Blood sugar

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Synonyms and Keywords: Blood glucose, fasting blood glucose, fasting blood sugar, FBG, FBS

Overview

Blood sugar is a term used to refer to the amount of glucose in the blood. Glucose, transported via the bloodstream, is the primary source of energy for the body's cells.

Blood sugar concentration, or glucose level, is tightly regulated in the human body. Normally, the blood glucose level is maintained between about 4 and 8 mmol/L (70 to 150 mg/dL). The total amount of glucose in the circulating blood is therefore about 3.3 to 7g (assuming an ordinary adult blood volume of 5 liters). Glucose levels rise after meals and are usually lowest in the morning, before the first meal of the day.

Failure to maintain blood glucose in the normal range leads to conditions of persistently high (hyperglycemia) or low (hypoglycemia) blood sugar. Diabetes mellitus, characterized by persistent hyperglycemia of several causes, is the most prominent disease related to failure of blood sugar regulation.

Though it is called "blood sugar" and sugars besides glucose are found in the blood, like fructose and galactose, only glucose levels are regulated via insulin and glucagon.

Glucose Measurement

Sample Type

Glucose can be measured in whole blood, serum, or plasma. Historically, blood glucose values were given in terms of whole blood, but most laboratories now measure and report the serum glucose levels. Because RBC (erythrocytes) have a higher concentration of protein (i.e. hemoglobin) than serum, serum has a higher water content and consequently more dissolved glucose than does whole blood. To convert from whole-blood glucose, multiply the value by 1.15 to give the serum/plasma level.

Collection of blood in clot (red-top) tubes for serum chemistry analysis permits the metabolism of glucose in the sample by blood cells until separated by centrifugation. Higher than normal amounts of white or red blood cell counts can lead to excessive glycolysis in the sample with substantial reduction of glucose level if the sample is not processed quickly. Ambient temperature at which the blood sample is kept prior to centrifugation and separation of Plasma/Serum also affects glucose levels. At refrigerator temperatures, glucose remains relatively stable for several hours in the blood sample. At room temperature (25°C), a loss of 1 to 2% of glucose per hour should be expected. The loss of glucose levels in aforementioned conditions can be prevented by using Fluoride top (gray-top) as the anticoagulant of choice upon blood collection, as Fluoride inhibits glycolysis. However, this should only be used when blood will be transported from one hospital laboratory to another for glucose measurement. Red-top serum separator tubes also preserve glucose in samples once they have been centrifugated to isolate the serum from cells, this tube would be the most efficient. Particular care should be given to drawing blood samples from the arm opposite the one in which an intravenous line is inserted, to prevent contamination of the sample with intravenous fluids (IV). Alternatively, blood can be drawn from the same arm with an IV line after the IV was turned off for at least 5 minutes and the arm is elevated to drain the infused fluids away from the vein. As little as 10% contamination with 5% dextrose (D5W) will elevate glucose in a sample by 500mg/dl or more. Arterial, capillary and venous blood have comparable glucose levels in a fasting individual, whereas after meals venous levels are lower than capillary or arterial blood.

Methodology

There are two different major methods that have been used to measure glucose. The older one is a chemical method that exploits the nonspecific reducing property of glucose in a reaction with an indicator substance that acquires or changes color on its reduction. Since other blood compounds also have reducing properties (e.g., urea, which can build up in uremic patients), this method can have erroneous measurements up to 5 to 15 mg/dl. This is solved by the Enzymatic methods that are highly specific for glucose. The two most common employed enzymes are glucose oxidase and hexokinase.

I. CHEMICAL METHODS
A. Oxidation-Reduction Reaction
1. Alkaline Copper Reduction
Folin Wu Method Blue end-product
Benedict's method
  • Modification of Folin wu for Qualitative Urine Glucose
Nelson Somoygi Method Blue end-product
Neocuproine Method * Yellow-orange color Neocuproine
Shaeffer Hartmann Somygi
  • Utilizes the principle of Iodine reaction with Cuprous byproduct.
  • Excess I2 is then titrated with thiosulfate.
2. Alkaline Ferricyanide Reduction
Hagedorn Jensen Colorless end product; other reducing substances interfere with reaction
B. Condensation
Orht-touidine Method
Anthrone (Phenols) Method
  • Forms hydroxymethyl furfural in hot acetic acid
II. ENZYMATIC METHODS
A. Glucose Oxidase
Saifer Gernstenfield Method Inhibited by reducing substances like BUA, Bilirubin, Glutathione, Ascorbic Acid
Trinder Method
Kodak Ektachem
  • A Dry Chemistry Method
  • Uses Reflectance Spectrophotometry to measure the intensity of color through a lower transparent film
Glucometer
  • Home monitoring blood glucose assay method
  • Uses a strip impregnated with a Glucose Oxidase reagent
B. Hexokinase

  • NADP as cofactor
  • NADPH (reduced product) is measured in 340 nm
  • More specific than Glucose Oxidase method due to G-6PO_4, which inhibits interfering substances except when sample is hemolyzed

Laboratory Tests Commonly Employed

  1. Fasting Blood Sugar or Glucose test (FBS)
  2. Urine Glucose test
  3. Two-hr Postprandial Blood Sugar Test (2-h PPBS)
  4. Oral Glucose Tolerance test (OGTT)
  5. Intravenous Glucose Tolerance test (IVGTT)
  6. Glycosylated Hemoglobin (HbA1C)
  7. Self-monitoring of Glucose level via Home Kits

Clinical Correlation

The fasting blood glucose (FBG) level is the most commonly used indication of overall glucose homeostasis. Conditions that affect glucose levels are shown in the table below. They reflect abnormalities in the multiple control mechanism of glucose regulation.

The metabolic response to a carbohydrate challenge is conveniently assessed by the postprandial glucose level drawn 2 hours after a meal or a glucose load. In addition, the glucose tolerance test, consisting of serial timed measurements after a standardized amount of oral glucose intake, is used to aid in the diagnosis of Diabetes.

Causes of Abnormal Glucose Levels
Persistent Hyperglycemia Transient Hyperglycemia Persistent Hypoglycemia Transient Hypoglycemia
Reference Range, FBG: 70-110 mg/dl
Diabetes Mellitus Pheochromocytoma Insulinoma Acute Alcohol Ingestion
Adrenal cortical hyperactivity Cushing's Syndrome Severe Liver Disease Adrenal cortical insufficiency Addison's Disease Drugs: salicylates, antituberculosis agents
Hyperthyroidism Acute stress reaction Hypopituitarism Severe Liver disease
Acromegaly Shock Galactosemia Several Glycogen storage diseases
Obesity Convulsions Ectopic Insulin production from tumors Hereditary fructose intolerance

Health Effects

If blood sugar levels drop too low, a potentially fatal condition called hypoglycemia develops. Symptoms may include lethargy, impaired mental functioning, irritability, and loss of consciousness.

If levels remain too high, appetite is suppressed over the short term. Long-term hyperglycemia causes many of the long-term health problems associated with diabetes, including eye, kidney, and nerve damage.

Low Blood Sugar

Some people report drowsiness or impaired cognitive function several hours after meals, which they believe is related to a drop in blood sugar, or "low blood sugar". For more information, see:

Converting Glucose Units

Countries that use the metric system use mmol/L. The U.S. uses mg/dL.
To convert Blood Glucose readings:

  • Divide the mg/dL by 18 to get mmol/L (or multiply by 0.055).
  • Multiply the mmol/L by 18 to get mg/dL (or divide with 0.055).

2013 American Diabetes Association Standards of Medical Care in Diabetes (DO NOT EDIT)[1]

Glucose Monitoring

"1. Patients on multiple-dose insulin (MDI) or insulin pump therapy should do self- monitoring of lood glucose (SMBG) at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving.. (Level of Evidence: B)"
"2. When prescribed as part of a broader educational context, SMBG results may be helpful to guide treatment decisions and/or patient self-management for patients using less frequent insulin injections or noninsulin therapies. (Level of Evidence: E)"
"3. When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG tech- nique and SMBG results, as well as their ability to use SMBG data to adjust therapy. (Level of Evidence: E)"
"4. Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (aged ≥25 years) with type 1 diabetes. (Level of Evidence: A)"
"5. Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. (Level of Evidence: C)"|-
"6. CGM may be a supplemental tool to SMBG in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. (Level of Evidence: E)"

Glycemic Goals in Adults

"1. Lowering A1C to below or around 7% has been shown to reduce microvascular complications of diabetes and if implemented soon after the diagnosis of diabetes is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is ,7%. (Level of Evidence: B)"
"2. Providers might reasonably suggest more stringent A1C goals (such as ,6.5%) for selected individual pa- tients, if this can be achieved without significant hypoglycemia or other ad- verse effects of treatment. Appropriate patients might include those with short duration of diabetes, long life expec- tancy, and no significant CVD. (Level of Evidence: C)"
"3. Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced mi-crovascular or macrovascular complications, extensive comorbid conditions, and those with long-standing diabetes in whom the general goal is difficult to attain despite DSME, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. (Level of Evidence: B)"

Sources

  • John Bernard Henry, M.D.: Clinical diagnosis and Management by Laboratory Methods 20th edition, Saunders, Philadelphia, PA, 2001.
  • Ronald A. Sacher and Richard A. McPherson: Widmann's Clinical Interpretation of Laboratory Tests 11th edition, F.A. Davis Company, 2001.

External links

References

  1. American Diabetes Association (2013). "Standards of medical care in diabetes--2013.". Diabetes Care. 36 Suppl 1: S11–66. PMC 3537269Freely accessible. PMID 23264422. doi:10.2337/dc13-S011. 
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