H YPOGLYCEMIA

Laboratory Testing Guideline for Investigation of Rare Endocrine Disorders: Hypoglycemia

This guideline has been adapted from the Endocrine Guidelines prepared by the Alberta Common Procedure List Committee of Alberta Health following an extensive review of the scientific literature.

Post-prandial hypoglycemia (<5 hours after a meal) is usually not associated with any serious disorders. Reagent strip testing may be sufficient to guide appropriate dietary recommendations.

GUIDELINE GOALS
To assist the practitioner in the initial laboratory investigation in patients with suspected Hypoglycemia. To optimize the use of diagnostic laboratory tests.

Hypoglycemia Clinical Features

Adrenergic excess: sweating palpitations anxiety tremor Neuroglycopenic, e.g., altered consciousness and seizures, behavioural changes.

RECOMMENDATIONS
Hypoglycemia is defined as a serum glucose level below 2.5 mmol/L concurrent with the patients symptoms. The symptoms should be rapidly reversible with the oral intake of glucose. Glucose tolerance testing is of NO value in investigating patients with hypoglycemia and SHOULD NOT BE ORDERED The presence of hypoglycemia cannot be established by capillary reagent strip testing. Fasting hypoglycemia should prompt a simultaneous fasting serum insulin and glucose measurement, i.e., occurring >5 hours after a meal. Consultation is recommended in patients with fasting hypoglycemia.

BACKGROUND
Hypoglycemia is a clinical syndrome which should only be considered if the clinical features are met. Typical symptoms occur at a time when the serum glucose is demonstrated to be equal to or less than 2.5 mmol/L and symptoms are relieved by treatment which increases serum glucose. The diagnosis cannot be established using capillary glucose measurment because of inaccuracy of the technology in the hypoglycemic range. Fasting hypoglycemia has greater pathogenic significance. If the patient appears well in other respects, consideration should be given to drug induced hypoglycemia (including sulphaonylureas and ethanol) or an insulinoma. Patients with other medical disorders may also experience hypoglycemia and investigation of adrenal or pituitary insufficiency, liver failure or renal impairment may be indicated.1-3

The above recommendations are systematically developed statements to assist practitioner decisions about appropriate laboratory testing for specific medical conditions

REFERENCES
1. Service FJ. Hypoglycemia. JOURNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM, 993:269-272 Service FJ. Hypoglycemic disorders. NEW ENGLAND JOURNAL OF MEDICINE, 1995; 332: 1144-1152 Marks V, Teale JT. Investigation of hypoglycemia. CLIN ENDOCRINOLOGY, 1996; 44: 133-136.

THE ALBERTA CLINICAL PRACTICE GUIDELINES PROGRAM

The Alberta Clinical Practice Guidelines Program promotes appropriate, effective and quality medical care in Alberta by supporting the use of clinical practice guidelines. The program is administered by the Alberta Medical Association under the direction of a multi-stakeholder steering committee. Alberta Clinical Practice Guidelines Steering Committee Alberta Health Alberta Medical Association College of Family Physicians of Canada, Alberta Chapter College of Physicians and Surgeons of Alberta Physicians at Large Public Representative Regional Health Authorities University of Alberta University of Calgary

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NOTES ON THE APPLICABILITY OF THIS GUIDELINE

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This guideline was developed after a detailed scientific review of the literature. In areas where evidence was inconclusive, the guideline was based on expert opinion in consultation with the Divisions of Endocrinology at the University of Alberta and the University of Calgary. This guideline limits itself to laboratory testing for rare endocrine disorders: Hypoglycemia. Reference ranges are based on 95 percent of the population. Therefore, results for 5 percent of normal individuals will fall outside the reference range. Reference ranges are specific to each laboratory. The diagnosis of endocrine disorders relies heavily on appropriate clinical assessment and interpretation of laboratory results. This guideline is strictly for laboratory testing not clinical practice and management.

TO PROVIDE FEEDBACK
The Alberta CPG Working Group for Endocrine Testing is a multi-discipline team composed of general practitioners, pathologists, endocrinologists, clinical biochemists, laboratory technologists and a member of public. The team encourages your feedback. If you have difficulty applying this guideline, if you find the recommendations problematic, or if you need more information on this guideline, please contact: The Alberta Clinical Practice Guidelines Program 12230 - 106 Avenue NW EDMONTON, AB T5N 3Z1 (403) 482-2626 or toll free 1-800-272-9680 Fax:(403) 482-5445 E-mail: ama_cog@amda.ab.ca

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Hypoglycemia - April 1998