Diabetes can manifest not only with hyperglycemia,but also as hypoglycemia. It typically occurs postprandially,3-5 hrs after meals and is preceded by early post meals hyperglycemia.
58 yrs old Saudi gentleman had Type 2 diabetes for 5 yrs,dyslipidemia,Mitral valve disease,Bronchial asthma, GERD,vitamin D deficiency,BPH and depressive illness. He had presented to the outpatient Diabetes clinic in November, 2015 with post-prandial hypoglycemia 2-3 hrs post-meals esp. lunch & supper (with sympathetic symptoms and Whipples triad). He denied any neurological symptoms. The minimum recorded RBS at home was 70 mg/dL. He had intermittent retrosternal burning. His weight & the bowel habits were usual. Rest of the systemic review was unremarkable. His deceased father had diabetes. Our patient was initially on Metformin that was later discontinued. Other medications included Simvastatin, Cholecalciferol, Mebeverine, Pantoprazole, Fluoxetine, Symbicorte inhaler and Ibuprofen.
He was fully alert, oriented and co-operative. Vitals were preserved. BMI 28.09 kg/m2. There was Lt hallux valgus deformity. CVS examination revealed a Grade 1,non-radiating systolic murmur in the mitral area. Rest of the general & systemic exam was unremarkable.
The complete blood count, ESR, liver and renal parameters were well within normal limits. Bone profile, Vitamin D,PTH were normal. HbA1c was 42 mols/mols IFCC. Serum testosterone,LH,FSH,Prolactin,PSA,C-peptide and insulin levels were normal. Echocardiogram showed mitral valve prolapse and mild MR. U/S Abdomen & prostate were normal. Upper GI endoscopy was consistent with gastro-esophageal reflux disease.
His fasting blood glucose was 82 mg/dl. The 75 G oral glucose tolerance test showed an RPG of 220 mg/dl,2 hrs post glucose,that dropped to 65 mg/dl after 3 hrs. The continuous glucose monitoring system for 7 days revealed post-prandial peaks of >250 mg/dl,followed by nadir upto 70 mg/dl.
Our patient was diagnosed to have a reactive hypoglycemia, which can be a feature of Mild Type 2 diabetes. He was referred to the nutritionist,advised avoidance of simple sugars,encouraged to take complex carbohydrates and small, frequent meals. The patient's hypoglycemic episodes got settled with the change in his dietary pattern.
Impaired glucose tolerance and diabetes are the known causes of reactive hypoglycemia,which should always be borne in mind.