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Factitious hypoglycemia may be difficult to document. A suspicion of self-induced hypoglycemia is supported when the patient is associated with the health professions or has access to diabetic medications taken by a member of the family who has diabetes. The triad of hypoglycemia, high immunoreactive insulin, and suppressed plasma C-peptide immunoreactivity is pathognomonic of exogenous insulin administration. Insulin and C-peptide are secreted in a 1:1 molar ratio. A large fraction of the endogenous insulin is cleared by the liver, whereas C-peptide, which is cleared by the kidney, has a lower metabolic clearance rate. For this reason, the molar ratio of insulin and C-peptide in a hypoglycemic patient should be less than 1.0 in cases of insulinoma and is greater than 1.0 in cases of exogenous insulin administration (see Hypoglycemia Due to Pancreatic B Cell Tumors, above). When sulfonylureas, repaglinide, and nateglinide are suspected as a cause of factitious hypoglycemia, a plasma level of these medications to detect their presence may be required to distinguish laboratory findings from those of insulinoma.

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