Diabetic hypoglycemia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Beleid bij acute hypoglykemie met verminderd bewustzijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022La prise en charge de l’hypoglycémie aiguë chez un patient présentant une diminution de la consciencePublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022

Key diagnostic factors

common

known diabetes

Suspect diabetic hypoglycemia if a person with diabetes presents with life-threatening alterations in mental and/or physical functioning, typical neuroglycopenic or sympathoadrenal symptoms of hypoglycemia (see entries below), or following a fall or motor accident.[1][3] Hypoglycemia occurs most commonly in people with type 1 diabetes, but can also occur in people with type 2 diabetes, particularly those treated with insulin or insulin secretagogues (sulfonylureas and meglitinides).[1][2][8][9][17]

presence of risk factors

Identify any risk factors for hypoglycemia in people who have diabetes, in order to determine their risk of future episodes, and to minimize the occurrence of these.[3] The most strongly associated risk factors include:[1][2][3][4][17]

Type 1 diabetes
Treatment with insulin, sulfonylureas, or meglitinides
Extremes of age (age <6 years or ≥75 years)
Suboptimal glycemic control (low [<6%] or high [>9%] HbA1c levels) and high glycemic variability
Intensive glycemic control efforts
Previous severe (level 3) or clinically significant (level 2) hypoglycemia
Increased duration of diabetes
Treatment with insulin >5 years
Impaired cognitive function
Impaired awareness of hypoglycemia
First trimester of pregnancy
Failure to thrive in children
Poor oral intake (e.g., if there is food insecurity, reduced intake of carbohydrates, or the patient is fasting), weight loss, or malnutrition.
End-stage kidney disease
Socioeconomic deprivation

In addition, be aware that patients are at particular risk of severe or asymptomatic hypoglycemia during sleep (nocturnal hypoglycemia) because sleep impairs the counterregulatory hormone response to hypoglycemia.[1]

For more information see Risk factors, below.

Other diagnostic factors

common

irritability

Typical neuroglycopenic symptom of hypoglycemia.[3] Neuroglycopenic symptoms usually occur at a blood glucose of <54 mg/dL (<3.0 mmol/L) and are more common than sympathoadrenal symptoms in children.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children than in adults.[1]

shakiness

Typical sympathoadrenal symptom of hypoglycemia.[1][3] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 54-61 mg/dL (3.0 to 3.4 mmol/L).[81] However, in people with diabetes and chronic recurrent hypoglycemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycemia).[1]

sweating

Typical sympathoadrenal symptom of hypoglycemia.[1][3] Sympathoadrenal symptoms usually occur before neuroglycopenic signs.[1]

tremor

Typical sympathoadrenal symptom of hypoglycemia.[1][79] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

palpitations

Typical sympathoadrenal symptom of hypoglycemia.[1][79] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

tachycardia

Typical sympathoadrenal symptom of hypoglycemia.[3] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

feeling warm

Typical sympathoadrenal symptom of hypoglycemia.[79] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

anxiety

Typical sympathoadrenal symptom of hypoglycemia.[79] Suspect nocturnal hypoglycemia if the patient experiences altered mood when waking up.[1]

nausea

Typical sympathoadrenal symptom of hypoglycemia.[1] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

hunger

Typical sympathoadrenal symptom of hypoglycemia.[1][79] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

pallor

Typical sympathoadrenal symptom of hypoglycemia.[1] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]

higher blood glucose than usual on waking up

Can be a feature of hypoglycemia.

uncommon

seizure

Suspect nocturnal hypoglycemia if the patient experiences seizures at night.[1]

loss of consciousness

A sign of severe (level 3) hypoglycemia (characterized by altered mental and/or physical status requiring the intervention of another person to actively administer carbohydrates or glucagon, or take other corrective actions).[3][4][5][17] In practice, severe hypoglycemia usually occurs when blood glucose is 35-40 mg/dL (1.9 to 2.2 mmol/L). The patient may also present with a motor accident or fall due to reduced consciousness level.[3] In these scenarios, always ascertain preceding events or precipitants that led to the fall or accident. This is key to identify because hypoglycemia that causes unconsciousness needs to be addressed to avoid future catastrophes.

coma

confusion

Typical neuroglycopenic symptom of hypoglycemia.[3] Suspect nocturnal hypoglycemia if the patient experiences confusion during the night, or impaired thinking when waking up.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

problems with short-term memory

Typical neuroglycopenic symptom of hypoglycemia.[3] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

changes in vision

Typical neuroglycopenic symptom of hypoglycemia.[1][79] Specifically, blurred or double vision and disturbed color vision may be present.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

changes in speech

Typical neuroglycopenic symptom of hypoglycemia.[1] Specifically, slurred speech may be present.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

difficulty hearing

Typical neuroglycopenic symptom of hypoglycemia.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

lethargy

Typical neuroglycopenic symptom of hypoglycemia.[1][79] Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

Suspect nocturnal hypoglycemia if the patient experiences lethargy on waking up.[1]

drowsiness

quietness

Typical neuroglycopenic symptom of hypoglycemia.[1] Behavioral changes such as irritability, agitation, quietness, and tantrums may be prominent in young children.[1] Other features may include erratic behavior.[1] Suspect nocturnal hypoglycemia if the patient experiences nightmares at night.[1]

Neuroglycopenic symptoms usually occur at a blood glucose of around <54 mg/dL (<3.0 mmol/L) and are more common in children than sympathoadrenal symptoms.[1][3][82] Bear in mind that signs and symptoms of hypoglycemia usually occur at a higher blood glucose level in children compared with adults.[1]

tantrums

erratic behavior

nightmares

Typical neuroglycopenic symptom of hypoglycemia.[1] Suspect nocturnal hypoglycemia if the patient experiences nightmares at night.[1]

headache

Typical neuroglycopenic symptom of hypoglycemia.[1] Suspect nocturnal hypoglycemia if the patient experiences headache when waking up.[1]

difficulty concentrating

Typical neuroglycopenic symptom of hypoglycemia.[1]

dizziness

Typical neuroglycopenic symptom of hypoglycemia.[79] The patient may have an unsteady gait.[1]

fall or motor vehicle accident

Falls and motor vehicle accidents can occur due to reduced consciousness level as a result of hypoglycemia.[80] Always ascertain the preceding events or precipitants that led to the fall or accident.[80] This is key to identify because hypoglycemia that causes unconsciousness needs to be addressed to avoid future catastrophes.[80]

bedwetting

Can be a feature of hypoglycemia.

Risk factors

strong

known diabetes

Hypoglycemia occurs most commonly in people with type 1 diabetes.[1][2][8][9] However, be aware that hypoglycemia can occur in people with type 2 diabetes due to treatment with insulin or insulin secretagogues (sulfonylureas and meglitinides).[1][2][8][9][17] The total number of hypoglycemic events in insulin-treated people with type 2 diabetes may be comparable to, or even exceed, that seen in people with type 1 diabetes, a phenomenon attributed to the higher overall prevalence of type 2 diabetes.[2][10]

use of insulin or sulfonylureas or meglitinides

Treatment with insulin, sulfonylureas, or meglitinides increases the risk of hypoglycemia compared with other glucose-lowering drugs.[3][4][17][43][44] Rates of hypoglycemia are highest for individuals treated with intensive insulin therapy (including multiple daily injections of insulin, continuous subcutaneous insulin infusion, or automated insulin delivery systems), followed by basal insulin, followed by sulfonylureas or meglitinides.[3] Combining treatment with insulin and sulfonylureas further increases hypoglycemia risk.[3]

If the patient is taking insulin, determine the timing of the insulin regimen and peak insulin action with the timing of hypoglycemia.[1] For instance:[45]

Bolus insulin used with meals typically causes postprandial hypoglycemia
Basal insulin typically causes fasting or preprandial hypoglycemia, but can cause hypoglycemia at other times (e.g., during increased activity or missed meals)
Bolus and basal insulin may cause hypoglycemia in fasting and fed states, but this is less uncommon.

In addition, an absolute or relative excess of insulin can lead to hypoglycemia due to:[1]

Errors when giving insulin (e.g., too much insulin used for correction of hyperglycemia, or wrong type or dose of insulin given)
Reduced carbohydrate intake or missed meals
Exercise
Concurrent use of alcohol.

age ≥75 years

Older adults, particularly those age ≥75 years, have higher rates of hypoglycemia than younger adults.[2][3][17] Older adults may have reduced ability to recognize symptoms of hypoglycemia and communicate that they need assistance.[1][3] Minor episodes of hypoglycemia frequently go unrecognized in older adults because they may present with nonspecific symptoms such as brief episodes of lightheadedness or vertigo.

In older adults, there is an age-related decline in renal and hepatic function, which can potentiate the effects of glucose-lowering drugs such as sulfonylureas and insulin.[2] There may also be age-related impairment of counterregulatory hormones such as glucagon and growth hormone.[2] Older patients also have an increase in comorbidities that may contribute to hypoglycemia.[2]

age <6 years

Young children have higher rates of hypoglycemia than young adults.[1][2][3] They may have reduced ability to recognize symptoms of hypoglycemia and communicate that they need assistance.[1][3]

Young children are also at increased risk of nocturnal hypoglycemia.[1]

suboptimal glycemic control and high glycemic variability

Suboptimal glycemic control (both low and high HbA1c levels) and high glycemic variability are strongly associated with increased risk of severe hypoglycemia.[3][46] One retrospective study of over 1000 adults with type 2 diabetes looked at self-reported rates of severe hypoglycemia at different HbA1c levels.[47] The relative risk of severe hypoglycemia varied across different HbA1c ranges when compared to patients with HbA1c levels of 7% to 7.9%. Specifically, the risk was 1.25 (95% CI 0.99 to 1.57) for those with HbA1c <6%, 1.01 (95% CI 0.87 to 1.18) for HbA1c 6% to 6.9%, 0.99 (95% CI 0.82 to 1.20) for HbA1c 8% to 8.9%, and 1.16 (95% CI 0.97 to 1.38) for HbA1c ≥9%.[47] However, in young people (age <18 years) with type 1 diabetes, low HbA1c is not a strong risk factor for hypoglycemia.[1][48][49][50]

People with lower HbA1c levels are also at increased risk of nocturnal hypoglycemia.[1]

intensive glycemic control efforts

Adults with intensive glycemic control (lower HbA1c target; in practice this varies, but is generally <7%) are at increased risk of severe hypoglycemia versus those with less intensive glycemic control (higher HbA1c target; generally ≥7% in practice).[3][51] The potential risk of hypoglycemia often outweighs the benefit of intensive glycemic control in those with long duration of diabetes, previous episodes of severe hypoglycemia or hypoglycemia unawareness, advanced microvascular or macrovascular complications, extensive comorbid conditions, older age, frailty, or limited life expectancy.[3]

previous level 2 or level 3 hypoglycemia

Urgently identify if the person has had previous episodes of level 2 (clinically significant) or level 3 (severe) hypoglycemia, in order to intervene quickly and prevent further episodes.[3] Recent episodes (in the preceding 3-6 months) indicate a high risk of future episodes.[3] Level 2 hypoglycemia is defined by blood glucose <54 mg/dL (<3.0 mmol/L) with or without clinical symptoms.[3][4][5][17] Level 3 hypoglycemia is characterized by altered mental and/or physical status requiring the intervention of another person to actively administer carbohydrates or glucagon, or take other corrective actions.[3][4][5][17] Repeated episodes of hypoglycemia can cause impaired awareness of hypoglycemia, which can in turn increase the risk of hypoglycemia.[3][17]

increased duration of diabetes

A longer duration of diabetes is associated with an increased risk of hypoglycemia relative to individuals with shorter disease duration.[2][4][15][17][52] In one study, 18.6% of patients with type 1 diabetes for ≥40 years had experienced an episode of severe hypoglycemia within the last year.[52]

treatment with insulin >5 years

Patients who have been treated with insulin for >5 years are at increased risk of hypoglycemia.[2][4][17]

impaired cognitive function

Cognitive impairment is strongly associated with increased risk of severe hypoglycemia.[3][46][53] People with cognitive impairment are at risk of hypoglycemia because of reduced ability to recognize symptoms of hypoglycemia and communicate that they need assistance.[53] They are also at risk of errors associated with insulin administration, which can lead to hypoglycemia.

In addition, patients with diabetes who have episodes of hypoglycemia are at increased risk of developing dementia compared to their counterparts who do not experience hypoglycemia.[54]

impaired awareness of hypoglycemia

Occurs when individuals no longer recognize the early signs and symptoms of low blood glucose. This condition often develops over time due to recurrent hypoglycemia, which blunts the release of counterregulatory hormones and diminishes the autonomic nervous system response to falling glucose levels.[2][3] As a result, patients may not perceive hypoglycemia until glucose levels are dangerously low, significantly increasing the risk of severe events.[1][2][55]

It is important to determine at what blood glucose level the patient recognizes hypoglycemia, and what symptoms they experience.[1] To reduce this risk, careful insulin dose adjustments, patient education, and use of advanced glucose monitoring technologies such as continuous glucose monitoring (CGM) are essential. CGM can help detect early glucose declines and alert patients before severe hypoglycemia occurs, even during sleep or when symptoms are absent. In patients with a history of long-term insulin use and recurrent hypoglycemia, clinicians should reassess insulin regimens, reduce glycemic targets temporarily, and consider incorporating CGM to improve safety and restore hypoglycemia awareness.[3]

first trimester of pregnancy

Incidence of diabetic hypoglycemia increases in early pregnancy, particularly around 10-15 weeks' gestation, in people with both type 1 and type 2 diabetes.[3][20][21][22][23] In pregnant women with preexisting type 1 diabetes, severe hypoglycemia occurs around 3 to 5 times more frequently in early pregnancy (but at lower incidence in the third trimester) than in the period before pregnancy.[2][24] Incidence rates of severe hypoglycemia have been reported as being as high as 19% to 44% in pregnant women who are treated with intensive insulin therapy.[25]

Hypoglycemia due to gestational diabetes is not covered in this topic.

failure to thrive in children

Decreases glycogen stores, which leads to hypoglycemia.[56]

poor oral intake

Decreases glycogen stores, which leads to hypoglycemia.[40][57] If the person is taking insulin, poor oral intake (e.g., if there is food insecurity or reduced intake of carbohydrates) or missed meals may result in a relative insulin excess, which can cause hypoglycemia.[1] It is important to determine the timing and amount of carbohydrates in any recent food intake, and the peak glucose effect of recent food intake.[1]

weight loss

In insulin-treated patients or those taking insulin secretagogues (e.g., sulfonylureas), significant weight loss can reduce insulin resistance and overall insulin requirements, making previously appropriate doses excessive and increasing the risk of hypoglycemia. This is especially common in individuals who lose weight rapidly due to dietary changes, bariatric surgery, glucagon-like peptide-1 (GLP-1) receptor agonist use, or illness, without corresponding adjustments in their drug regimen. If drug regimens are not adjusted accordingly, the risk of hypoglycemia increases, especially when hepatic glycogen stores are depleted, further impairing the body's ability to recover from low glucose levels.[58] It is crucial to closely monitor both glucose levels and body weight, and to reassess insulin or oral hypoglycemic agent doses during periods of weight change to avoid adverse events and maintain optimal diabetes management.

malnutrition

Malnutrition leads to depletion of glycogen stores, reduced gluconeogenesis, and impaired hormonal counterregulation, all of which compromise the body’s ability to maintain normal glucose levels, especially during fasting or stress.[40][57] In malnourished individuals, even short periods without food can precipitate hypoglycemia, as the liver lacks the necessary substrates (such as amino acids and lactate) to produce glucose.[40][57] In people with diabetes, malnutrition further heightens hypoglycemia risk, particularly when glucose-lowering therapies like insulin or sulfonylureas are not adjusted to match reduced caloric intake.

sleep

During sleep, people are at particular risk of severe or asymptomatic hypoglycemia due to impaired counterregulatory hormone responses.[1] Sleep blunts the release of hormones such as epinephrine, and reduces the likelihood of awakening in response to adrenergic symptoms like palpitations or sweating. As a result, falling glucose levels may go unnoticed, leading to prolonged hypoglycemia, which can cause seizures, loss of consciousness, or, in rare cases, sudden death (a phenomenon sometimes referred to as the “dead-in-bed” syndrome in patients with type 1 diabetes). One 2010 study by the Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group reported frequent, prolonged nocturnal hypoglycemia on 8.5% of nights in both children and adults, but more prolonged episodes in children.[59]

Suspect nocturnal hypoglycemia if the patient has any of:[1]

Low pre-breakfast blood glucose
Episodes of confusion, nightmares, or seizures at night
Impaired thinking, altered mood, or headaches when waking up in the morning.

Patients with hypoglycemia unawareness, or a history of severe hypoglycemia, are at the highest risk for nocturnal episodes. Continuous glucose monitoring (CGM) with low-glucose alerts and alarms is one of the most effective tools to prevent and detect nighttime hypoglycemia. Some CGM systems can even be integrated with insulin pumps to automatically suspend insulin delivery when glucose levels fall or are predicted to fall. Clinicians should evaluate nighttime insulin dosing, bedtime snacks, and CGM data trends to reduce risk. Educating patients and caregivers about the importance of monitoring and recognizing nighttime hypoglycemia symptoms (like morning headaches, fatigue, or night sweats) is also crucial for safer diabetes management.

fasting for religious or cultural reasons

Fasting may increase the risk for hypoglycemia among individuals treated with insulin or insulin secretagogues if not properly planned for.[3]

socioeconomic deprivation

Low-income status (includes factors associated with low income, such as living in a socioeconomically deprived area), housing insecurity, underinsurance, and food insecurity are strongly associated with increased level 2 or 3 hypoglycemia risk in patients with diabetes treated with insulin, sulfonylureas, or meglitinides.[3]

end-stage kidney disease

End-stage kidney disease (ESKD) is strongly associated with an increased risk for level 2 or 3 diabetic hypoglycemia.[3][60] Chronic kidney disease causes loss of renal gluconeogenesis, whereas acute kidney injury can decrease insulin clearance, which in turn leads to hypoglycemia.[61][62] If individuals with ESKD are treated with insulin and/or sulfonylureas, their treatment needs to be closely monitored and adjusted as estimated glomerular filtration rate declines, and they need to be educated about and closely monitored for hypoglycemia occurrence.

chronic kidney disease (estimated glomerular filtration rate <60 mL/min/ 1.73 m² or albuminuria)

Chronic kidney disease (CKD) significantly increases the risk of hypoglycemia in patients with diabetes, especially those treated with insulin or insulin secretagogues.[61][62] As kidney function declines, insulin clearance is reduced, leading to prolonged insulin action; gluconeogenesis is impaired, decreasing the body’s ability to generate glucose during fasting; and renal metabolism of hypoglycemic agents is altered, increasing drug levels and hypoglycemic risk. Hypoglycemia in people with CKD can be prolonged and more severe due to blunted counterregulatory responses and delayed drug clearance. Regular glucose monitoring, especially with continuous glucose monitoring, can help detect asymptomatic or nocturnal hypoglycemia in this high-risk group, improving safety and glycemic control.

weak

female sex

Female sex has been found to be an independent risk factor for hypoglycemia in multiple studies, although the mechanisms of this relationship are unclear and require further research.[3]

multiple recent episodes of level 1 hypoglycemia

Associated with increased risk of recurrent episodes.[3] Level 1 hypoglycemia is defined by blood glucose <70 mg/dL (<3.9 mmol/L) and ≥54 mg/dL (≥3.0 mmol/L) with or without symptoms.

use of hypoglycemia-causing drugs (nondiabetic)

Nondiabetic drugs can increase the risk of hypoglycemia in patients with diabetes.[40][63]

In particular, beta-blockers can mask the signs and symptoms of hypoglycemia, which can predispose to severe, life-threatening hypoglycemia.[63] Nonselective beta-blockers can also impair hepatic and renal release of glucose into the circulation, which can cause hypoglycemia.[40]

Many other drugs (e.g., certain antibiotics [particularly sulfonamides and fluoroquinolones], quinine, pentamidine, indomethacin) have been linked to hypoglycemia in patients without diabetes, but the evidence is unclear as to whether they cause hypoglycemia in patients with diabetes.[40] This list of drugs is not exhaustive, and you should consult a drug information source for more information.

Polypharmacy also increases the risk of hypoglycemia.[3]

exercise

Exercise can increase the risk of hypoglycemia during, immediately after, or with prolonged delay (up to 24 hours) following the activity.[1][3][4][36] This typically occurs in patients with type 1 diabetes treated with insulin. The greater the intensity of exercise and the longer the duration of activity, the greater the risk of hypoglycemia, with aerobic activities (e.g., walking, jogging, cycling, or swimming) posing more risk than brief anaerobic activities (e.g., sprinting or weightlifting).[36] Exercise induces hypoglycemia through a variety of mechanisms, which include increased insulin sensitivity and insulin-dependent transport of glucose into the muscles through glucose transporter type 4 (GLUT4) receptors.[36][42] Patients who increase their activity levels over time may experience a reduction in their overall insulin requirements due to the sustained increase in insulin sensitivity.[36]

liver failure

Underlying liver dysfunction leads to loss of hepatic gluconeogenesis.[64]

endocrine disorders

Endocrine disorders such as adrenal insufficiency (including Addison disease) and hypothyroidism can precipitate hypoglycemia because they reduce the counterregulatory response to a drop in blood glucose.[14] Celiac disease can also increase the risk of hypoglycemia through malabsorption.[65] It is important to rule out Addison disease and celiac disease in any patient with type 1 diabetes and hypoglycemia, and particularly in children with frequent, unexplained hypoglycemia.[1][66][67] The prevalence of these disorders is higher in people with type 1 diabetes than in the general population because these are all autoimmune diseases that share a similar genetic background.[65][68][69]

critical illness

Critical illness (e.g., sepsis) increases metabolic demands and subsequent utilization of glucose, which can cause hypoglycemia.[40] In particular, hypoglycemia due to sepsis is common and thought to be initiated by activation of proinflammatory mediators and counterregulatory hormones.[40]

alcohol ingestion

Alcohol ingestion is a common risk factor particularly in adolescents.[1][17] Drinking alcohol can cause hypoglycemia during and after consumption, particularly if the person has not eaten recently.[3][4][36] In addition, alcohol-related liver disease can lead to hepatic insufficiency, which decreases gluconeogenesis as well as depleting glycogen stores.

severe mental illness

Severe mental illness, including major depressive disorder, is associated with increased hypoglycemia risk.[3]

presence of cardiovascular disease, neuropathy, or retinopathy

The presence of comorbid cardiovascular disease, neuropathy, or retinopathy has been linked to an increased risk of hypoglycemia in patients with diabetes.[3]

low health literacy

Low health literacy is a recognized risk factor for hypoglycemia in people with diabetes.[3] Limited understanding of diabetes management can lead to difficulties interpreting blood glucose readings, adjusting insulin doses, and recognizing or treating hypoglycemic symptoms. This can result in inappropriate drug use, delayed treatment of low blood glucose, and increased risk of severe events.

substance use disorder

Substance use disorder can increase the risk of hypoglycemia in individuals with diabetes.[3] Alcohol and certain illicit substances may impair gluconeogenesis, alter appetite, or interfere with the recognition of hypoglycemic symptoms.[70] In addition, cognitive and behavioral effects of substance use can reduce adherence to meal planning, glucose monitoring, and insulin dosing, further increasing risk.[71]

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Diabetic hypoglycemia

History and exam

Your Organizational Guidance

Key diagnostic factors

common

known diabetes

presence of risk factors

Other diagnostic factors

common

irritability

shakiness

sweating

tremor

palpitations

tachycardia

feeling warm

anxiety

nausea

hunger

pallor

higher blood glucose than usual on waking up

uncommon

seizure

loss of consciousness

coma

confusion

problems with short-term memory

changes in vision

changes in speech

difficulty hearing

lethargy

drowsiness

quietness

tantrums

erratic behavior

nightmares

headache

difficulty concentrating

dizziness

fall or motor vehicle accident

bedwetting

Risk factors

strong

known diabetes

use of insulin or sulfonylureas or meglitinides

age ≥75 years

age <6 years

suboptimal glycemic control and high glycemic variability

intensive glycemic control efforts

previous level 2 or level 3 hypoglycemia

increased duration of diabetes

treatment with insulin >5 years

impaired cognitive function

impaired awareness of hypoglycemia

first trimester of pregnancy

failure to thrive in children

poor oral intake

weight loss

malnutrition

sleep

fasting for religious or cultural reasons

socioeconomic deprivation

end-stage kidney disease

chronic kidney disease (estimated glomerular filtration rate <60 mL/min/ 1.73 m² or albuminuria)

weak

female sex

multiple recent episodes of level 1 hypoglycemia

use of hypoglycemia-causing drugs (nondiabetic)

exercise

liver failure

endocrine disorders

critical illness

alcohol ingestion

severe mental illness

presence of cardiovascular disease, neuropathy, or retinopathy

low health literacy

substance use disorder