A puzzling case of hypoglycemia: the clue in the medication history.

Learning objectives were (1) recognize the importance of taking a detailed history, (2) recognize the interactions of herbal medications with prescription drugs. A 30-year-old white female with well controlled insulin dependent diabetes mellitus for 13 years presented with 2 months of numerous hypoglycemic episodes. A decrease in her insulin regimen did not resolve the hypoglycemia. On further review of the patient's medications, the only new addition was ginseng, which she began taking 2 months ago for "increased energy." Complete work-up including renal function was normal. The ginseng was discontinued and her hypoglycemia resolved. She was able to resume her previous insulin regimen. Herbal therapy is an ancient practice that appears to be experiencing resurgence in the US. In numerous previous studies, the ginseng glycopeptides (GGP) from the roots of Panax ginseng had hypoglycemic activity on both normal and hyperglycemic animals. Studies in diabetic humans have also suggested that ginseng lowers blood glucose. The hypoglycemia is due to the enhancement of aerobic glycolysis. The administration of GGP decreases both the level of plasma lactic acid and the activities of plasma and liver LDH while enhancing the rate limiting enzymes in aerobic glycolysis (tricar-boxylic acid cycle). The hypoglycemic action of GGP could last up to 16 hours. This case reflects the increasing frequency of herbal and alternative medication use and supports the fact that patients often neglect to tell their physicians. Direct inquiry about herbal medication use should be a routine part of history taking.

Susie Estes, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga Unit, Chattanooga, TN.