Plasma Glucose Concentrations at the Onset of Hypoglycemic Symptoms in Patients with Poorly Controlled Diabetes and in Nondiabetics

We tested the hypothesis that during decrements in plasma glucose concentration, symptoms of hypoglycemia may occur at higher glucose concentrations in patients with poorly controlled insulin-dependent diabetes mellitus than in persons without diabetes. Symptoms of hypoglycemia and counterregulatory neuroendocrine responses were quantified during hypoglycemic and euglycemic clamp studies in eight patients with insulin-dependent diabetes mellitus selected because their hemoglobin A₁ levels were above 10 percent. These data were compared with similar observations in 10 nondiabetic subjects studied previously. Glycemic thresholds — the plasma glucose concentrations during each hypoglycemic clamp study at which a given symptom or biochemical measurement first exceeded its 95 percent confidence interval determined in the euglycemic clamp studies — were calculated for each variable. The mean (±SE) glycemic threshold for the symptoms of hypoglycemia was 4.3±0.3 mmol per liter (78±5 mg per deciliter) in patients with poorly controlled diabetes — significantly higher (P<0.001) than the value of 2.9±0.1 mmol per liter (53±2 mg per deciliter) in subjects without diabetes. The mean glycemic thresholds for growth hormone, epinephrine, and cortisol secretions were not significantly different in the two groups. Thus, during decreases in the plasma glucose concentration, patients with poorly controlled insulin-dependent diabetes mellitus may experience symptoms of hypoglycemia at higher plasma glucose concentrations than persons without diabetes. The mechanism underlying this observation remains to be defined. (N Engl J Med 1988; 318:1487–92.)