Epidemiology

Etiology

Pathophysiology

• Neurogenic symptoms are mediated via norepinephrine/epinephrine and acetylcholine release during sytimpathec stimulation. Symptoms due to norepinephrine/epinephrine include tremulousness, tachycardia, and anxiety/arousal, whereas acetylcholine causes sweating, hunger, and paresthesias.
• Neuroglycopenic symptoms are due to inadequate availability of glucose in the CNS and include behavioral changes, confusion, visual disturbances, stupor, and seizures.

Clinical features

• Beta blockers can mask signs of hypoglycemia.
  • Nonselective beta blockers attenuate the norepinephrine/epinephrine-mediated symptoms of hypoglycemia, but cholinergic symptoms (eg, hunger) are unaffected.
  • In addition, nonselective beta blockers can contribute to the severity of hypoglycemia; epinephrine stimulates hepatic gluconeogenesis and peripheral glycogenolysis, but this effect is diminished by nonselective beta blockers.

Diagnostics

Treatment

• Alert and oriented patients
  • Oral glucose 15–20 g
  • Fast-acting carbohydrates (e.g., glucose tablets, candy, or fruit juice)
• Patients with altered mental status (or impaired oral intake)
  • IV dextrose (e.g., D50W): Repeat after 15 minutes if hypoglycemia persists; multiple doses may be required.
    • Adults: 50% dextrose
    • Children (excluding neonates): 10% dextrose OR 25% dextrose
  • IM glucagon: if neither oral nor IV routes of administering glucose are feasible
    • Glucagon therapy is only successful if the patient's glycogen reserves have not been depleted, as glucagon elevates endogenous glucose production via hepatic glycogenolysis and gluconeogenesis.