Hypoglycemia

Dubai February 2014

WorkshopHypoglycaemia and

its management

Hypoglycaemia

• Formal definition– Blood glucose <70-mg/dl

• Causes– Too much insulin?– Too little food?– Unusual exercise?

• FOUR IS THE FLOOR

WHICH PATIENTS WITH HYPOGLYCAEMIA SHOULD BE ADMITTED TO HOSPITAL FROM A & E FOLLOWING

HYPOGLYCAEMIC COMA?

• Insulin treated patients who recover quickly from hypoglycaemic coma and who are otherwise well and able to eat normally may not need to be admitted to hospital.

Admission is advised for:

– Any insulin treated patient who is slow to recover

– Large amounts of insulin injected in error or with suicidal intent

– Insulin treated patients who are drunk - alcohol may precipitate or prolong hypoglycaemia

– Insulin treated patients with hypopituitarism, hypoadrenalism or chronic renal failure

– Elderly patients on sulfonylureas

Clinical features of hypoglycaemia 

Adrenergic symptoms

• Tachycardia

• Palpitations

• Tremor

• Anxiety

• Sweating

Flight or fright symptoms

Neuroglycopenia

• Faintness

• Feeling of hunger

• Headache

• Abnormal behaviour

• Altered consciousness

• Eventually, coma

Lack of glucose to brain

Hypoglycemia unawareness

Autonomic: tremor, sweating, hunger, heart palpitations,anxiety.

Neuroglycopenic: confusion, difficulty concentrating, blurred vision, weakness, drowsiness, irritability.

Fall in blood glucose

COUNTER-REGULATORY MECHANISM ACTIVATED BY HYPOGLYCAEMIA

Vagal stimulation

Adrenal medulla

stimulation

Neuroglycopenia

Parasympathetic

Sympathetic

Glucagon release

Adrenaline release

Stimulates glycogen

breakdown in liver

HYPOGLYCAEMIC COMA IN DIABETIC PATIENT

IMMEDIATE MANAGEMENT

Hypoglycaemic reaction (‘hypo’) in a diabetic patient on insulin can result from excessive insulin dosage, excessive exercise or decreased carbohydrate intake due to missed or delayed meal. It can also occur in elderly patients due to sulfonylurea therapy

Diagnosis

• Patient’s skin feels moist and sweaty

• Reflexes may be brisk with extensor plantar response

• Confirm with plasma glucose <3 mmol/L

Treatment

• If conscious, sugar or sweet drinks e.g. 75g glucose or 250mls lucozade

• If drowsy, HYPOSTOP gel

• If unconscious:

• Glucagon* 1mg i.v., i.m. or s.c.

Restores consciousness in 10-15 mins

• 20ml 50% dextrose i.v.

Restores consciousness within 5 mins

Severe hypoglyceamia with no response to glucagon or dextrose - ? cerebral oedema

and/or

• high dose steroids e.g. 2 mg dexamethasone i.v. 4-6 hourly

• 200ml 20% mannitol over 20-30 mins

• high flow oxygen

• dextrose infusion 10% or 20%, 0.5 litre 2-4 hourly

• consider ITU for ventilation

* If hypoglycaemia is precipitated or associated with excess alcohol intake, glucagon may be ineffective as alcohol blocks glycogenolytic action of glucagon

Hypoglycaemia: Treatment

Exercise

Diet

Insulin

Diabetes Diabetes EquilibriumEquilibrium

Sulphonylurea induced hypoglycaemia

• Sulphonylureas cause release of insulin from the pancreatic cells• Continued production of insulin without adequate carbohydrate

HYPOGLYCAEMIA• Check blood glucose to confirm hypoglycaemia• Treatment iv dextrose• May need prolonged infusion

1. Nathan DM, et al. Diabetologia. 2009;52:17-306. 2. Cefalu WT. Nature. 2007;81:636-49.

Glucose-lowering agents classified by risk of hypoglycaemia in type 2

diabetes

Hypoglycemia

High risk1 Low risk1,2

Insulin Metformin

Sulphonylureas α-glucosidase inhibitors

Meglitinides Thiazolidinediones

GLP-1 receptor agonists

DPP-4 inhibitors

50

40

30

20

10

0

Annual prevalence of severe hypoglycemia (%)

(Severe: requiring external assistance)

T2DMSU

T2DM< 2 yrs

T2DM> 5 yrs

T1DM< 5 yrs

Adapted from: UK Hypoglycaemia Study Group (2007) Diabetologia; 50: 1140

Type 2 DM Sulfonylureas (n = 103)Type 2 DM <2 years insulin (85)Type 2 DM >5 years insulin (75)Type 1 DM <5 years (46)Type 1 DM >15 years (54)

UK Hypoglycaemia Group Study: Frequency of Severe Hypoglycemia

Error bars = 95% confidence intervals

T1DM> 15 yrs

Holstein A et al. Exper Opin Drug Saf 2010

Holstein A et al. Exper Opin Drug Saf 2010

Holstein A et al. Exper Opin Drug Saf 2010

Morbidity of Hypoglycaemia in Diabetes

Musculoskeletal Falls, accidents (& driving accidents)

Fractures, dislocations

BrainBlackouts, seizures,

coma Cognitive dysfunctionPsychological effects

CardiovascularMyocardial ischaemia (angina and infarction)Cardiac arrhythmias

Outcomes of Hypoglycaemia

DeSouza CV, et al. Diabetes Care 2010; 33: 1389.

Cardiac function during hypoglycaemia

Fisher et al (1987) Diabetologia; 30: 841 Hilsted et al (1984) Diabetologia; 26: 328

OTHER POINTS TO NOTE RE PATIENTS WITH HYPOGLYCAEMIC COMA

• Hypoglycaemia may cause hypothermia

• Hypoglycaemic fitting can cause vertebral and occasionally long bone fractures

• Watch for ‘delayed’ hypoglycaemia due to excessive exercise

KEY TEACHING POINTS

• Always consider hypoglycaemia in any person whose behaviour or conscious level is abnormal.

• Hypoglycaemia can present with fitting.

• Even close colleagues may not be aware that the patient is on insulin.

• Neurological signs will disappear quickly with correction of hypoglycaemia.

• Prolonged hypoglycaemic coma can cause irreversible neurological damage.