Plasma glucose falls from 90 mg/dL to 60 mg/dL in a healthy adult. Which sequence of counterregulatory responses occurs as glucose declines?

• A Epinephrine rises first, glucagon second, cortisol and growth hormone last
• B All four hormones rise simultaneously at the same glycemic threshold
• C Cortisol rises first, glucagon second, epinephrine last
• D Glucagon rises first, epinephrine second, cortisol and growth hormone last ✓

Explanation

As glucose falls below roughly 70 mg/dL, suppression of insulin and a rise in glucagon are the earliest defenses, followed by sympathoadrenal activation with epinephrine around 65 to 70 mg/dL. Cortisol and growth hormone rise later and mainly defend against prolonged hypoglycemia rather than acute episodes. The hierarchical thresholds are well established in experimental insulin clamp studies, ruling out simultaneous onset.

Reference: Williams Textbook of Endocrinology, 14th ed.

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