Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

reactive hypoglycemia

1st line – dietary changes

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ACUTE
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reactive hypoglycemia
1st line – 

dietary changes

Reactive hypoglycemia (RH) is often successfully treated with dietary changes.[44] The diet should be high in proteins and low in carbohydrates, with frequent but smaller feeds to avoid the big fluctuations in the insulin secretion from the pancreas.[53][54][55] A high-fiber diet or fiber supplementation is also recommended to prevent RH.[56]

exposure/overdose medication, toxin, ethanol

1st line – supportive care ± psychiatric evaluation and treatment

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ACUTE
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exposure/overdose medication, toxin, ethanol
1st line – 

supportive care ± psychiatric evaluation and treatment

May require inpatient monitoring and glucose infusion until the effects of the offending medication, toxin or exogenous insulin/sulfonylurea diminish; timeframe is variable.

Options include D10 or D50 infusion or glycogen infusion or injection, closely monitored with frequent blood glucose checks or, as glucose stabilizes in the normal range, glucometer readings. The aim is to monitor for sustained hypoglycemia and prompt correction.

If intentional overdosing of salicylates, ethanol, insulin, or sulfonylureas is suspected, the patient should be screened to determine whether referral to a psychiatric specialty is warranted.

If suicidality is present, involuntary commitment may be necessary.

bariatric surgery, anorexia, malnutrition, ackee fruit ingestion

1st line – supportive care ± referral to specialist

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ACUTE
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bariatric surgery, anorexia, malnutrition, ackee fruit ingestion
1st line – 

supportive care ± referral to specialist

In addition to correcting the glucose deficiency by supportive care with glucose and/or glucagon, referral or consultation with endocrinology, eating disorders, toxicology, or gastrointestinal disease specialists may be necessary in these patients.

insulinoma

1st line – surgical excision

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ACUTE
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insulinoma
1st line – 

surgical excision

If hypoglycemic events continue after surgery, consideration should be given to repeating surgery to look for incomplete excision of primary tumor or rare malignant transformation with metastases.[7]

Plus – supportive care

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ACUTE
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insulinoma
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Supportive care while awaiting surgery may include self-administered glucagon injections.

2nd line – medical therapy

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ACUTE
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insulinoma
2nd line – 

medical therapy

For those who fail surgery or who are not surgical candidates, these pharmacologic agents may be used to control hypoglycemia for a period of time.

Primary options

diazoxide: 3-8 mg/kg/day orally given in 2-3 divided doses

OR

octreotide: 50 micrograms subcutaneously twice to three times daily

OR

streptozocin: consult specialist for guidance on dose

Plus – supportive care

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ACUTE
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insulinoma
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

All patients may require supportive care to maintain their blood glucose levels while awaiting definitive therapy.[48] Options include D10 or D50 infusion or glycogen infusion or injection, closely monitored with frequent blood glucose checks or, as glucose stabilizes in the normal range, glucometer readings. The aim is to monitor for sustained hypoglycemia and prompt correction.

Plus – focal embolization or chemotherapy

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ACUTE
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insulinoma
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metastatic disease
Plus – 

focal embolization or chemotherapy

Treatment recommended for ALL patients in selected patient group

If hypoglycemic events continue after surgery, one possibility is rare malignant transformation with metastases.[7]

Focal embolization or chemotherapy may be required for metastatic disease.[49]

IGF-II-secreting tumor

1st line – surgical excision ± chemotherapy/radiation therapy

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ACUTE
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IGF-II-secreting tumor
1st line – 

surgical excision ± chemotherapy/radiation therapy

The patient with insulin-like growth factor (IGF)-II hypersecretion should be referred to a surgeon for excision of the offending mass.

Therapies that reduce tumor burden (e.g., chemotherapy, radiation therapy) may help to relieve symptoms in some cases.[44]

Plus – supportive care

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ACUTE
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IGF-II-secreting tumor
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

While awaiting surgery, glucose levels may need to be supported with intermittent glucose infusion or glucagon administration.

renal failure, liver failure, sepsis, or other endocrinopathy

1st line – management of underlying condition

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ACUTE
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renal failure, liver failure, sepsis, or other endocrinopathy
1st line – 

management of underlying condition

Mainstay of therapy in these etiologies of hypoglycemia is management of the underlying condition, with supportive therapies to maintain adequate blood glucose level.

Plus – supportive care

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ACUTE
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renal failure, liver failure, sepsis, or other endocrinopathy
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Support with glucose infusion may be necessary until the condition resolves, especially if the patient cannot tolerate oral intake.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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