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Hypoglycaemia

Hypoglycaemia. Definition of hypoglycaemia. When the level of glucose falls in the blood so that the cells in the periphery, and eventually the brain cells, do not get adequate glucose to function. Endogenous insulin secretion suppressed

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Hypoglycaemia

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  1. Hypoglycaemia Slides current until 2008

  2. Definition of hypoglycaemia When the level of glucose falls in the blood so that the cells in the periphery, and eventually the brain cells, do not get adequate glucose to function. Slides current until 2008

  3. Endogenous insulin secretion suppressed Release of glucagon, epinephrine, cortisol, growth hormone Autonomic response The body’s response Slides current until 2008

  4. The body’s response • Brain lacks glucose • Temporary cognitive impairment • Wide variation in symptoms Slides current until 2008

  5. Glucagon Hypoglycaemia stimulates release It acts in the liver to increase glucose production • releasing stored glycogen • activating production of new glucose • stimulating production of ketones Slides current until 2008

  6. Epinephrine • Releases stored glycogen • Activates production of glucose from protein • Reduces uptake of glucose • Reduces production of insulin Slides current until 2008

  7. Cortisol and growth hormone • Reduce cellular uptake of glucose • Stimulate breakdown of proteins to make glucose • Stimulate breakdown of body fats Slides current until 2008

  8. Hypoglycaemia • Symptoms • Low blood glucose • Relief of symptoms when blood glucose raised Slides current until 2008

  9. Symptoms of hypoglycaemia Slides current until 2008

  10. Mild-moderate fear anxiety affects self-care social stigma prejudice Severe injury seizures transient paralysis cognitive impairment death Consequences of hypoglycaemia Slides current until 2008

  11. People at risk of 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

  12. People at risk of hypoglycaemia Increased risk: • Recent severe hypoglycaemia • Gastroparesis • Liver disease or kidney failure • Pregnancy • Injection-related • Over-correction of high BGL Slides current until 2008

  13. How would you advise people to treat the following? • Mild hypoglycaemia • Moderate hypoglycaemia • Severe hypoglycaemia Slides current until 2008

  14. 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

  15. Management Severe • 20 g glucose • Glucagon • Intravenous dextrose • Manage seizure – place person on their side if not too agitated Slides current until 2008

  16. Glucagon/IV dextrose options 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

  17. Carbohydrate + protein Next dose taken as usual Consider reducing insulin Assess cause Prevent recurrence Avoid BGLs < 4 mM If BGL < 7mM before bed, eat a snack Follow-up management CDA, 2003 Slides current until 2008

  18. Other management strategies • Glargine/levemir insulin • Pump • Different injection sites • Depth of injection Slides current until 2008

  19. Relative hypoglycaemia Symptoms of hypoglycaemia without low blood glucose levels Associated with: • suboptimal control • significant and sudden change in blood glucose Slides current until 2008

  20. After nocturnal hypoglycaemia Low levels in early hours Fasting ketones may be present in prolonged hypoglycaemia Rebound hyperglycaemia Slides current until 2008

  21. Rebound hypoglycaemia Treatment options • Decrease evening intermediate-acting insulin • Intermediate insulin at bedtime • Long-acting insulin analogue • Increase bedtime snack Slides current until 2008

  22. 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

  23. Developing unawareness • Glucagon response often lost after five years with type 1 diabetes • Epinephrine response may be blunted and delayed • Adrenergic symptoms blunted • Reliance on recognizing neuroglycopenic symptoms Slides current until 2008

  24. Managing hypoglycaemic unawareness • Unawareness is reversible • Encourage hypoglycaemia-free state • Medical alert identification • Test before potentially hazardous behaviour Slides current until 2008

  25. Increased risk of 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

  26. Alcohol • Increased risk of hypoglycaemia • Decreased gluconeogenesis • Decreased ability to recognize symptoms • ‘Safe’ drinking Turner 2001 Slides current until 2008

  27. Hypoglycaemia in older people • Risk of injury from falls • May be missed or mistaken for dementia • Malnutrition may increase risk of hypoglycaemia • Avoid long-acting sulphonylureas in older people Slides current until 2008

  28. Driving – type 1 diabetes • Driving skills tested at three blood glucose ranges • Driving impaired at all three ranges • Preventive action • Cox, Gonder-Fredericks 2000 Slides current until 2008

  29. 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? Slides current until 2008

  30. Summary Hypoglycaemia • Common • Frightening for person with diabetes and family • Can usually be prevented • Reduced through education, self-monitoring and self-care • Must be addressed at every visit to healthcare professional • Treatment must be revised if recurrent Slides current until 2008

  31. Review question • Which of the following symptoms are part of the autonomic response to hypoglycaemia? • Trembling, palpitations, drowsiness • Hunger, sweating, confusion • Palpitations, sweating, drowsiness • Palpitations, trembling, hunger Slides current until 2008

  32. Review question 2. Hypoglycaemia unawareness is thought to be caused by impaired counter-regulation due to: • Repeated hypoglycaemia • Autonomic neuropathy • Nephropathy • Absent glucagon production Slides current until 2008

  33. Review question 3. At what blood glucose level do neuroglycopenic symptoms generally begin to show? • Less than 3.7mmol/L (66mg/dL) • Less than 3.1mmol/L (56mg/dL) • Less than 2.5mmol/L (45mg/dL) • Less than 2.0mmol/L (36mg/dL) Slides current until 2008

  34. Review question 4. Glucagon secretion results in: • Increased production of glucose in the liver • Increased sensitivity to glucose in the cells • Decreased absorption of glucose from the gastrointestinal tract • Decrease in glucose passed in the urine Slides current until 2008

  35. Review question 5. Which would be the most appropriate to treat mild-to-moderate hypoglycaemia? • Cup of tea • Chocolate bar • Six crackers • Glass of fruit juice Slides current until 2008

  36. Answers 1. d 2. a 3. c 4. a 5. d Slides current until 2008

  37. References • 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. • 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. • 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

  38. References • 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. • 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. • 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. Slides current until 2008

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