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Hypoglycemia
Definition (Cont.)
In addition, a BG that falls > 100 mg/dL in
one hour may be accompanied by symptoms
of hypoglycemia.
For example, a BG level of 120 mg/dL may
elicit signs and symptoms of hypoglycemia if
the BG has fallen from 220 mg/dL an hour
earlier.
11. Hypoglycemia
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1. Development of neurogenic or neuroglycopenic symptoms
2. Low blood glucose (<70mg/dl ) if on insulin or
secretagogue)
3. Response to carbohydrate load
Neurogenic
(autonomic)
Neuroglycopenic
Trembling Difficulty Concentrating
Palpitations Confusion
Sweating Weakness
Anxiety Drowsiness
Hunger Vision Changes
Nausea Difficulty Speaking
Dizziness
Definition of Hypoglycemia
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Symptoms of Hypoglycemia
13
Classification
Blood Glucose
Level
(mg/dL)
Typical Signs and Symptoms
Mild hypoglycemia ~60-70
• Neurogenic: palpitations, tremor, hunger,
sweating, anxiety, paresthesia
Moderate hypoglycemia ~50-60
• Neuroglycopenic: behavioral changes, emotional
lability, difficulty thinking, confusion
Severe hypoglycemia <50*
• Severe confusion, unconsciousness, seizure,
coma, death
• Requires help from another individual
*Severe hypoglycemia symptoms should be treated regardless of blood glucose level.
Q6. How should hypoglycemia be managed?
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May not be reprinted in any form without express written permission from AACE.
Consequences of Hypoglycemia
CV events
Cardiac autonomic neuropathy
Cardiac ischemia
Angina
Fatal arrhythmia
Cognitive, psychological changes (eg, confusion,
irritability)
Accidents
Falls
Recurrent hypoglycemia and hypoglycemia unawareness
Refractory diabetes
Dementia (elderly)
17
Q6. How should hypoglycemia be managed?
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May not be reprinted in any form without express written permission from AACE. 18
25. Hypoglycemia
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Hypoglycemic Symptoms
Autonomic symptoms :
After few years of diabetes duration (2-5 years).
Glucagon secretion is impaired in type 1 (irreversible).
Epinephrine secretion becomes the primary mechanism
for raising low blood glucose levels.
Over the course of type 1 diabetes (10-12 Ys)-, epinephrine
response to hypoglycemia becomes diminished or
delayed resulting in:
↓Hypoglycemic symptom awareness (Hypoglycemia
Unawareness)
↑↑Severe hypoglycemic episodes
26. Hypoglycemia
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Vicious circle where recurrent hypoglycemia during intensive treatment of type 1
diabetes causes hypoglycemia unawareness and impaired counterregulation,
ultimately increasing the risk for severe hypoglycemia.
27. Hypoglycemia
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Recognize Risk Factors for Severe
Hypoglycemia
Risk factors in Type 1 DM
patients
Risk factors in Type 2 DM
patients
Adolescence Elderly
Children unable to detect and/or
treat mild hypoglycemia
Poor health literacy, Food
insecurity
A1C <6.0% Increased A1C
Long duration of diabetes Duration of insulin therapy
Prior episode of severe
hypoglycemia
Severe cognitive impairment
Hypoglycemia unawareness Renal impairment
Autonomic neuropathy Neuropathy
30. Hypoglycemia
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Factors That Risk of Hypoglycemia in
Type 2 DM
Advanced age.
Poor nutrition.
Hepatic disease.
Renal Disease.
Hypothyroidism and/or adrenal insufficiency.
Postpartum bleeding can lead to pituitary damage.
35. High risk of hypoglycemia is obtained from
commonly used combination SU/Met
CI=confidence interval; Glyb=glyburide; Met=metformin; repag=repaglinide; SU=sulfonylurea; TZD=thiazolidinediones.
Bolen S, et al. Ann Intern Med. 2007;147:386–399
Met vs Met + TZD
Weighted absolute risk difference
0.20.150.150.50
3 (1557)
5 (1495)
6 (2238)
8 (2026)
3 (1028)
5 (1921)
8 (1948)
9 (1987)
Studies
(participated)
0.00 (-0.01 to 0.01)
0.02 (-0.02 to 0.05)
0.03 (0.00 to 0.05)
0.04 (0.0 to 0.09)
0.08 (0.00 to 0.16)
0.09 (0.03 to 0.15)
0.11 (0.07 to 0.14)
0.14 (0.07 to 0.21)
Pooled effect
(95% CI)
SU vs repag
Glyb vs other SU
SU vs Met
SU + TZD vs SU
SU vs TZD
SU + Met vs SU
SU + Met vs Met
Drug 1 more harmfulDrug 1 less harmful
37. Hypoglycemia
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DRUGS CAUSING HYPOGLYCEMIA
ESTABLISHED
DRUGS:
DISORDE R DRUG
DM Insulin, SU, other secretogogues, metformin,
alcohol
Infection Pentamidine, Quinine, Sulphonamides
Arrhythmias Quinidine, dispyramide, cibenzoline
Pain Acetylsalicylic acid
40. Hypoglycemia
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Hypoglycemia
. Insulin Program Setup (Meal/Bolus)
Blood Sugar Rise After
Eating Carbs
Analog (Humalog or
Novolog taken with
meal)
Regular (taken 30 min.
pre-meal)
NPH / Lente (taken 4
hours prior)
Only rapid analogs work when needed – right after eating!
42. Hypoglycemia
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Conventional Therapy: traditional
regimens
50-70% don’t attain target A1c
Erratic blood glucose values
Requires fixed life style
Danner T et al Diabetes Care (2001)
8 12 16 20 24 4 8
Hypergl
.
Hypogl. Hypergl
.
Hypogl.
Premixed Premixed
43. Hypoglycemia
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Compared to biphasic human insulins
More patient convenience regarding administration
Better pharmacokinetics and pharmacodynamics
Lower incidence of hypoglcemia
8 am 12 4 pm 8pm 12 4am 8am 12
. . . . . .. .
Biphasic insulin analogues
Biphasic Aspart: Aspart + NPAspart (30/70 Novomix)
Biphasic Lispro: Lispro + NPLispro (25/75 humalogue mix)
45. Hypoglycemia
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Nocturnal Hypoglycemia
Causes:
1. Exercise during the previous day.
2. Failure to eat a bedtime snack.
3. Predinner injections of intermediate-acting insulin (NPH,
Lente) may peak in action during the night and cause
relative hyperinsulinemia overnight.
4. Insulin requirements decrease between midnight and 3 AM.
5. Significant increases in physical activity, combined with
failure to increase carbohydrate consumption and/or
reduce the insulin dose.
6. Concomitant use of sulfa antibiotics (TMP, Septrin, Bactrim)
with a sulfonylurea cause profound and refractory
hypoglycemia.
46. Hypoglycemia
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Intermediate acting insulins:
NPH and Lente
Day time Peak Nocturnal Peak
Dawn pheno
8 am 12 4 pm 8pm 12 4am 8am
B D
. . . . .
Morning
Hyperglycemia
High Insulin
Sensitivity
Hyperglycemia
.
2 Peaks
Nocturnal Hypoglycemia
47. Hypoglycemia
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Prevention of Nocturnal Hypoglycemia
Do not skip presleep snacks.
Measure presleep blood glucose levels
regularly.
Increase the carbohydrate content of the
snack.
If daytime physical activity was increased.
Eat additional slowly absorbed carbohydrate snack
before bed time.
Move the Predinner NPH or Lente to presleep
rather than decreasing the predinner dose.
Reduction in evening regular insulin dose.
49. Hypoglycemia
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4:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
12:008:00
Time
Glargine
PlasmaInsulin
Aspart Aspart Aspart
or or or
Lispro Lispro Lispro
Basal-bolus Treatment Program
Rapid-acting & Long-acting Analogs
Lower Incidence of hypoglycemia
51. Hypoglycemia
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The use of Subcutaneous glucose
sensors for continuous glucose
monitoring with sophisticated
software may make it possible
to trigger an alarm when
hypoglycemia risk is
detected..
Hypoglycemia Prevention
(cont.)
52. Hypoglycemia
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Setting for hypoglycemia
Food intake
Skipped or delayed meals
Vomiting after meal & meds intake
Mismatch:
Wrong dose or too high a dose of medications
for the amount of food;
Too little carbohydrate
54. Hypoglycemia
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Snack Or Not To Snack ?
With Twice daily mixture of NPH +R
Use snack at time of inappropriate
hyperinsulinemia (10-11 am & at bedtime).
With Multiple Daily Injections (MDI) or
Insulin Pumps
No need for snacks. They may increase the BG
before the next meal.
In adults no need for snacks.
56. Hypoglycemia
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Setting for hypoglycemia
Unplanned / Excess exercise
without snack / Rx adjustment
Excessive insulin / OHA doses
Organ Failure Medications
Alcohol use
Identification of the precipitating factors is
important to prevent future events
57. Hypoglycemia
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When adequate insulin level is present, muscular
activity lowers BG during, immediately after and /or
several hrs after exercise
This has been attributed to increased insulin levels
originating from subcutaneous depots and increased
insulin sensitivity by enhancing receptor site binding.
Particularly if the patient takes a hot shower after
exercising.
68. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 1
1. Mild to moderate hypoglycemia should be treated
by oral ingestion of 15 g carbohydrate; glucose or
sucrose tablets/solutions are preferable to orange
juice and glucose gels [Grade B, Level 2]
Patients should retest blood sugar in 15 minutes
and retreat with another 15 g of carbohydrates if BG
remains <4.0 mmol/L [Grade D, Consensus]
69. Hypoglycemia
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15 g of glucose in the form of glucose
tablets
15 mL (3 teaspoons) or 3 packets of sugar
dissolved in water
175 mL (3/4 cup) of juice or regular soft
drink
15 mL (1 tablespoon) of honey
Examples of 15 g Simple Carbohydrate
71. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 2
2. Severe hypoglycemia in a conscious person
should be treated by oral ingestion of 20 g of
carbohydrate, preferable as glucose tablets or
equivalent.
Blood sugar should be retested in 15 minutes, and
then retreated with a further 15 g of glucose if BG
remains <4.0 mmol/L [Grade D, Consensus]
72. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
3. Severe hypoglycemia in an unconscious
individual:
– No IV access: 1 mg of glucagon should be
administered subcutaneously or intramuscularly.
Caregivers or support persons should call for
emergency services and the episode should be
discussed with the diabetes healthcare team as
soon as possible [Grade D, Consensus]
– With IV access: 10-25 g (20-50 cc of D50W) of
glucose should be given intravenously over 1-3
minutes [Grade D, Consensus]
Recommendation 3
73. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 5
5. Once the hypoglycemia has been reversed, the
person should have the usual meal or snack that
is due at that time of the day to prevent repeated
hypoglycemia [Grade D, Consensus].
If a meal is > 1 hour away, a snack (including 15 g
of carbohydrate and protein source) should be
consumed [Grade D, Consensus]
74. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 6
6. Patients receiving antihyperglycemic agents that
may cause hypoglycemia should be counseled
about strategies for prevention, recognition and
treatment of hypoglycemia related to driving and
be made aware of provincial driving regulations
[Grade D, consensus]
2013
76. ADA 2015 - HYPOGLYCEMIA
Hypoglycemia unawareness or
one or more episodes of severe hypoglycemia
should trigger reevaluation of the treatment regimen. E
Action:
Raise their glycemic targets
to avoid further hypoglycemia for at least several weeks
Aiming to partially reverse hypoglycemia unawareness and reduce
risk of future episodes. A
78. Hypoglycemia
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Take home messages
The Patient with chronic disease like diabetes has a
very good chance of living a long life, especially if he
has good glycemic control.
Hypoglycemia can occur with very little warning.
The patient should be aware of these.
With good education , matching insulin ,
food and physical activity , most patients will
survive these problems after exclusion of co-
morbid conditions.
79. Hypoglycemia
The
DELTA
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Take home messages
Know the risk factors /setting
Beware of nocturnal , exercise-induced and
unawareness forms
Treat and try to prevent recurrence
Educate your self , your patients and their families
