Frequency of Adrenal Insufficiency in Patients With Hypoglycemia in an Emergency Department: A Cross-sectional Study

Tetsuya Kawahara, Maiko Tsuji, Naoki Tominaga, Nagahiro Toyama, Mikio Toda, Tetsuya Kawahara, Maiko Tsuji, Naoki Tominaga, Nagahiro Toyama, Mikio Toda

Abstract

Context: In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.

Objective: We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.

Methods: In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level < 70 mg/dL (3.9 mmol/L)] between April 1, 2016 and March 31, 2021 using a rapid adrenocorticotropic hormone (ACTH) test.

Results: There were 528 cases with hypoglycemia included [52.1% male; median age 62 years (range 19-92)]. The majority [389 (73.7%)] of patients were using antidiabetes drugs. Additionally, 33 (6.3%) consumed alcohol; 17 (3.2%) had malnutrition; 13 (2.5%), liver dysfunction; 12 (2.3%), severe infectious disease; 11 (2.1%), malignancy; 9 (1.7%), heart failure; 4 (0.8%), insulin autoimmune syndrome; 3 (0.6%), insulinoma; 2 (0.4%) were using hypoglycemia-relevant drugs; and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs 139 mEq/L, P < 0.01), eosinophil counts were higher (14 vs 8%, P < 0.01), and systolic blood pressure was lower (120 vs 128 mmHg, P < 0.05) at baseline than in patients with the other etiologies.

Conclusion: The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.

Keywords: adrenal insufficiency; emergency department; hypoglycemia; rapid ACTH test.

© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society.

Figures

Figure 1.
Figure 1.
Study flow diagram.
Figure 2.
Figure 2.
Percentage of each etiology in patients with hypoglycemia. Out of 528 patients with hypoglycemia transported to our emergency department, 389 (73.7%) were on antidiabetes drugs; 35 (6.6%) had alcohol abuse problem; 32 (6.1%), adrenal insufficiency; 18 (3.4%), malnutrition; 15 (2.8%), liver dysfunction; 11 (2.1%), malignancy; 9 (1.7%), heart failure; 7 (1.3%), severe infection; 4 (0.8%), insulin antibody syndrome; 3 (0.6%), insulinoma; 2 (0.4%) were receiving hypoglycemia-related drugs; 2 (0.4%) had unknown etiology; and 1 (0.2%), non-islet cell tumor.

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