James K. Rone, MD, FACP, FACE

Nondiabetic Hypoglycemia

July 18, 2012

Tags: Hypoglycemia

THIS WAS MY REPLY TO A PERSON IN ANOTHER STATE WHO CONTACTED ME BY EMAIL FOR A SECOND OPINION ABOUT HER HYPOGLYCEMIA EVALUATION:

Nondiabetic hypoglycemia is actually a frustrating problem for endocrinologists and their patients. Obviously hypoglycemia is a common and possibly life-threatening complication of some diabetes therapy. And some people have serious hypoglycemia problems after gastric bypass surgery for obesity.

ON the assumption that you’re not on any diabetes therapy and haven’t had obesity surgery, I will confine my discussion to other causes of “nondiabetic hypoglycemia,” which range from life-threatening insulinomas (benign or malignant pancreas tumors that secrete excess insulin), to “reactive” or “alimentary” or “postprandial” hypoglycemia which seems more common in prediabetic people and those with family histories of diabetes, to more or less normal fluctuations of blood glucose around meals that sometimes cause symptoms. There are a few other causes but that list covers the spectrum pretty well.

Obviously my comments are meant as friendly information and should not be construed as a medical evaluation or second opinion, since I don’t have access to all the information, including the most important source--a face-to-face evaluation of you. That said…

The most important determination for the endocrinologist is whether the problem is an insulinoma (big deal) or something else (not so big a deal). Usually insulinoma patients are sicker, have documented glucoses <40, and have passed out/had seizures/episodes of serious confusion. It’s these people who usually need the drastic step of a 72-hr fast--but that’s also a way of ruling out something serious if questions remain after all other evaluations. Obviously though we like to avoid doing the hospital fast in most people--I’ve only done one in my 13 years in Murfreesboro. You don’t sound that sick, and most of your glucoses have really been pretty normal. There certainly could be minor or early-stage cases where the symptoms are mild or easily masked by eating, so I’m not ruling out anything, but I think it’s statistically unlikely you’ve got an insulinoma.

Playing devil’s advocate though: pituitary tumors are genetically associated with pancreas tumors such as insulinoma and you did mention a pituitary lesion. That very easily could be a coincidence, but if you’ve ever had high calciums due to hyperparathyroidism (PARAthyroid--not thyroid) or if family members have had pituitary, hyperparathyroid, or pancreas tumors, that would up the ante.

Assuming you don’t have an insulinoma, then that leaves the rest of my list, which amounts to a spectrum of severe to mild meal-related fluctuations in blood sugar, which everyone has to some degree--just that some notice it more than others, like a lot of things. Basically sugar goes up after eating and goes down after insulin is released. If a lot of insulin is released—as happens with a high-carb meal or in prediabetes/insulin resistance—then the sugar might drop very rapidly and “overshoot” and get temporarily low enough to trigger symptoms like shaking, rapid pulse, sweating, hunger, sense of dread. This is never life-threatening and the “passing out/seizures/serious confusion” mentioned above don’t happen. However, it can be very uncomfortable, and if the person doesn’t understand what’s happening, it can be frightening.

And what does fear do? It releases adrenaline and adrenaline causes shaking, rapid pulse, sweating, hunger, and a sense of dread. In fact hypoglycemia causes adrenaline to be released (it’s a neurochemical that elevates blood sugar) and that’s what causes the symptoms I mentioned. Then fear triggers more adrenaline and more of the same symptoms—in other words the problem feeds on itself and builds to become a crisis/medical emergency that in reality amounts to nothing. And if the person is a caffeine drinker, that enhances adrenaline’s effect, making the symptoms worse. And if the person surmises or is told the problem is hypoglycemia, what do they do at the first sign of an episode? They eat a doughnut or drink a Pepsi which throws more sugar on the fire, spikes insulin, drops sugar, starting the whole thing over again. And worse yet Pepsi has caffeine in it. Worse yet, the patient starts doing finger-stick blood sugars at home--sees a normal dip in sugar (some women dip into the 40s and don’t know it)--and reacts by eating or drinking sugar. I’ve seen people become glucose invalids--tethered to glucose monitors and snacks. I strongly discourage doing home glucose monitoring unless you’re a diabetic or unless you’ve had a very severe episode that include loss of consciousness, for example. Our bodies usually can figure out what to do without too much help from us.

In my opinion and experience, most “hypoglycemia” is what I’ve just described. The cure is patient education--eliminating the fear component--and a change in diet. Lower carbs (use a book like Sugar-Busters or another low glycemic-index diet book as a guide to what food to avoid--the one with a “high glycemic index”), more protein, less caffeine and sugary soft drinks. My second step if that doesn’t fix the problem is the same diet given in 6 small meals per day which has the combined advantage of keeping some calories coming in all the time and avoid big slugs of calories that trigger the big spike in insulin. I usually see these people once--explain all this and never see them again. So, I guess they get better.

At the risk of sounding sexist—this is mostly a problem of women because most women have a smaller muscle mass and muscle stores glycogen which helps prevent drops in blood sugar. Also some women tend to more emotional on average (the “fear component”) and it’s conventional wisdom in medicine that women tend to focus on symptoms and go the doctor more than men do.

I don’t do the 2- or 3-hr glucose tolerance test for this because a lot of normal people drop their sugar under a glucose load like that. I don’t think the results are too valuable—you might ask Dr. XXXX her opinion on that before doing another one—not saying don’t do it—I’m not running the show—but as with any test I think you need to hear some justification that makes sense to you, from the ordering physician, on the basis of what exactly will be done differently in response to a given result.

That’s my take on hypoglycemia, for what it’s worth.

Now, here’s my take on endocrinologists’ management of hypoglycemia. First--it was a “fad disease” of the eighties, so some doctors just go deaf when they hear the word come out of a patient’s mouth. Second…

Let me digress, before going on—you mentioned thinking of a second opinion. Obviously you have to decide about your own comfort and confidence in your physician. I don’t know Dr. XXXX and certainly don’t know anything bad about her. Unless I’m mistaken she’s on the XXX [major medical school] faculty, which should be a good thing. I do however have some reservations about academic endocrinologists in that they are very focused on numbers and seem to forget the clinical evaluation of the patient. That is obviously a broad generalization and might or might not apply at all to your situation. However, I have personally witnessed a Mayo Clinic endocrinologist lecturing about hypoglycemia at a national meeting, spend an hour talking about insulinomas and then ignore—IGNORE—a question from a Nashville endocrinologist in the audience about reactive hypoglycemia, that is, the situation I describe in paragraphs 6, 7, and 8 above. It’s not a disease so much as it is a variation of normal physiology and so they don’t see it as worthy of consideration. It may not be a disease but it is a clinical problem that is very distressing for the patient and for the doctor the patient goes to.

What I laid out above, nobody taught me in medical school or residency or fellowship—I figured it out for myself or if any of it was taught it was in bits and pieces I had to put together. This is an example, I think, of a failing of current mainstream medicine: a lot of focus on numbers (“evidence-based medicine”) and not enough focus on the patient.

And please accept my apology for infusing politics into this—especially since I don’t know your politics—but ObamaCare won’t fix that problem, it will only make it worse.

Now, I’ve gone off on a big tangent that may or may not have anything to do with you. What gets broadly labeled “hypoglycemia” can be a serious problem but often isn’t. You didn’t tell me what set off this evaluation in the first place--that might help me assess how aggressively I think it should be pursued.

Lastly, adrenal insufficiency is a cause of serious hypoglycemia and that’s a whole nother kettle of controversial fish. As I’ve said, the cortisol of 5.1 at 11AM doesn’t mean much. The ACTH stimulation test was said to be normal. That rules out a problem in the adrenal glands and it rules out a severe long-standing problem with brain and pituitary regulation of the adrenals. It does not necessarily rule out a partial defect in that brain and pituitary regulation. This is another situation where the numbers have to be interpreted carefully in the context of what is happening with the patient. This is not an easy clear-cut evaluation either, but there are other tests that can help.

At a bare minimum I’d like to see an ACTH and cortisol drawn 1st thing in the morning (absolutely no later than 8AM). That has the advantage of telling us what the adrenals and pituitary are doing on their own at the time of day they should be working the hardest. If you get that you may fax the report to me at XXX-XXX-XXXX. If you do that also fax the full report of the ACTH stim test and any other cortisol levels.

I’m not really encouraging you to send any other reports because I think their proper interpretation will be too difficult from a distance. But certainly I’m happy to try to answer any specific questions you have.

Sorry about the tirade. I hope this is helpful more than confusing.

Best,

jkr

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