215. How low can you go? An Approach to Hypoglycemia

Hypoglycemia represents a critical clinical state defined by Whipple’s Triad: low plasma glucose, neurogenic or neuroglycopenic symptoms, and symptom resolution upon carbohydrate administration. The body normally maintains glucose homeostasis through a complex neurohormonal response involving decreased insulin and the secretion of counter-regulatory hormones like glucagon, epinephrine, and cortisol. Clinical management requires distinguishing between stable and unstable patients while identifying underlying causes, which range from exogenous insulin use and oral secretagogues to rare conditions like insulinomas or adrenal insufficiency. Treatment follows the "15-15 rule" for mild cases—administering 15 grams of fast-acting carbohydrates and retesting in 15 minutes—while severe episodes in unconscious patients necessitate intravenous dextrose or intramuscular glucagon. Long-term prevention focuses on adjusting glycemic targets, frequent monitoring, and patient education on carrying fast-acting glucose sources to mitigate risks of cognitive impairment and cardiovascular mortality.