Causes of Fasting-Evoked en Route Hypoglycemia in Diabetes (FEEHD): A Case Series Study

Abstract

<p class="MsoNormal"> <b><span lang="EN-US">Background: </span></b><span lang="EN-US">A recent study reported that some patients with diabetes who fast overnight for laboratory tests are at risk of developing hypoglycemia, which could occur while patients are in risky situations which could result in harm to pa</span><span lang="EN-US">tients or others. Due to limitation in study design of the aforementioned study, the causes of hypoglycemia could not be elucidated</span><span lang="EN-US">. </span><b><span lang="EN-US">Objective:</span></b><span lang="EN-US"> To better understand fasting-evoked en route hypoglycemia in diabetes (FEEHD), a recently recognized overlooked safety problem in diabetes management. <b>Methods and Patients: </b>A recent study reported that some patients with diabetes who fast overnight for laboratory tests are at risk of developing hypoglycemia, which could occur while patients are in risky situations which could result in harm to patients or others. Due to limitation in study design of the aforementioned study, the causes of hypoglycemia could not be elucidated. We undertook this retrospec</span><span lang="EN-US">tive case series study, which enrolled 4 consecutive cases of fasting hypoglycemia in patients with diabetes who were on diverse antidiabetic medications. The study duration was June 1, 2010 to June 1, 2012.</span><b><span lang="EN-US"> Results: </span></b><span lang="EN-US">The 4 cases (3 women, 1 man), with either type 1 or type 2 diabetes, revealed multiple defects in either the patients’ knowledge and education regarding preparation for lab tests requiring fasting. The degree of hypoglycemia ranged from mild (65 mg/dl) to severe (31 mg/dl), and the events were either mildly symptomatic or asymptomatic. The possible causes of, and con</span><span lang="EN-US">tributing factors to hypoglycemia are discussed, and recommendations for preventive measures are provided.</span><b><span lang="EN-US"> Conclu</span></b><b><span lang="EN-US">sion: </span></b><span lang="EN-US">Some patients with diabetes who fast for lab tests are at risk of hypoglycemia, and there seems to be an overall lack of proper education of patients with diabetes about this form of hypoglycemia. This overlooked problem can be prevent</span><span lang="EN-US">ed</span><span lang="EN-US"> by proper education and preparation.</span><span lang="EN-US"><o:p></o:p></span> </p&gt

Fasting for Laboratory Tests Poses a High Risk of Hypoglycemia in Patients with Diabetes: A Pilot Prevalence Study in Clinical Practice

“…Whereas patients who are not taking hypoglycemic medications (i.e., insulin and insulin secretagogues) are protected by a complex physiological response that inhibits insulin production by the beta cells during fasting, patients taking such medications typically do not have such a protective mechanism in view of continued circulating insulin [10]. This risk is further aggravated in patients with long-standing diabetes due to the loss of additional counter-regulatory mechanisms that protect from hypoglycemia during fasting, i.e., glucagon and catecholamines [12]- [15].…”

“…As recently reported, patients with diabetes on hypoglycemic medications are especially vulnerable to fasting that can increase their risk for hypoglycemia especially if they are not adequately prepared for fasting [10]- [12]. Specifically, patients with diabetes who use insulin or sulfonylureas are put at increased risk for hypoglycemia when fasting [10]- [13].…”

“…While FEEHD has been described recently in two small studies [10] [11] and a case series [12], the exact prevalence of FEEHD remains largely unknown. Thus, we hypothesized that this form of iatrogenic hypoglycemia is widely prevalent in clinical practice but judging from the dearth of reports is greatly under recognized.…”

Letter by Aldasouqi and Abela Regarding Article, “Prognostic Value of Fasting Versus Nonfasting Low-Density Lipoprotein Cholesterol Levels on Long-Term Mortality: Insight From the National Health and Nutrition Survey III (NHANES-III)”

“…4 Another case series elaborated further on the causes of this newly recognized form of hypoglycemia, depicting a series of cases of diverse demographic and clinical presentations. 5 These recent reports emphasized the seriousness of hypoglycemia induced in patients with diabetes mellitus who are asked to fast overnight for lipid testing. [3][4][5] Overnight fasting is often requested in a routine manner, at least annually in this patient population.…”

“…[3][4][5] A recent pilot study 3 demonstrated an increased risk of hypoglycemia in patients who fast for laboratory tests if such patients are not well informed about adjustment of their antidiabetic medications (ie, insulin and sulfonylureas). In another study, the same authors reported a practice that almost completely eliminated the fasting prerequisite for lipid testing.…”