treated for diabetes (type 1 and type 2). Patients with pre-diabetes who have insulin resistance can also have low sugars on occasion if their high circulating insulin levels are further challenged by a prolonged period of fasting. There are other rare causes for hypoglycemia, such as insulin producing tumors (insulinomas) and certain medications. These uncommon causes of hypoglycemia will not be discussed in this article, which will primarily focus on the hypoglycemia occurring with diabetes mellitus and its treatment.

Despite our advances in the treatment of diabetes, hypoglycemic episodes are often the limiting factor in achieving optimal blood sugar control. In large scale studies looking at tight control in both type 1 and type 2 diabetes, low blood sugars occurred more often in the patients who were managed most intensively. This is important for patients and physicians to recognize, especially as the goal for treating patients with diabetes become tighter blood sugar control.

Low Blood sugar is Also Bad:
The body needs fuel to work. One of its major fuel sources is sugars, which the body gets from what is consumed as either simple sugar or complex carbohydrates. For emergency situations (like prolonged fasting), the body stores a stash of sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to “make new sugar”) and converts these stores of glycogen to sugar. This backup process emphasizes that the fuel source of sugar is important (important enough for human beings to have developed an evolutionary system of storage to avoid a sugar drought).

Of all the organs in the body, the brain depends on sugar (which we are now going to refer to as glucose) almost exclusively. Rarely, if absolutely necessary, the brain will use ketones as a fuel source, but this is not preferred. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. If for some reason, the glucose level in the blood falls (or if the brain’s requirements increase and demands are not met) there can be effects on the function of the brain.

Our Body’s Natural Protection
:
When the circulating level of blood glucose falls, the brain actually senses the drop. The brain then sends out messages that trigger a series of events, including changes in hormone and nervous system responses that are aimed at increasing blood glucose levels. Insulin secretion decreases and hormones that promote higher blood glucose levels, such as glucagon, cortisol, growth hormone and epinephrine, all increase. As mentioned above, there is a store in the liver of glycogen that can be converted to glucose rapidly.

In addition to the biochemical processes that occur, the body starts to consciously alert the affected person that is needs food by causing the signs and symptoms of hypoglycemia discussed below.

Signs and symptoms:
Hypoglycemic symptoms and manifestations can be divided into those produced by the counterregulatory hormones (epinephrine/adrenaline and glucagon) triggered by the falling glucose, and the neuroglycopenic effects produced by the reduced brain sugar.

Adrenergic manifestations

*Shakiness, anxiety, nervousness, tremor

*Palpitations, tachycardia

*Sweating, feeling of warmth

*Pallor, coldness, clamminess

*Dilated pupils (mydriasis)

Feeling of numbness “pins and needles” (parasthaesia) in the fingers

Glucagon manifestations:

*Hunger, borborygmus

*Nausea, vomiting, abdominal discomfort

*Headache

Neuroglycopenic manifestations:

*Abnormal mentation, impaired judgement

*Nonspecific dysphoria, anxiety, moodiness, depression, crying

*Negativism, irritability, belligerence, combativeness, rage

*Personality change, emotional lability

*Fatigue, weakness, apathy, lethargy, daydreaming, sleep

*Confusion, amnesia, dizziness, delirium

*Staring, “glassy” look, blurred vision, double vision

*Automatic behavior, also known as automatism

*Difficulty speaking, slurred speech

*Ataxia, incoordination, sometimes mistaken for “drunkenness”

*Focal or general motor deficit, paralysis, hemiparesis

*Paresthesia, headache

*Stupor, coma, abnormal breathing

*Generalized or focal seizures

Not all of the above manifestations occur in every case of hypoglycemia. There is no consistent order to the appearance of the symptoms, if symptoms even occur. Specific manifestations may vary by age and by severity of the hypoglycemia. In young children, vomiting can sometimes accompany morning hypoglycemia with ketosis. In older children and adults, moderately severe hypoglycemia can resemble mania, mental illness, drug intoxication, or drunkenness. In the elderly, hypoglycemia can produce focal stroke-like effects or a hard-to-define malaise. The symptoms of a single person may be similar from episode to episode, but are not necessarily so and may be influenced by the speed at which glucose levels are dropping, and previous incidence.

In newborns, hypoglycemia can produce irritability, jitters, myoclonic jerks, cyanosis, respiratory distress, apneic episodes, sweating, hypothermia, somnolence, hypotonia, refusal to feed, and seizures or “spells”. Hypoglycemia can resemble asphyxia, hypocalcemia, sepsis, or heart failure.

In both young and old patients, the brain may habituate to low glucose levels, with a reduction of noticeable symptoms despite neuroglycopenic impairment. In insulin-dependent diabetic patients this phenomenon is termed hypoglycemia unawareness and is a significant clinical problem when improved glycemic control is attempted. Another aspect of this phenomenon occurs in type I glycogenosis, when chronic hypoglycemia before diagnosis may be better tolerated than acute hypoglycemia after treatment is underway.

Nearly always, hypoglycemia severe enough to cause seizures or unconsciousness can be reversed without obvious harm to the brain. Cases of death or permanent neurological damage occurring with a single episode have usually involved prolonged, untreated unconsciousness, interference with breathing, severe concurrent disease, or some other type of vulnerability. Nevertheless, brain damage or death has occasionally resulted from severe hypoglycemia.

Causes:-
Hundreds of conditions can cause hypoglycemia. Common causes by age are listed below. While many aspects of the medical history and physical examination may be informative, the two best guides to the cause of unexplained hypoglycemia are usually

1.The circumstances

2.A critical sample of blood obtained at the time of hypoglycemia, before it is reversed.

There are several ways to classify hypoglycemia. The following is a list of the more common causes and factors which may contribute to hypoglycemia grouped by age, followed by some causes that are relatively age-independent. See causes of hypoglycemia for a more complete list grouped by etiology.

Hypoglycemia in newborn infants:-

Hypoglycemia is a common problem in critically ill or extremely low birthweight infants. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant hyperinsulinism, hypopituitarism or an inborn error of metabolism and presents more of a management challenge.

*Transient neonatal hypoglycemia

*Prematurity, intrauterine growth retardation, perinatal asphyxia

*Maternal hyperglycemia due to diabetes or iatrogenic glucose administration

*Sepsis

*Prolonged fasting (e.g., due to inadequate breast milk or condition interfering with feeding)

*Congenital hypopituitarism

*Congenital hyperinsulinism, several types, both transient and persistent

*Inborn errors of carbohydrate metabolism such as glycogen storage disease

Hypoglycemia in young children:-

Single episodes of hypoglycemia may occur due to gastroenteritis or fasting, but recurrent episodes nearly always indicate either an inborn error of metabolism, congenital hypopituitarism, or congenital hyperinsulinism. A list of common causes:

*Prolonged fasting

*Diarrheal illness in young children, especially rotavirus gastroenteritis

*Idiopathic ketotic hypoglycemia

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*Isolated growth hormone deficiency, hypopituitarism

*Insulin excess

*Hyperinsulinism due to several congenital disorders of insulin secretion

*Insulin injected for type 1 diabetes

*Hyperinsulin Hyperammonia syndrome (HIHA)due toGlutamate dehydrogenase 1gene.Can cause mental retardation and epilepsy in severe cases.

*Gastric dumping syndrome (after gastrointestinal surgery)

*Other congenital metabolic diseases; some of the common include

*Maple syrup urine disease and other organic acidurias

*Type 1 glycogen storage disease

*Type III glycogen storage disease. Can cause less severe hypoglycemia than type I

*Disorders of fatty acid oxidation

*Medium chain acylCoA dehydrogenase deficiency (MCAD)

*Familial Leucine sensitive hypoglycemia

*Accidental ingestions

*Sulfonylureas, propranolol and others

*Ethanol (mouthwash, “leftover morning-after-the-party drinks”)

Hypoglycemia in older children and young adults:-

By far, the most common cause of severe hypoglycemia in this age range is insulin injected for type 1 diabetes. Circumstances should provide clues fairly quickly for the new diseases causing severe hypoglycemia. All of the congenital metabolic defects, congenital forms of hyperinsulinism, and congenital hypopituitarism are likely to have already been diagnosed or are unlikely to start causing new hypoglycemia at this age. Body mass is large enough to make starvation hypoglycemia and idiopathic ketotic hypoglycemia quite uncommon. Recurrent mild hypoglycemia may fit a reactive hypoglycemia pattern, but this is also the peak age for idiopathic postprandial syndrome, and recurrent “spells” in this age group can be traced to orthostatic hypotension or hyperventilation as often as demonstrable hypoglycemia.

*Insulin-induced hypoglycemia

*Insulin injected for type 1 diabetes

*Factitious insulin injection (Munchausen syndrome)

*Insulin-secreting pancreatic tumor

*Reactive hypoglycemia and idiopathic postprandial syndrome

*Addison’s disease

*Sepsis

Hypoglycemia in older adults:-

The incidence of hypoglycemia due to complex drug interactions, especially involving oral hypoglycemic agents and insulin for diabetes rises with age. Though much rarer, the incidence of insulin-producing tumors also rises with advancing age. Most tumors causing hypoglycemia by mechanisms other than insulin excess occur in adults.

*Insulin-induced hypoglycemia

*Insulin injected for diabetes

*Factitious insulin injection (Munchausen syndrome)

*Excessive effects of oral diabetes drugs, beta-blockers, or drug interactions

*Insulin-secreting pancreatic tumor

*Alimentary (rapid jejunal emptying with exaggerated insulin response)

*After gastrectomy dumping syndrome or bowel bypass surgery or resection

*Reactive hypoglycemia and idiopathic postprandial syndrome

*Tumor hypoglycemia, Doege-Potter syndrome

*Acquired adrenal insufficiency

*Acquired hypopituitarism

*Immunopathologic hypoglycemia

Treatment:-
Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause, and taking measures to hopefully prevent future episodes.

Reversing acute hypoglycemia:-
The blood glucose can be raised to normal within minutes by taking (or receiving) 10-20 grams of carbohydrate. It can be taken as food or drink if the person is conscious and able to swallow. This amount of carbohydrate is contained in about 3-4 ounces (100-120 ml) of orange, apple, or grape juice although fruit juices contain a higher proportion of fructose which is more slowly metabolized than pure dextrose, alternatively, about 4-5 ounces (120-150 ml) of regular (non-diet) soda may also work, as will about one slice of bread, about 4 crackers, or about 1 serving of most starchy foods. Starch is quickly digested to glucose (unless the person is taking acarbose), but adding fat or protein retards digestion. Symptoms should begin to improve within 5 minutes, though full recovery may take 10-20 minutes. Overfeeding does not speed recovery and if the person has diabetes will simply produce hyperglycemia afterwards.

If a person is suffering such severe effects of hypoglycemia that they cannot (due to combativeness) or should not (due to seizures or unconsciousness) be given anything by mouth, medical personnel such as EMTs and Paramedics, or in-hospital personnel can establish an IV and give intravenous Dextrose, concentrations varying depending on age (Infants are given 2cc/kg Dextrose 10%, Children Dextrose 25%, and Adults Dextrose 50%). Care must be taken in giving these solutions because they can be very necrotic if the IV is infiltrated. If an IV cannot be established, the patient can be given 1 to 2 milligrams of Glucagon in an intramuscular injection. More treatment information can be found in the article diabetic hypoglycemia.

One situation where starch may be less effective than glucose or sucrose is when a person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors prevents starch and other sugars from being broken down into monosaccharides that can be absorbed by the body, patients taking these medications should consume monosaccharide-containing foods such as glucose tablets, honey, or juice to reverse hypoglycemia.

Prevention:
The most effective means of preventing further episodes of hypoglycemia depends on the cause.

The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise, or alcohol intake.

Many of the inborn errors of metabolism require avoidance or shortening of fasting intervals, or extra carbohydrates. For the more severe disorders, such as type 1 glycogen storage disease, this may be supplied in the form of cornstarch every few hours or by continuous gastric infusion.

Several treatments are used for hyperinsulinemic hypoglycemia, depending on the exact form and severity. Some forms of congenital hyperinsulinism respond to diazoxide or octreotide. Surgical removal of the overactive part of the pancreas is curative with minimal risk when hyperinsulinism is focal or due to a benign insulin-producing tumor of the pancreas. When congenital hyperinsulinism is diffuse and refractory to medications, near-total pancreatectomy may be the treatment of last resort, but in this condition is less consistently effective and fraught with more complications.

Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal insufficiency usually ceases when the appropriate hormone is replaced.

Hypoglycemia due to dumping syndrome and other post-surgical conditions is best dealt with by altering diet. Including fat and protein with carbohydrates may slow digestion and reduce early insulin secretion. Some forms of this respond to treatment with a glucosidase inhibitor, which slows starch digestion.

Reactive hypoglycemia with demonstrably low blood glucose levels is most often a predictable nuisance which can be avoided by consuming fat and protein with carbohydrates, by adding morning or afternoon snacks, and reducing alcohol intake.

Idiopathic postprandial syndrome without demonstrably low glucose levels at the time of symptoms can be more of a management challenge. Many people find improvement by changing eating patterns (smaller meals, avoiding excessive sugar, mixed meals rather than carbohydrates by themselves), reducing intake of stimulants such as caffeine, or by making lifestyle changes to reduce stress.

Herbal medication for Hypoglycemia:-
THE following HERBS as stated below can help to ease low blood sugar with symptoms that include lightheadedness, headache, irritability, depression, anxiety, cravings for sweets, confusion, night sweats, weakness in the legs and arms, swollen feet, insatiable hunger, eye pain, nervous tics, mental disturbances, insomnia, aggressiveness, hair-trigger temper.

Cinnamon bark extract, coral calcium with trace minerals, L-carnitine, bilberry extract, Mexican wild yam, dandelion root, milk thistle extract.

Quik Tip
: Cinnamon bark decreases insulin resistance and improves blood-sugar profiles better than most prescription drugs, USDA studies confirm.

Hypoglycemia as “folk” medicine:-
Hypoglycemia is also a term of contemporary folk medicine which refers to a recurrent state of symptoms of altered mood and subjective cognitive efficiency, sometimes accompanied by adrenergic symptoms, but not necessarily by measured low blood glucose. Symptoms are primarily those of altered mood, behavior, and mental efficiency. This condition is usually treated by dietary changes which range from simple to elaborate. Advising people on management of this condition is a significant “sub-industry” of alternative medicine. More information about this form of “hypoglycemia”, with far more elaborate dietary recommendations, is available on the internet and in health food stores. Most of these websites and books describe a conflation of reactive hypoglycemia and idiopathic postprandial syndrome but do not recognize a distinction. The value of most of their recommendations is – from a scientific perspective – unproved.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.medicinenet.com/hypoglycemia/article.htm
http://en.wikipedia.org/wiki/Hypoglycemia
http://www.herbnews.org/hypoglycemiadone.htm

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