title: Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline.
abstract: OBJECTIVE
  The aim is to provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus.
  
  
  METHODS
  Using the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, the quality of evidence is graded very low (plus sign in circle ooo), low (plus sign in circle plus sign in circle oo), moderate (plus sign in circle plus sign in circle plus sign in circle o), or high (plus sign in circle plus sign in circle plus sign in circle plus sign in circle).
  
  
  CONCLUSIONS
  We recommend evaluation and management of hypoglycemia only in patients in whom Whipple's triad--symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised--is documented. In patients with hypoglycemia without diabetes mellitus, we recommend the following strategy. First, pursue clinical clues to potential hypoglycemic etiologies--drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies. Insulin or insulin secretagogue treatment of diabetes mellitus is the most common cause of hypoglycemia. We recommend the practice of hypoglycemia risk factor reduction--addressing the issue of hypoglycemia, applying the principles of intensive glycemic therapy, and considering both the conventional risk factors and those indicative of compromised defenses against falling plasma glucose concentrations--in persons with diabetes.
authors.affiliation: Washington University School of Medicine, St. Louis, Missouri 63110, USA.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Cryer
authors.forename: Lloyd
authors.initials: L
authors.lastname: Axelrod
authors.forename: Ashley B
authors.initials: AB
authors.lastname: Grossman
authors.forename: Simon R
authors.initials: SR
authors.lastname: Heller
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
authors.forename: Elizabeth R
authors.initials: ER
authors.lastname: Seaquist
authors.forename: F John
authors.initials: FJ
authors.lastname: Service
mesh_terms: D000328:Adult; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000628:therapy; D019317:Evidence-Based Medicine; D006801:Humans; D007003:Hypoglycemia / Q000145:classification / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D012307:Risk Factors