Symptoms Of Hypoglycemia

For most adults with T1DM, hypoglycemia is an unfortunate fact of life (1-6). Those attempting to achieve better glycemic control suffer many episodes of mild-to-moderate hypoglycemia. Early detection and recognition of hypoglycemic symptoms is critical for the individual to self-treat the hypoglycemic episode before becoming disabled.

The two categories of hypoglycemic symptoms are neurogenic and neuroglycopenic. The neurogenic symptoms are activated by the ANS (usually occur at ~ 60 mg/dL in nondiabetic individuals) and are mediated in part by sympathoadrenal release of cate-cholamines (norepinephrine and epinephrine) from the adrenal medullae and acetylcholine from postsynaptic sympathetic nerve endings (7-9). These symptoms are triggered by a falling glucose. This defense is critical for the recognition of symptoms that will alert the individual to treat the hypoglycemic episode. Neurogenic signs and symptoms include shakiness, anxiety, nervousness, palpitations, sweating, dry mouth and pallor, and pupil dilation (7,10,20). Cholinergic-medicated neurogenic symptoms include diaphoresis, hunger, and paresthesias (Table 1) (3,7,20). Recent work by Aftab-Guy et al. (12) has demonstrated that simulating epinephrine levels found during moderate hypoglycemia on a background of hyperinsulinemic euglycemia only produces about 20% of the neurogenic symptom scores usually observed during moderate hypoglycemia. This indicates that the genesis of hypoglycemic symptoms is multifocal and probably arises mainly from CNS efferent pathways (12).

The second category of hypoglycemic symptoms includes neuroglycopenic symptoms, which usually occur at approximately 50 mg/dL in nondiabetic individuals. These

Table 1 Neurogenic Symptoms of Hypoglycemia

Sweating

Shakiness

Tremulousness

Paresthesias

Anxiety

Nervousness

Palpitations

Hunger are generated as a result of brain neuronal glucose deprivation (3-7,10-12). The brain is vulnerable to any glucose deprivation and neuroglycopenia causes a rapid impairment of cerebral function. These symptoms include abnormal mentation, irritability, confusion, difficulty speaking, ataxia, paresthesias, headaches, stupor, and eventually (if untreated) seizures, coma, and even death (3,7-10,20-23). Neuroglycopenic symptoms can also include a wide array of transient and at times idiosyncratic focal neurological deficits (e.g., diplopia, hemiparesis) (3,7,20) (Table 2).

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