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Quick Reference
  • Normal Range (Fasting): 70-100 mg/dL
  • Prediabetes (Fasting): 100-125 mg/dL
  • Diabetes (Fasting): ≥126 mg/dL
  • Random/Non-fasting Normal: <200 mg/dL
  • Critical Low: <50 mg/dL (severe hypoglycemia)
  • Critical High: >400 mg/dL (hyperglycemic crisis risk)
  • SI Units: To convert mg/dL to mmol/L, divide by 18
  • Primary Use: Diabetes screening, diagnosis, and management; assessment of glucose metabolism
  • Sample Type: Serum or plasma (fasting preferred for diagnosis)
  • Key Point: Single elevated value requires confirmation; fasting status critical for interpretation

Test Description

What is Glucose?

Glucose is a simple sugar (monosaccharide) that serves as the primary energy source for all cells in the body, particularly the brain and red blood cells. Blood glucose levels are tightly regulated by a complex interplay of hormones, primarily insulin and glucagon, to maintain metabolic homeostasis. Measurement of blood glucose is one of the most commonly performed laboratory tests and is essential for screening, diagnosing, and managing diabetes mellitus and other disorders of glucose metabolism.

How Does It Work?

After food intake, carbohydrates are broken down into glucose and absorbed into the bloodstream, causing blood glucose levels to rise. In response, the pancreas secretes insulin, which facilitates glucose uptake by cells and promotes glucose storage as glycogen in the liver and muscles. Between meals and during fasting, blood glucose is maintained by hepatic glucose production through glycogenolysis (breakdown of glycogen) and gluconeogenesis (synthesis of new glucose). Counter-regulatory hormones such as glucagon, cortisol, epinephrine, and growth hormone raise blood glucose when levels drop too low.

Clinical Use

Blood glucose testing is used for multiple clinical purposes:

  • Diabetes screening and diagnosis: Identifying impaired fasting glucose, prediabetes, and diabetes mellitus
  • Diabetes management: Monitoring glycemic control and guiding treatment adjustments
  • Hypoglycemia evaluation: Investigating symptoms of low blood sugar in diabetic and non-diabetic patients
  • Critical illness monitoring: Assessing stress hyperglycemia and guiding insulin therapy in hospitalized patients
  • Metabolic syndrome assessment: Evaluating cardiovascular risk factors
  • Medication monitoring: Assessing effects of corticosteroids, antipsychotics, and other medications affecting glucose
Normal Ranges

Blood glucose levels vary based on fasting status, time of day, and recent food intake. The American Diabetes Association (ADA) has established specific diagnostic criteria for glucose categories:

Swipe to see more
Category Fasting Glucose Random Glucose
Normal 70-100 mg/dL <200 mg/dL
Impaired Fasting Glucose (Prediabetes) 100-125 mg/dL —
Diabetes Mellitus ≥126 mg/dL (on 2 separate occasions) ≥200 mg/dL (with symptoms)
Hypoglycemia (Mild) 50-70 mg/dL 50-70 mg/dL
Hypoglycemia (Severe) <50 mg/dL <50 mg/dL
Critical High >400 mg/dL >400 mg/dL
SI Unit Conversion: To convert mg/dL to mmol/L (used internationally), divide by 18. For example, 100 mg/dL = 5.6 mmol/L.
Important Considerations:
  • Fasting status is critical: For diagnosis, fasting glucose requires no caloric intake for at least 8 hours
  • Confirmation required: A single elevated fasting glucose should be confirmed on a separate day unless classic symptoms are present
  • Point-of-care limitations: Bedside glucometers are less accurate than laboratory plasma glucose and should not be used for diagnosis
  • Pregnancy screening: Different criteria apply for gestational diabetes (see 1-hour and 3-hour glucose tolerance tests)
Clinical Significance

Hyperglycemia (Elevated Glucose)

Elevated blood glucose occurs when insulin secretion is insufficient, insulin action is impaired, or glucose production exceeds utilization. Chronic hyperglycemia leads to microvascular and macrovascular complications.

Diabetes Mellitus

  • Type 1 Diabetes: Autoimmune destruction of pancreatic beta cells resulting in absolute insulin deficiency. Typically presents with acute onset, weight loss, polyuria, and polydipsia
  • Type 2 Diabetes: Insulin resistance combined with relative insulin deficiency. Most common form, associated with obesity, metabolic syndrome, and gradual onset
  • Gestational Diabetes: Glucose intolerance first recognized during pregnancy, typically in 2nd or 3rd trimester
  • Secondary Diabetes: Due to medications (corticosteroids, antipsychotics), pancreatic disease (chronic pancreatitis, cystic fibrosis), or endocrine disorders (Cushing's syndrome, acromegaly)

Stress Hyperglycemia

  • Critical illness: Elevated counter-regulatory hormones (cortisol, epinephrine, glucagon) in sepsis, trauma, MI, or surgery
  • Acute coronary syndrome: Stress response and reduced insulin sensitivity during cardiac events
  • Stroke: Associated with worse outcomes and increased mortality
  • Severe infection: Inflammatory cytokines and stress hormones drive glucose elevation

Endocrine Causes

  • Cushing's syndrome: Excess cortisol increases gluconeogenesis and insulin resistance
  • Acromegaly: Growth hormone excess causes insulin resistance
  • Pheochromocytoma: Catecholamine excess stimulates glycogenolysis and inhibits insulin release
  • Hyperthyroidism: Increased hepatic glucose output and enhanced GI absorption

Medication-Induced

  • Corticosteroids: Most common drug-induced cause; dose-dependent hyperglycemia
  • Thiazide diuretics: May impair insulin secretion and increase insulin resistance
  • Atypical antipsychotics: Especially clozapine and olanzapine; associated with weight gain and metabolic syndrome
  • Beta-blockers: May mask hypoglycemia symptoms and impair glucose recovery
  • Protease inhibitors: HIV medications associated with insulin resistance and diabetes

Hypoglycemia (Low Glucose)

Low blood glucose represents an imbalance between glucose supply and utilization. Symptoms typically occur below 70 mg/dL, with severe neuroglycopenia (confusion, seizures, coma) below 50 mg/dL.

Diabetic Causes

  • Excessive insulin or sulfonylurea: Most common cause in diabetics; due to medication overdose, missed meals, or increased exercise
  • Insulin autoimmune syndrome: Rare; antibodies to insulin cause erratic glucose control
  • Gastroparesis: Delayed gastric emptying leads to insulin-food mismatch

Non-Diabetic Causes

  • Insulinoma: Insulin-secreting pancreatic tumor causing fasting hypoglycemia
  • Critical illness: Sepsis, liver failure, renal failure, or adrenal insufficiency
  • Alcohol-induced: Inhibits gluconeogenesis, especially in fasting or malnourished patients
  • Post-gastric bypass: Exaggerated insulin response (late dumping syndrome)
  • Medication-induced: Quinolones, pentamidine, quinine, beta-blockers
  • Hormonal deficiencies: Cortisol or growth hormone deficiency (pediatrics)
  • Reactive hypoglycemia: Postprandial glucose drop 2-5 hours after meals (controversial diagnosis)
Interpretation Guidelines

ADA Diagnostic Criteria for Diabetes

Diabetes mellitus can be diagnosed using any of the following criteria (requires confirmation on separate day unless symptoms present):

Swipe to see more
Test Diabetes Diagnosis Prediabetes
Fasting Plasma Glucose ≥126 mg/dL 100-125 mg/dL
2-Hour OGTT ≥200 mg/dL 140-199 mg/dL
HbA1c ≥6.5% 5.7-6.4%
Random Glucose ≥200 mg/dL (with symptoms) —
Classic Diabetes Symptoms: Polyuria, polydipsia, unexplained weight loss, blurred vision, fatigue, or recurrent infections. In the presence of these symptoms, a single random glucose ≥200 mg/dL is diagnostic.

Correlation with HbA1c

HbA1c reflects average glucose over 2-3 months and is useful for assessing long-term glycemic control:

  • HbA1c <5.7%: Normal glucose metabolism (average glucose ~100-120 mg/dL)
  • HbA1c 5.7-6.4%: Prediabetes (average glucose ~120-150 mg/dL)
  • HbA1c 6.5-7%: Diabetes, good control (average glucose ~140-170 mg/dL)
  • HbA1c 7-8%: Diabetes, fair control (average glucose ~170-200 mg/dL)
  • HbA1c 8-10%: Diabetes, poor control (average glucose ~200-260 mg/dL)
  • HbA1c >10%: Diabetes, very poor control (average glucose >260 mg/dL)

Hypoglycemia Severity

Swipe to see more
Severity Glucose Level Clinical Features
Mild 50-70 mg/dL Tremor, palpitations, diaphoresis, hunger (adrenergic symptoms)
Moderate 40-50 mg/dL Confusion, difficulty concentrating, weakness, drowsiness
Severe <40 mg/dL Altered mental status, seizures, loss of consciousness, coma
EMERGENCY Treatment of Severe Hypoglycemia
INDICATIONS: Glucose <50 mg/dL or symptomatic hypoglycemia with altered mental status
  1. If patient can swallow: Give 15-20g fast-acting carbohydrate (juice, glucose tablets, candy)
  2. If altered or unconscious: IV Dextrose 50% (D50) 25-50mL (12.5-25g) bolus, or IM Glucagon 1mg
  3. Recheck glucose in 15 minutes: Repeat treatment if still <70 mg/dL
  4. Follow with complex carbohydrate: Prevent recurrent hypoglycemia after initial correction
  5. Monitor closely: Sulfonylurea-induced hypoglycemia may recur for 12-24 hours; consider octreotide and admission
Interfering Factors

Factors That Increase Glucose

  • Medications: Corticosteroids (most common), thiazide diuretics, beta-blockers, atypical antipsychotics (clozapine, olanzapine), protease inhibitors, niacin, tacrolimus, phenytoin
  • Stress and illness: Acute MI, stroke, sepsis, trauma, surgery, burns (stress hyperglycemia from counter-regulatory hormones)
  • Endocrine disorders: Cushing's syndrome, acromegaly, hyperthyroidism, pheochromocytoma, glucagonoma
  • Pancreatic disease: Pancreatitis (acute or chronic), pancreatic cancer, hemochromatosis, cystic fibrosis
  • Collection issues: Delayed processing (glycolysis lowers glucose ~10 mg/dL per hour at room temperature)
  • IV dextrose infusion: Blood drawn from arm with running IV fluids
  • Recent food intake: Non-fasting sample (physiologic, not pathologic)

Factors That Decrease Glucose

  • Medications: Insulin, sulfonylureas (glyburide, glipizide), meglitinides, alcohol, quinolones, pentamidine, quinine, beta-blockers (mask symptoms), salicylates (high dose)
  • Prolonged fasting: More than 24 hours without food
  • Excessive exercise: Increased glucose utilization by muscles
  • Organ failure: Severe liver failure (impaired gluconeogenesis), renal failure (reduced insulin clearance), adrenal insufficiency
  • Collection issues: Delayed processing without glycolysis inhibitor (fluoride tube); hemolysis
  • Factitious: Surreptitious insulin or sulfonylurea use

Pseudoabnormal Results

  • Pseudohypoglycemia: Marked leukocytosis or thrombocytosis (>100,000/μL WBC) causing in vitro glycolysis if sample not processed quickly. Use sodium fluoride tube to prevent.
  • Point-of-care meter inaccuracy: Bedside glucometers less accurate at extremes (<60 or >400 mg/dL) and affected by hematocrit, hypotension, and hypoxia. Should not be used for diagnosis.
  • Maltose interference: Some glucometers falsely elevated with IV immunoglobulins containing maltose or icodextrin (peritoneal dialysis)
Clinical Pearls
Clinical Pearl
"Dawn Phenomenon": Morning hyperglycemia (4-8 AM) due to overnight surge in counter-regulatory hormones (cortisol, growth hormone, glucagon). Common in Type 1 and Type 2 diabetes. Managed by adjusting evening insulin dose or adding basal insulin.
Clinical Pearl
"Somogyi Effect": Rebound morning hyperglycemia following nocturnal hypoglycemia (excessive insulin causes low glucose at 2-3 AM, triggering counter-regulatory response). Differentiate from dawn phenomenon by checking 2-3 AM glucose. Managed by reducing evening insulin.
Clinical Pearl
Stress hyperglycemia predicts outcomes: Elevated glucose in non-diabetic patients during critical illness, MI, or stroke is associated with worse outcomes and higher mortality. Consider insulin therapy for glucose >180 mg/dL in ICU patients.
Clinical Pearl
Rule of 15: For hypoglycemia treatment, give 15 grams of fast-acting carbohydrate, wait 15 minutes, recheck glucose. If still <70 mg/dL, repeat. Examples of 15g: 4 oz juice, 3-4 glucose tablets, 1 tablespoon honey.
Clinical Pearl
Whipple's Triad for hypoglycemia: (1) Symptoms consistent with hypoglycemia, (2) Low plasma glucose at time of symptoms, (3) Relief of symptoms with glucose correction. Required to diagnose true hypoglycemia and rule out factitious causes.
Don't use point-of-care meters for diagnosis: Bedside glucometers are screening tools only. Always confirm diabetes diagnosis with laboratory plasma glucose or HbA1c. Meters can be off by 15-20% and are particularly inaccurate at extremes.
Steroid-induced hyperglycemia is predictable: Typically peaks 4-8 hours after dose, affects postprandial glucose more than fasting. Most pronounced with long-acting steroids like dexamethasone. May require short-acting prandial insulin.
Clinical Pearl
Hypoglycemia unawareness: Recurrent hypoglycemia blunts adrenergic warning symptoms (tremor, palpitations, sweating), leading to sudden severe neuroglycopenia without warning. More common in longstanding Type 1 diabetes and tight glucose control. Raising glucose targets can restore awareness.
Alcohol blocks gluconeogenesis: Ethanol inhibits hepatic glucose production, causing hypoglycemia 6-36 hours after binge drinking, especially in fasting or malnourished patients. Treat with IV dextrose, not just glucagon (which won't work).
HbA1c limitations: HbA1c can be falsely low in hemolytic anemia, recent transfusion, EPO therapy, or hemoglobinopathies (shortened RBC lifespan). Falsely high in iron deficiency, B12 deficiency, or uremia. Use glucose when HbA1c unreliable.
References
  1. Kratz, A., Ferraro, M., Sluss, P. M., & Lewandrowski, K. B. (2004). Laboratory reference values. New England Journal of Medicine, 351, 1548-1564.
  2. Lee, M. (Ed.). (2009). Basic skills in interpreting laboratory data. Ashp.
  3. Farinde, A. (2021). Lab values, normal adult: Laboratory reference ranges in healthy adults. Medscape. https://emedicine.medscape.com/article/2172316-overview?form=fpf
  4. Nickson, C. (n.d.). Critical Care Compendium. Life in the Fast Lane • LITFL. https://litfl.com/ccc-critical-care-compendium/
  5. Farkas, Josh MD. (2015). Table of Contents - EMCrit Project. EMCrit Project. https://emcrit.org/ibcc/toc/
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