Reactive Hypoglycaemia- A challenge for Diabetes Management!

Abstract

Imagine you get a routine blood sugar test done and your post prandial blood sugar (PPBS) level is reported lower than fasting blood sugar level, contrary to the common perception of the reverse by your family physician, you and general population is reported. This rare phenomenon is called Reactive Hypoglycaemia! Reactive hypoglycaemia (RH) is a condition characterized by recurrent episodes of hypoglycaemia occurring after consumption of carbohydrate rich meals usually within four hours after meals. Type 2 diabetes (T2D) patients experience RH less frequently than type 1 diabetes (T1D) patients. Most RH episodes in T2D are mild to moderate, therefore this is noticed as surprise outcome in a routine check-up among prediabetics or early diabetics Majority of such clients are symptomless or may have Symptoms varying from almost mild or self-resolving weakness after meals to severe manifestations if BS falls below 70mg/ Dl. Severe symptoms include loss of consciousness, seizures, falls, and impaired cognition that may lead to hospitalization for emergency treatment. Managing RH poses challenges to the doctors also due to limited & often ineffective treatment options known till day. Materials and Methods: This article is an outcome of the diagnostic and management challenge the author is facing as a family physician in one case currently. 62 years old lady sought second opinion as lab report on 10 Augst 2024 reported her FBS as 136 mg/dl and PPBS 2 hrs after breakfast as 114mg/Dl in a routine check-up. Repeat test report on 15 August showed PPBS= 108mg/Dl and FBS= 146 mg/Dl and Hb1Ac =7.65 % making us to. Diagnose her as Early diabetes case. She was put on Metformin 500mg BD after main meals. Outcome: A comprehensive whole-body check-up on 5th September 2024 showed abnormal biomarkers of i) Fasting Blood Glucose level=136mg/dl, PPBS= 103 mg/Dl, and Hb1Ac=6.8%. Total Cholesterol=211mg/dl- borderline high, Transferrin saturation=15.8%, Vitamin D Total= 10.2 mg/Dl and Uric Acid=6.4 mg/dl. Two weeks of metformin had yielded some effect. Current approach adopted is to correct Vit D efficiency first and try to identify the Hypoglycaemia timings (after 4 hours of lunch) and consider giving Metformin an hour before the BS starts rising beyond 140mg/Dl. Though ideal to use the continuous Glucose monitoring tools, affordability is the constraint.