Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): From Guidelines to Clinical Practice

Author(s): Omar M. Abdelfattah, Mohamed Hassanein, Anas M. Saad, George Abela, Saleh Aldasouqi*

Journal Name: Current Diabetes Reviews

Volume 16 , Issue 9 , 2020


Become EABM
Become Reviewer
Call for Editor

Abstract:

Background: Lipid profiles have been used for the purposes of health screening and monitoring of the effects of lipid-lowering medications, especially in patients with diabetes who are prone to hyperlipidemia. Fasting for lipid profiles has been the norm for the past decades. This long-lasting tradition poses a risk of hypoglycemia, especially in patients with diabetes.

Objective: Our aim is to review the overlooked occurrence of hypoglycemia in patients who fast for laboratory tests, especially lipid profile tests, and commute to the laboratory facility while fasting; a condition we titled “Fasting-Evoked En route Hypoglycemia in Diabetes patients” or “FEEHD”. We also review its prevalence and clinical impact on patients with diabetes.

Methods: We undertook an extensive literature search using search engines such as PubMed and Google Scholar. We used the following keywords for the search: Fasting, Non-fasting; Hypoglycemia; Hypoglycemic Agents; Laboratory Tests; Glucose, Hypoglycemia, Lipid Profiles, FEEHD.

Results: Our literature review has shown that the prevalence of FEEHD is alarmingly high (17-21% of patients at risk). This form of hypoglycemia is under recognized in the clinical practice despite its frequent occurrence. Recent changes in various international guidelines have uniformly endorsed the utilization of non-fasting lipid profiles as the new standard for obtaining lipid profiles with the exception of certain conditions. Multiple studies showed the efficacy of non-fasting lipid tests in comparison to fasting lipid tests, in routine clinical practice.

Conclusion: We hope to increase awareness among clinicians about this overlooked and potentially harmful form of hypoglycemia in patients with diabetes, which can be easily avoided. We also hope to call upon clinicians to consider changing the habit of ordering lipid profiles in the fasting state, which has been recently shown to be largely unnecessary in routine clinical settings, with few exceptions in selected cases.

Keywords: Fasting, non-fasting, hypoglycemia, hypoglycemic agents, laboratory tests, glucose, hypoglycemia, lipid profiles, FEEHD.

[2]
American Diabetes Association. Standards of Medical Care in Diabetes--2014. Diabetes Care 2014; 37(1): 14-80.
[http://dx.doi.org/10.2337/dc14-S014.] [PMID: 24357209]
[3]
Darras P, Mattman A, Francis GA. Nonfasting lipid testing: the new standard for cardiovascular risk assessment. CMAJ 2018; 190(45): E1317-8.
[http://dx.doi.org/10.1503/cmaj.180804] [PMID: 30420386]
[4]
Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: A report of the american college of cardiology/american heart association task force on clinical practice guidelines. Circulation 2019; 139(25)
[5]
Aldasouqi S, Sheikh A, Klosterman P, et al. Hypoglycemia in patients with diabetes on antidiabetic medications who fast for laboratory tests. Diabetes Care 2011; 34(5)e52
[http://dx.doi.org/10.2337/dc10-2402] [PMID: 21525492]
[6]
Aldasouqi S, Grunberger G. The traditions and risks of fasting for lipid profiles in patients with diabetes. Postgrad Med 2014; 126(7): 98-107.
[http://dx.doi.org/10.3810/pgm.2014.11.2837] [PMID: 25387218]
[7]
Aldasouqi S, Sheikh A, Klosterman P, et al. Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program. Postgrad Med 2013; 125(1): 136-43.
[http://dx.doi.org/10.3810/pgm.2013.01.2629] [PMID: 23391679]
[8]
Aldasouqi S, Abela G. 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). Circulation 2015; 131(19)e471
[http://dx.doi.org/10.1161/CIRCULATIONAHA.114.012564] [PMID: 25964284]
[9]
Aldasouqi S, Corser WS, Abela G, et al. Fasting for laboratory tests poses a high risk of hypoglycemia in patients with diabetes: A pilot prevalence study in clinical practice. Int J Clin Med 2016; 07(10): 653-67.
[http://dx.doi.org/10.4236/ijcm.2016.710071]
[10]
Wiwanitkit V. Case of sudden death in venipuncture clinic. Phlebol J Venous Dis 2004; 19(4): 193-3.
[http://dx.doi.org/10.1258/0268355042554993]
[11]
Boughton B. Patients with diabetes lack knowledge about hypoglycemia Available at: http://www.medscape.com/view article/7408812011.
[12]
Aldasouqi S, Mora S, Bhalla G, et al. Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice. Int J Endocrinol 2018.20181528437
[http://dx.doi.org/10.1155/2018/1528437] [PMID: 30473710]
[13]
Kackov S, Šimundić A-M, Gatti-Drnić A. Are patients well informed about the fasting requirements for laboratory blood testing? Biochem Med (Zagreb) 2013; 23(3): 326-31.
[http://dx.doi.org/10.11613/BM.2013.040] [PMID: 24266303]
[14]
Standards of Medical Care in Diabetes--2012. Diabetes Care 2012; 35(1): 11-63.
[PMID: 22187469 doi: 10.2337/dc12-s011]
[15]
Standards of Medical Care in Diabetes--2011. Diabetes Care 2011; 34(1): 11-61.
[PMID: 21193625 doi: 10.2337/dc11-S011]
[16]
Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L. A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education. Patient Educ Couns 2007; 68(1): 10-5.
[http://dx.doi.org/10.1016/j.pec.2007.05.003] [PMID: 17582726]
[17]
Khan SG, Huda MS. Hypoglycemia and Cardiac Arrhythmia; Mechanisms, Evidence Base a nd Current Recommendations. Curr Diabetes Rev 2017; 13(6): 590-7.
[http://dx.doi.org/10.2174/1573399812666161201155941] [PMID: 27908250]
[18]
[19]
Skyler JS, Bergenstal R, Bonow RO, et al. American Diabetes Association; American College of Cardiology Foundation; American Heart Association. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care 2009; 32(1): 187-92.
[http://dx.doi.org/10.2337/dc08-9026] [PMID: 19092168]
[20]
Nauck MA, Lindmeyer AM, Mathieu C, Meier JJ. Twenty-Four Hour Fasting (Basal Rate) Tests to Achieve Custom-Tailored, Hour-by-Hour Basal Insulin Infusion Rates in Patients With Type 1 Diabetes Using Insulin Pumps (CSII). J Diabetes Sci Technol 2019.1932296819882752
[http://dx.doi.org/10.1177/1932296819882752] [PMID: 31633384]
[21]
Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points—a joint consensus statement from the European Atherosclerosis Society and European Federa. Eur Heart J 2016; 37(25): 1944-58.
[http://dx.doi.org/10.1093/eurheartj/ehw152] [PMID: 27122601]
[22]
Nordestgaard BG. A Test in Context: Lipid Profile, Fasting Versus Nonfasting. J Am Coll Cardiol 2017; 70(13): 1637-46.
[http://dx.doi.org/10.1016/j.jacc.2017.08.006] [PMID: 28935041]
[23]
Mora S, Rifai N, Buring JE, Ridker PM. Fasting compared with nonfasting lipids and apolipoproteins for predicting incident cardiovascular events. Circulation 2008; 118(10): 993-1001.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.108.777334] [PMID: 18711012]
[24]
Langsted A, Freiberg JJ, Nordestgaard BG. Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction. Circulation 2008; 118(20): 2047-56.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.108.804146] [PMID: 18955664]
[25]
Di Angelantonio E, Sarwar N, Perry P, et al. Emerging Risk Factors Collaboration Major lipids, apolipoproteins, and risk of vascular disease. JAMA 2009; 302(18): 1993-2000.
[http://dx.doi.org/10.1001/jama.2009.1619] [PMID: 19903920]
[26]
Lund SS, Petersen M, Frandsen M, et al. Agreement between fasting and postprandial LDL cholesterol measured with 3 methods in patients with type 2 diabetes mellitus. Clin Chem 2011; 57(2): 298-308.
[http://dx.doi.org/10.1373/clinchem.2009.133868] [PMID: 20947697]
[27]
Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population: a cross-sectional study. Arch Intern Med 2012; 172(22): 1707-10.
[http://dx.doi.org/10.1001/archinternmed.2012.3708] [PMID: 23147400]
[28]
Sathiyakumar V, Park J, Golozar A, et al. Fasting Versus Nonfasting and Low-Density Lipoprotein Cholesterol Accuracy. Circulation 2018; 137(1): 10-9.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.117.030677] [PMID: 29038168]
[29]
Farukhi Z, Mora S. The Future of Low-Density Lipoprotein Cholesterol in an Era of Nonfasting Lipid Testing and Potent Low-Density Lipoprotein Lowering. Circulation 2018; 137(1): 20-3.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.117.031857] [PMID: 29279336]
[30]
Ansar S, Koska J, Reaven PD. Postprandial hyperlipidemia, endothelial dysfunction and cardiovascular risk: focus on incretins. Cardiovasc Diabetol 2011; 10(1): 61.
[http://dx.doi.org/10.1186/1475-2840-10-61] [PMID: 21736746]
[31]
Tverdal A, Foss OP, Leren P, Holme I, Lund-Larsen PG, Bjartveit K. Serum triglycerides as an independent risk factor for death from coronary heart disease in mtddle-aged norwegian men. Am J Epidemiol 1989; 129(3): 458-65.
[http://dx.doi.org/10.1093/oxfordjournals.aje.a115157] [PMID: 2916539]
[32]
Stensvold I, Tverdal A, Urdal P, Graff-Iversen S. Non-fasting serum triglyceride concentration and mortality from coronary heart disease and any cause in middle aged Norwegian women. BMJ 1993; 307(6915): 1318-22.
[http://dx.doi.org/10.1136/bmj.307.6915.1318] [PMID: 8257886]
[33]
Langsted A, Freiberg JJ, Tybjaerg-Hansen A, Schnohr P, Jensen GB, Nordestgaard BG. Nonfasting cholesterol and triglycerides and association with risk of myocardial infarction and total mortality: the Copenhagen City Heart Study with 31 years of follow-up. J Intern Med 2011; 270(1): 65-75.
[http://dx.doi.org/10.1111/j.1365-2796.2010.02333.x] [PMID: 21198993]
[34]
Mora S, Rifai N, Buring JE, Ridker PM. Comparison of LDL cholesterol concentrations by Friedewald calculation and direct measurement in relation to cardiovascular events in 27,331 women. Clin Chem 2009; 55(5): 888-94.
[http://dx.doi.org/10.1373/clinchem.2008.117929] [PMID: 19395440]
[35]
Bansal S, Buring JE, Rifai N, Mora S, Sacks FM, Ridker PM. Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women. JAMA 2007; 298(3): 309-16.
[http://dx.doi.org/10.1001/jama.298.3.309] [PMID: 17635891]
[36]
Finelli C, Sommella L, Gioia S, La Sala N, Tarantino G. Should visceral fat be reduced to increase longevity? Ageing Res Rev 2013; 12(4): 996-1004.
[http://dx.doi.org/10.1016/j.arr.2013.05.007] [PMID: 23764746]
[37]
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360(9326): 7-22.
[http://dx.doi.org/10.1016/S0140-6736(02)09327-3] [PMID: 12114036]
[38]
Armitage J, Bowman L, Wallendszus K, et al. Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group. Intensive lowering of LDL cholesterol with 80 mg versus 20 mg simvastatin daily in 12,064 survivors of myocardial infarction: a double-blind randomised trial. Lancet 2010; 376(9753): 1658-69.
[http://dx.doi.org/10.1016/S0140-6736(10)60310-8] [PMID: 21067805]
[39]
Sever PS, Chang CL, Gupta AK, Whitehouse A, Poulter NR. ASCOT Investigators. The Anglo-Scandinavian Cardiac Outcomes Trial: 11-year mortality follow-up of the lipid-lowering arm in the U.K. Eur Heart J 2011; 32(20): 2525-32.
[http://dx.doi.org/10.1093/eurheartj/ehr333] [PMID: 21873710]
[40]
Mora S, Chang CL, Moorthy MV, Sever PS. Association of nonfasting vs. fasting lipid levels with risk of major coronary events in the anglo-scandinavian cardiac outcomes trial-lipid lowering arm. JAMA Intern Med 2019; 179(7): 898-905.
[http://dx.doi.org/10.1001/jamainternmed.2019.0392] [PMID: 31135812]
[41]
Nordestgaard BG, Hilsted L, Stender S. Plasma lipids in non-fasting patients and signal values of laboratory results. Ugeskr Laeger 2009; 171(13): 1093.
[PMID: 19321088]
[42]
Miller M, Stone NJ, Ballantyne C, et al. American heart association clinical lipidology, thrombosis, and prevention committee of the council on nutrition, physical activity, and metabolism; council on arteriosclerosis, thrombosis and vascular biology; council on cardiovascular nursing; council on the kidney in cardiovascular disease. triglycerides and cardiovascular disease: A scientific statement from the American Heart Association. Circulation 2011; 123(20): 2292-333.
[http://dx.doi.org/10.1161/CIR.0b013e3182160726] [PMID: 21502576]
[43]
Reiner Z, Catapano AL, De Backer G, et al. European Association for Cardiovascular Prevention & Rehabilitation; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 2011; 32(14): 1769-818.
[http://dx.doi.org/10.1093/eurheartj/ehr158] [PMID: 21712404]
[44]
Anderson TJ, Grégoire J, Hegele RA, et al. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2013; 29(2): 151-67.
[http://dx.doi.org/10.1016/j.cjca.2012.11.032] [PMID: 23351925]
[46]
Downs JR, O’Malley PG. Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med 2015; 163(4): 291-7.
[http://dx.doi.org/10.7326/M15-0840] [PMID: 26099117]
[47]
Catapano AL, Graham I, De Backer G, et al. ESC Scientific Document Group. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Eur Heart J 2016; 37(39): 2999-3058.
[http://dx.doi.org/10.1093/eurheartj/ehw272] [PMID: 27567407]
[48]
Anderson TJ, Grégoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol 2016; 32(11): 1263-82.
[http://dx.doi.org/10.1016/j.cjca.2016.07.510] [PMID: 27712954]
[49]
Leung AA, Nerenberg K, Daskalopoulou SS, et al. CHEP Guidelines Task Force. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol 2016; 32(5): 569-88.
[http://dx.doi.org/10.1016/j.cjca.2016.02.066] [PMID: 27118291]
[50]
Scartezini M, Ferreira CEDS, Izar MCO, et al. Positioning about the Flexibility of Fasting for Lipid Profiling. Arq Bras Cardiol 2017; 108(3): 195-7.
[http://dx.doi.org/10.5935/abc.20170039] [PMID: 28443960]
[51]
Jellinger PS, Handelsman Y, Rosenblit PD, et al. American association of clinical endocrinologists and american college of endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract 2017; 23(Suppl. 2): 1-87.
[http://dx.doi.org/10.4158/EP171764.APPGL] [PMID: 28437620]
[52]
Stone NJ, Robinson JG, Lichtenstein AH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129(25)(Suppl. 2): S1-S45.
[http://dx.doi.org/10.1161/01.cir.0000437738.63853.7a] [PMID: 24222016]
[53]
Farukhi Z, Mora S. Re-assessing the role of non-fasting lipids; a change in perspective. Ann Transl Med 2016; 4(21): 431-1.
[http://dx.doi.org/10.21037/atm.2016.11.15] [PMID: 27942522]


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 16
ISSUE: 9
Year: 2020
Page: [949 - 956]
Pages: 8
DOI: 10.2174/1573399816666200107103829
Price: $65

Article Metrics

PDF: 15
HTML: 6
EPUB: 5
PRC: 5