History and exam
Key diagnostic factors
common
known diabetes
Suspect diabetic hypoglycaemia if a person with diabetes presents with life-threatening alterations in mental and/or physical functioning, typical neuroglycopenic or sympathoadrenal symptoms of hypoglycaemia (see entries below), or following a fall or motor accident.[1][3] Hypoglycaemia 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 hypoglycaemia in people who have diabetes, in order to determine their risk of future episodes, and to minimise the occurrence of these.[3] The most common risk factors include:
Intensive glycaemic control efforts (low [<6%] or high [>9%] HbA1c levels)[3][49][50]
Previous severe (level 3) or clinically significant (level 2) hypoglycaemia[3]
First trimester of pregnancy[2][4][20][21][22][23][24][25][26]
Failure to thrive in children
Poor oral intake (e.g, if there is food insecurity or reduced intake of carbohydrates), weight loss, or malnutrition.
In addition, be aware that patients are at particular risk of severe or asymptomatic hypoglycaemia during sleep (nocturnal hypoglycaemia) because sleep impairs the counter-regulatory hormone response to hypoglycaemia.[1]
For more information see Risk factors, below.
Other diagnostic factors
common
irritability
Typical neuroglycopenic symptom of hypoglycaemia.[3] Neuroglycopenic symptoms usually occur at a blood glucose of <3.0 mmol/L (<54 mg/dL) and are more common than sympathoadrenal symptoms in children.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children than in adults.[1]
shakiness
Typical sympathoadrenal symptom of hypoglycaemia.[1][3] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
sweating
Typical sympathoadrenal symptom of hypoglycaemia.[1][3] Sympathoadrenal symptoms usually occur before neuroglycopenic signs.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
tremor
Typical sympathoadrenal symptom of hypoglycaemia.[1][78] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
palpitations
Typical sympathoadrenal symptom of hypoglycaemia.[1][78] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
tachycardia
Typical sympathoadrenal symptom of hypoglycaemia.[3] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
feeling warm
Typical sympathoadrenal symptom of hypoglycaemia.[78] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
anxiety
Typical sympathoadrenal symptom of hypoglycaemia.[78] Suspect nocturnal hypoglycaemia if the patient experiences altered mood when waking up.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
nausea
Typical sympathoadrenal symptom of hypoglycaemia.[1] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
hunger
Typical sympathoadrenal symptom of hypoglycaemia.[1][78] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
pallor
Typical sympathoadrenal symptom of hypoglycaemia.[1] Sympathoadrenal symptoms usually occur before neuroglycopenic symptoms.[1]
In people without diabetes, sympathoadrenal symptoms may occur from a blood glucose of 3.0 to 3.4 mmol/L (54-61 mg/dL).[80] However, in people with diabetes and chronic recurrent hypoglycaemia, symptoms may occur at a lower blood glucose (and at a higher blood glucose in people with diabetes and chronic hyperglycaemia).[1]
higher blood glucose than usual on waking up
Can be a feature of hypoglycaemia.
uncommon
seizure
A sign of severe (level 3) hypoglycaemia (characterised 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 hypoglycaemia usually occurs when blood glucose is 1.9 to 2.2 mmol/L (35-40 mg/dL).
Suspect nocturnal hypoglycaemia if the patient experiences seizures at night.[1]
loss of consciousness
A sign of severe (level 3) hypoglycaemia (characterised 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 hypoglycaemia usually occurs when blood glucose is 1.9 to 2.2 mmol/L (35-40 mg/dL). 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 hypoglycaemia that causes unconsciousness needs to be addressed to avoid future catastrophes.
coma
A sign of severe (level 3) hypoglycaemia (characterised 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 hypoglycaemia usually occurs when blood glucose is 1.9 to 2.2 mmol/L (35-40 mg/dL).
confusion
Typical neuroglycopenic symptom of hypoglycaemia.[3] Suspect nocturnal hypoglycaemia 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 <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
problems with short-term memory
Typical neuroglycopenic symptom of hypoglycaemia.[3] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
changes in vision
Typical neuroglycopenic symptom of hypoglycaemia.[1][78] Specifically, blurred or double vision and disturbed colour vision may be present.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
changes in speech
Typical neuroglycopenic symptom of hypoglycaemia.[1] Specifically, slurred speech may be present.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
difficulty hearing
Typical neuroglycopenic symptom of hypoglycaemia.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
lethargy
Typical neuroglycopenic symptom of hypoglycaemia.[1][78] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
Suspect nocturnal hypoglycaemia if the patient experiences lethargy on waking up.[1]
drowsiness
Typical neuroglycopenic symptom of hypoglycaemia.[1] Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
quietness
Typical neuroglycopenic symptom of hypoglycaemia.[1] Behavioural changes such as irritability, agitation, quietness, and tantrums may be prominent in young children.[1] Other features may include erratic behaviour.[1] Suspect nocturnal hypoglycaemia if the patient experiences nightmares at night.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
tantrums
Typical neuroglycopenic symptom of hypoglycaemia.[1] Behavioural changes such as irritability, agitation, quietness, and tantrums may be prominent in young children.[1] Other features may include erratic behaviour.[1] Suspect nocturnal hypoglycaemia if the patient experiences nightmares at night.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
erratic behaviour
Typical neuroglycopenic symptom of hypoglycaemia.[1] Behavioural changes such as irritability, agitation, quietness, and tantrums may be prominent in young children.[1] Other features may include erratic behaviour.[1] Suspect nocturnal hypoglycaemia if the patient experiences nightmares at night.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
nightmares
Typical neuroglycopenic symptom of hypoglycaemia.[1] Suspect nocturnal hypoglycaemia if the patient experiences nightmares at night.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
headache
Typical neuroglycopenic symptom of hypoglycaemia.[1] Suspect nocturnal hypoglycaemia if the patient experiences headache when waking up.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
difficulty concentrating
Typical neuroglycopenic symptom of hypoglycaemia.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
dizziness
Typical neuroglycopenic symptom of hypoglycaemia.[78] The patient may have an unsteady gait.[1]
Neuroglycopenic symptoms usually occur at a blood glucose of around <3.0 mmol/L (<54 mg/dL) and are more common in children than sympathoadrenal symptoms.[1][3][81] Bear in mind that signs and symptoms of hypoglycaemia usually occur at a higher blood glucose level in children compared with adults.[1]
fall or motor vehicle accident
Falls and motor vehicle accidents can occur due to reduced consciousness level as a result of hypoglycaemia.[79] Always ascertain the preceding events or precipitants that led to the fall or accident.[79] This is key to identify because hypoglycaemia that causes unconsciousness needs to be addressed to avoid future catastrophes.[79]
bedwetting
Can be a feature of hypoglycaemia.
Risk factors
strong
type 1 diabetes
Hypoglycaemia occurs most commonly in people with type 1 diabetes.[1][2][8][9] However, be aware that hypoglycaemia 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 hypoglycaemic events in people with type 2 diabetes who are treated with insulin may be as high as, or higher than, in people with type 1 diabetes, due to the higher overall prevalence of type 2 diabetes.[2][10]
antidiabetic drugs
Treatment with insulin, sulfonylureas, or meglitinides increases the risk of hypoglycaemia compared with other antidiabetic drugs.[3][4][17][45][46][47]
If the patient is taking insulin, determine the timing of the insulin regimen and peak insulin action in relation to the timing of hypoglycaemia.[1] For instance:[48]
Bolus insulin used with meals typically causes postprandial hypoglycaemia
Basal insulin typically causes fasting or preprandial hypoglycaemia, but can cause hypoglycaemia at other times (e.g., during increased activity or missed meals)
Bolus and basal insulin may cause hypoglycaemia in fasting and fed states, but this is less uncommon.
In addition, an absolute or relative excess of insulin can lead to hypoglycaemia due to:[1]
Errors when giving insulin (e.g., too much insulin used for correction of hyperglycaemia, or wrong type or dose of insulin given)
Reduced carbohydrate intake or missed meals
Exercise
Concurrent use of alcohol.
age >60 years
Older adults, particularly those aged >60 years, have higher rates of hypoglycaemia than younger adults.[1][2][3][17] Older adults may have reduced ability to recognise symptoms of hypoglycaemia and communicate that they need assistance.[1][3] Minor episodes of hypoglycaemia frequently go unrecognised in older adults because they may present with non-specific symptoms such as brief episodes of lightheadedness or vertigo.
In older adults, there is age-related decline in renal and hepatic function, which can potentiate the effects of antidiabetic drugs such as sulfonylureas and insulin.[2] There may also be age-related impairment of counter-regulatory hormones in older adults such as glucagon and growth hormone.[2] Older patients also have an increase in comorbidities that may contribute to hypoglycaemia.[2]
age <6 years
poor glycaemic control
Poor glycaemic control (both low and high HbA1c levels) is strongly associated with increased risk of severe hypoglycaemia.[49] One retrospective study of over 1000 adults with type 2 diabetes looked at self-reported rates of severe hypoglycaemia at different HbA1c levels.[50] Compared with patients with HbA1c levels of 7% to 7.9%, the relative risk of severe hypoglycaemia was 1.25 (95% CI 0.99 to 1.57), 1.01 (95% CI 0.87 to 1.18), 0.99 (95% CI 0.82 to 1.20), and 1.16 (95% CI 0.97 to 1.38) among those with HbA1c levels of <6%, 6% to 6.9%, 8% to 8.9%, and ≥9%, respectively.[50] However, in young people (those aged <18 years in practice) with type 1 diabetes, low HbA1c is no longer a strong risk factor for hypoglycaemia.[1][51][52][53]
People with lower HbA1c levels are also at increased risk of nocturnal hypoglycaemia.[1]
intensive glycaemic control efforts
Adults with intensive glycaemic control (lower HbA1c target; in practice this varies but is generally <7%) are at increased risk of severe hypoglycaemia compared to those with less intensive glycaemic control (higher HbA1c target; generally ≥7% in practice).[3][54] The potential risk of hypoglycaemia outweighs the benefit of intensive glycaemic control in those with long duration of diabetes, previous episodes of hypoglycaemia, significant atherosclerosis, older age (particularly those >50 years), or frailty.[3]
previous severe (level 3) hypoglycaemia
Urgently identify if the person has had previous episodes of level 3 hypoglycaemia, in order to intervene quickly and prevent further episodes.[3] Level 3 hypoglycaemia is characterised 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 particular, repeated episodes of hypoglycaemia can cause impaired awareness of hypoglycaemia, which can increase the risk of hypoglycaemia.[3][17]
previous clinically significant (level 2) hypoglycaemia
Urgently identify if the person has had previous episodes of level 2 hypoglycaemia, in order to intervene quickly and prevent further episodes.[3] Level 2 hypoglycaemia is defined by blood glucose <3.0 mmol/L (<54 mg/dL) with or without clinical symptoms.[3][4][5][17] In particular, repeated episodes of hypoglycaemia can cause impaired awareness of hypoglycaemia, which can increase the risk of hypoglycaemia.[3][4][17]
increased duration of diabetes
treatment with insulin >5 years
impaired cognitive function
Cognitive impairment is strongly associated with increased risk of severe hypoglycaemia.[3][49][56] People with cognitive impairment are at risk of hypoglycaemia because of reduced ability to recognise symptoms of hypoglycaemia and communicate that they need assistance.[56] They are also at risk of errors associated with insulin administration, which can lead to hypoglycaemia.
Conversely, patients with diabetes who have episodes of hypoglycaemia are also at increased risk of dementia compared to those who do not have episodes of hypoglycaemia.[57]
impaired awareness of hypoglycaemia
Can be caused by recurrent episodes of hypoglycaemia, which leads to deficient release of counter-regulatory hormones and reduced autonomic response when the patient's blood glucose falls.[2][3] This means that a person will not experience typical signs and symptoms of hypoglycaemia in response to a progressively lower blood glucose, which puts them at increased risk of severe hypoglycaemia.[1][2][58][59]
Determine at what blood glucose the patient recognises hypoglycaemia, and what symptoms they experience.[1]
first trimester of pregnancy
Incidence of diabetic hypoglycaemia increases in early pregnancy, particularly around 10-15 weeks' gestation, in people with type 1 or type 2 diabetes.[20][21][22][23][24] In pregnant women with pre-existing type 1 diabetes, severe hypoglycaemia 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][25] Incidence rates of severe hypoglycaemia have been reported as high as 19% to 44% in pregnant women who are treated with intensive insulin therapy.[26]
Hypoglycaemia due to gestational diabetes is not covered in this topic.
failure to thrive in children
Decreases glycogen stores, which leads to hypoglycaemia.[60]
poor oral intake
Decreases glycogen stores, which leads to hypoglycaemia.[42][61] 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 hypoglycaemia.[1] Determine the timing and amount of carbohydrates in any recent food intake, and the peak glucose effect of recent food intake.[1]
weight loss
Accompanied by decreased glycogen stores, which leads to hypoglycaemia.[62]
sleep
During sleep, people are at particular risk of severe or asymptomatic hypoglycaemia because sleep impairs the counter-regulatory hormone response to hypoglycaemia.[1] Frequent, prolonged nocturnal hypoglycaemia may occur on 8.5% of nights in adults and children.[1] However, in children and adolescents with type 1 diabetes, prolonged nocturnal hypoglycaemia has been reported to occur on 15% to 25% of nights.[1]
Suspect nocturnal hypoglycaemia 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.
weak
hypoglycaemia-causing drugs (non-diabetic)
Non-diabetic drugs can increase the risk of hypoglycaemia in patients with diabetes.[42][63]
In particular, beta-blockers can mask the signs and symptoms of hypoglycaemia, which can predispose to severe, life-threatening hypoglycaemia.[63] Non-selective beta-blockers can also impair hepatic and renal release of glucose into the circulation, which can cause hypoglycaemia.[42]
Many other drugs (e.g., certain antibiotics [particularly sulfonamides and fluoroquinolone], quinine, pentamidine, indometacin) have been linked to hypoglycaemia in patients without diabetes, but the evidence is unclear as to whether they cause hypoglycaemia in patients with diabetes.[42] This list of drugs is not exhaustive, and you should consult a drug formulary for more information.
Polypharmacy with many hypoglycaemia-causing drugs also increases the risk of hypoglycaemia in people with type 2 diabetes.[3]
exercise
Determine the timing, duration, and intensity of exercise or recent activity.[1] Exercise can increase the risk of hypoglycaemia during, immediately after, or with prolonged delay (up to 24 hours) following the activity.[1][3][4][37][38] Post-exercise hypoglycaemia is caused by increased glucose uptake by exercising muscles. 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 hypoglycaemia, with aerobic posing more risk than anaerobic activity.[37] Exercise induces hypoglycaemia 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.[37][44] 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.[37]
renal failure
liver failure
Underlying liver dysfunction leads to loss of hepatic gluconeogenesis.[66]
endocrine disorders
Endocrine disorders such as adrenal insufficiency (including Addison's disease) and hypothyroidism can precipitate hypoglycaemia because they reduce the counter-regulatory response to a drop in blood glucose.[14] Coeliac disease can also increase the risk of hypoglycaemia through malabsorption.[67] Rule out Addison's and coeliac disease in any patient with type 1 diabetes and hypoglycaemia, and particularly in children with frequent, unexplained hypoglycaemia.[1][68][69] The prevalence of these disorders is higher in people with type 1 diabetes than the general population because these are all autoimmune diseases that share a similar genetic background.[67][70][71]
critical illness
alcohol ingestion
A common risk factor particularly in adolescents.[1][17] Drinking alcohol can cause hypoglycaemia during and after consumption, particularly if the person has not eaten recently.[3][4][37] In addition, alcohol-related liver disease can lead to hepatic insufficiency, which decreases gluconeogenesis as well as depleting glycogen stores.
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