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4 1 Hypoglycemia
4 1 Hypoglycemia
Hypoglycaemia
Definition of hypoglycaemia
When the level of glucose falls in the blood so that the cells in the
glucose to function
Hypoglycaemia
Hypoglycaemia
Hypoglycaemia
Glucagon
Hypoglycaemia
Epinephrine
Releases stored glycogen Activates production of glucose from protein Reduces uptake of glucose Reduces production of insulin
Hypoglycaemia
Reduce cellular uptake of glucose Stimulate breakdown of proteins to make glucose Stimulate breakdown of body fats
Hypoglycaemia
Hypoglycaemia
Symptoms Low blood glucose Relief of symptoms when blood glucose raised
Hypoglycaemia
Symptoms of hypoglycaemia
Mild
Capable of selftreating Tremors, palpitation, sweating, hunger, fatigue Adrenergic
Moderate
May require prompting Headache, mood changes, low attentiveness Neuroglycopenic
Severe
Not capable of selftreatment Conscious or unconscious
Neuroglycopenic
Hypoglycaemia
Consequences of hypoglycaemia
Hypoglycaemia
Only those taking glucose-lowering medicines or insulin Increased risk: too little or wrong type of carbohydrate late or missed meal fasting or malnourishment too much insulin or insulin secretagogues prolonged or unplanned activity
Slides current until 2008
Hypoglycaemia
Increased risk:
Recent severe hypoglycaemia Gastroparesis Liver disease or kidney failure Pregnancy
Injection-related
Over-correction of high BGL
Slides current until 2008
ACTIVITY
Hypoglycaemia
Curriculum Module III-6 Slide 13 of 38
Hypoglycaemia
Management
Mild or moderate Test if possible 15 g glucose; re-test Glucose tablets Fruit juice Soft drink Sugar Re-treat if level remains low
CDA 2003
Slides current until 2008
Hypoglycaemia
Management
Severe 20 g glucose glucagon intravenous dextrose Manage seizure place person on their side if not too agitated
Hypoglycaemia
If unable to treat orally: Glucagon subcutaneously or intramuscular 1 ml for adult (0.5ml for child) blood glucose 3.0 to 11.8 in 45 min vomiting severe headache IV dextrose: 25-50 ml IV over 2-3 minutes immediate response
Slides current until 2008
Hypoglycaemia
Assess cause
Prevent recurrence Avoid BGLs < 4 mM If BGL < 7mM before bed, eat a snack
CDA, 2003
Slides current until 2008
Hypoglycaemia
Hypoglycaemia
Relative hypoglycaemia
Hypoglycaemia
Rebound hyperglycaemia
Hypoglycaemia
Rebound hypoglycaemia
Treatment options
Decrease evening intermediateacting insulin Intermediate insulin at bedtime Long-acting insulin analogue
Hypoglycaemia
Frequency of hypoglycaemia
Recognized hypoglycaemia twice a week Up to 50% unrecognized Increased frequency may decrease counter-regulatory response and awareness Asymptomatic nocturnal low blood glucose is common, often prolonged Risk of death
Slides current until 2008
Hypoglycaemia
Developing unawareness
Glucagon response often lost after five years with type 1 diabetes Epinephrine response may be blunted and delayed Adrenergic symptoms blunted
Hypoglycaemia
Unawareness is reversible Encourage hypoglycaemia-free state Medical alert identification Test before potentially hazardous behaviour
Hypoglycaemia
DCCT intensively treated group three times the number of severe hypoglycaemic episodes UKPDS 30% of intensively treated experienced hypoglycaemia; events rare in the conventional group Current research no increased risk with current medications, monitoring and appropriate education
Slides current until 2008
Hypoglycaemia
Alcohol
Hypoglycaemia
Hypoglycaemia
Driving skills tested at three blood glucose ranges Driving impaired at all three ranges Preventive action
ACTIVITY
Hypoglycaemia
Curriculum Module III-6 Slide 29 of 38
Are there any local regulations regarding driving and insulin use. For instance, can people on insulin hold a license to drive a tractor or fly an airplane? Are you required by law to report people who have frequent hypoglycaemia or unawareness?
Hypoglycaemia
Summary
Hypoglycaemia Common Frightening for person with diabetes and family Can usually be prevented Reduced through education, selfmonitoring and self-care Must be addressed at every visit to healthcare professional Treatment must be revised if recurrent
Slides current until 2008
Hypoglycaemia
Review question
1. Which of the following symptoms are part of the autonomic response to hypoglycaemia?
a. b. c. d. Trembling, palpitations, drowsiness Hunger, sweating, confusion Palpitations, sweating, drowsiness Palpitations, trembling, hunger
Hypoglycaemia
Review question
Hypoglycaemia
Review question
Hypoglycaemia
Review question
Hypoglycaemia
Review question
Hypoglycaemia
Answers
1. d
2. a 3. c 4. a 5. d
Hypoglycaemia
References
1.
Clarke WL, Cox DJ, Gonder-Frederick LA, Julian D, Schlundt D, Polonsky W. The relationship between nonroutine use of insulin, food, and exercise and the occurrence of hypoglycaemia in adults with IDDM and varying degrees of hypoglycemic awareness and metabolic control. Diabetes Educ 1997; 23(1): 55-8. Jones TW, Porter P, Sherwin RS, et al. Decreased epinephrine responses to hypoglycaemia during sleep. N Eng J Med 1998; 338: 1657-62. Frier BM, Ewing FM, Lindholm A, Hylleberg B, Kanc K. Symptomatic and counterregulatory hormonal responses to acute hypoglycaemia induced by insulin aspart and soluble human insulin in Type 1 diabetes. Diabetes Metab Res Rev 2000; 16(4): 262-8.
2. 3.
4.
The Diabetes Control and Complications Trial Research Group. Effects of intensive diabetes therapy on neuropsychological function in adults in the Diabetes Control and Complications Trial. Ann Intern Med 1996; 124: 379-88.
UKPDS. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patinets with type 2 diabetes (UKPDS 33). Lancet 1998; 352(9131): 837-53.
5.
6.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003; 27(suppl 2).
Garg SK, Paul JM, Karsten JI, et al. Reduced severe hypoglycemia with insulin glargine in intensively treated adults with type 1 diabetes. Diabetes Technol Ther 2004; 6(5): 589-95.
Slides current until 2008
7.
Hypoglycaemia
References
8.
Garb SK, Gottlieb PA, Hisamoti ME, et al. Improved glycemic control without an increase in severe hypoglycemic episodes in intensively treated patients with type 1 diabetes receiving morning, evening, or split doses insulin glargine. Diabetes Res Clin Pract 2004; 66(1): 49-56. Rosenstock J, Dailey G, Massi-Benedetti M, et al. Reduced hypoglycemia risk with insulin glargine: A meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care 2005; 28(4): 950-5. Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood glucose awareness training (BGAT-2): Long-term benefits. Diabetes Care 2001; 24(4): 637-42.
9.
10.
11.
Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001; 24(11): 1888-93.
Cox DJ, Gonder-Frederick LA, Kovatchev BP, Julian DM, Clarke WL. Progressive hypoglycaemia's impact on driving simulation performance. Occurrence, awareness and correction. Diabetes Care 2000; 23(2): 163-70.
12.
13.
Kalergis M, Schiffrin A, Gougeon R, Jones PJ, Yale JF. Impact of bedtime snack composition on prevention of nocturnal hypoglycaemia in adults with type 1 diabetes undergoing intensive insulin management using lispro insulin before meals: a randomized, placebo-controlled, crossover trial. Diabetes Care 2003; 26(1): 9-15.