Evaluation and management of adult hypoglycemic disorders: An endocrine society clinical practice guideline

Philip E. Cryer, Lloyd Axelrod, Ashley B. Grossman, Simon R. Heller, Victor M. Montori, Elizabeth R. Seaquist, F. John Service

Research output: Contribution to journalArticlepeer-review

597 Scopus citations


Objective: The aim is to provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus. Evidence: Using the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, the quality of evidence is graded very low (⊕○○○), low (⊕⊕○○), moderate (⊕⊕⊕○), or high (⊕ ⊕ ⊕ ⊕). 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, β-hydroxy-butyrate, 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.

Original languageEnglish (US)
Pages (from-to)709-728
Number of pages20
JournalJournal of Clinical Endocrinology and Metabolism
Issue number3
StatePublished - Mar 2009

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Biochemistry
  • Endocrinology
  • Clinical Biochemistry
  • Biochemistry, medical


Dive into the research topics of 'Evaluation and management of adult hypoglycemic disorders: An endocrine society clinical practice guideline'. Together they form a unique fingerprint.

Cite this