Commentary on The High Cost of Low Quality: Recurring Hypoglycemia in a 63-Year-Old Man Free

Hypoglycemia in a healthy patient without diabetes is uncommon and warrants further evaluation. Although patients without diabetes may routinely have blood glucose concentrations in the 60 mg/dL (3.3 mmol/L) range, most healthy patients without chronic hypoglycemia develop symptoms of hypoglycemia with a plasma glucose concentration below 55 mg/dL (3.0 mmol/L) (1). The plasma glucose of 28 mg/dL (1.6 mmol/L) in this case in combination with altered mental status warranted immediate medical attention.

Many of the laboratory tests used to evaluate hypoglycemia must be performed while the blood glucose is low, whether due to spontaneous hypoglycemia or during a supervised fast. Increased or inappropriately normal insulin and C-peptide concentrations during hypoglycemia can result from endogenous hyperinsulinism or a medication that stimulates pancreatic insulin release, such as a sulfonylurea. A sulfonylurea screen is also ideally performed close to the time of hypoglycemia when blood concentrations of the medication are likely to be high but can provide useful information even if drawn after treating hypoglycemia.

Medication-induced hypoglycemia is often accidental, although it may be surreptitious or malicious. Even in patients without known access to diabetes medications, careful identification of all medications, including prescriptions and over-the-counter products, is crucial. This case illustrates a public health success with over-the-counter products. Healthcare providers obtained history from the patient of use of the male enhancement supplement marketed as “V8” and suspected exposure to a hypoglycemic agent based on symptoms. Because similar cases had been reported to poison centers, the Virginia Department of Health and Virginia Department of Agriculture and Consumer Services were able to issue warnings to consumers and health professionals within days of the first reported cases and eventually removed the product from shelves across Virginia (2). Notifications were sent to other states to prevent the public from greater harm.

Author Contributions

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Authors' Disclosures or Potential Conflicts of Interest

No authors declared any potential conflicts of interest.

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