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Management of
Diabetic
Emergencies:
Hypoglycaemia
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2
Hypoglycaemia
Definition
• Hypoglycaemia is defined by either one of the following
two conditions:
• Low plasma glucose level (<4.0 mmol/L).
• Development of autonomic or neuroglycopenic
symptoms in patients treated with insulin or OADs which
are reversed by caloric intake.
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3
Symptoms of Hypoglycaemia
Autonomic Neuroglycopenic
Trembling
Palpitations
Sweating
Anxiety
Hunger
Nausea
Tingling
Difficulty concentrating
Confusion
Weakness
Drowsiness
Vision changes
Difficulty speaking
Headache
Dizziness
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Mild Autonomic symptoms are present. The
individual is able to self-treat.
Moderate Autonomic and neuroglycopenic symptoms
are present. The individual is able to self-
treat.
Severe Individual requires assistance of another
person.
May become unconscious, plasma glucose is
usually less than 2.8 mmol/L.
Severity of Hypoglycaemia
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Slide Source:
Lipids Online Slide Library www.lipidsonline.org
Vicious circle of hypoglycemia awareness
Hypoglycemic events
lead
hypoglycaemic events
Frequent hypo
<4.0 mmol/l
Adapted from Hermanns et al. Diabetologie 2009; 4: R 93-R112
Symptoms of hypo
- weaker
- appear later
- change
Awareness of hypo:
- more difficult
- less reliable
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Hypoglycaemic Symptoms Based on Blood Glucose Levels
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Slide Source:
Lipids Online Slide Library www.lipidsonline.org
Complications and Effects of Severe Hypoglycemia
Plasma glucose level
10
20
30
40
50
60
70
80
90
100
110
1
2
3
4
5
6
mg/dL
mmol/L
1. Landstedt-Hallin L et al. J Intern Med. 1999;246:299–307. 2. Cryer PE. J Clin Invest. 2007;117(4):868–870.
Increased Risk of Cardiac
Arrhythmia1
Progressive
Neuroglycopenia2
Abnormal prolonged cardiac
repolarization—
↑ QTc and QTd
Sudden death
Cognitive impairment
Unusual behavior
Seizure
Coma
Brain death
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Slide Source:
Lipids Online Slide Library www.lipidsonline.org
Severe Hypoglycemia Causes QTc Prolongation
P=NS
P=0.0003
Landstedt-Hallin L et al. J Intern Med. 1999;246:299–307.
Euglycemic clamp (n=8)
Hypoglycemic clamp 2 weeks after
glibenclamide withdrawal (n=13)
0
360
370
380
390
400
410
420
430
440
450
Mean
QT in
terval,
ms
Baseline (t=0)
End of clamp (t=150 min) ACCORD?
Significant QTc prolongation
during
hypoglycemia
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Slide Source:
Lipids Online Slide Library www.lipidsonline.org
Asymptomatic Episodes of Hypoglycemia May Go Unreported
In a cohort of patients with
diabetes, more than 50%
had asymptomatic
(unrecognized)
hypoglycemia, as
identified by continuous
glucose monitoring1
Other researchers have
reported similar findings2,3
1. Copyright © 2003 American Diabetes Association. Chico A et al. Diabetes Care. 2003;26(4):1153–1157. Reprinted with permission from the American Diabetes Association.
2. Weber KK et al. Exp Clin Endocrinol Diabetes. 2007;115(8):491–494. 3. Zick R et al. Diab Technol Ther. 2007;9(6):483–492.
0
25
50
75
100
All patients
with diabetes
Type 1
diabetes
Pat
ien
ts,
%
Type 2
diabetes
55.7 62.5
46.6
Patients With ≥1 Unrecognized
Hypoglycemic Event, %
n=70 n=40 n=30
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Sleep blunts the counter-regulatory catecholamine response to hypoglycaemia
Jones et al. N Engl J Med 1998;338:1657–62
Baseline was defined as mean plasma concentrations of the values at −20 and 0 min
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Hypoglycemia Outcomes
VADT, ACCORD,
ADVANCE
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Risk factors for hypoglycaemia:
• Advancing age
• Severe cognitive impairment
• Poor health knowledge
• Increased A1c
• Hypoglycaemia unawareness
• Long standing insulin therapy
• Renal impairment, Neuropathy
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• Patients at high risk for severe hypoglycaemia should be
informed of their risk and counselled, along with their
family members and friends.
• Patients at risk of hypoglycaemia are discouraged from
driving, riding, cycling or operating heavy machineries, as
these activities may endanger oneself and the public.
Treatment of Hypoglycaemia
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Treatment of SEVERE Hypoglycemia in
Unconscious Person with IV Access
1. Treat with 10-25 g (20-50 cc of D50W) of glucose
intravenously over 1-3 minutes
2. Retest in 15 minutes to ensure the BG >4.0 mmol/L
and retreat with a further 15 g of carbohydrate if
needed
3. Once conscious, eat usual snack or meal due at that
time of day or a snack with 15 g carbohydrate plus
protein
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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
• 6 Lifesavers (1=2.5 g of carbohydrate)
• 15 mL (1 tablespoon) of honey
Examples of 15 g Simple Carbohydrate
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The aims of treatment are to:
• Detect and treat a low blood glucose level promptly.
• Eliminate the risk of injury to oneself and to relieve
symptoms quickly.
• Avoid overcorrection of hypoglycaemia especially in
repeated cases as this will lead to poor glycaemic control
and weight gain.
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• In severe hypoglycaemia where the individual is
still conscious:
• Ingest 20 grams of carbohydrate and the above steps
are repeated.
• In severe hypoglycaemia and unconscious
individual:
• He/she should be given IV 20–50 mL of D50% over 1-3
minutes.
• Outside the hospital setting, a tablespoon of honey
should be administered into the oral cavity
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• Once hypoglycaemia has been reversed, the patient
should have the usual meal or snack that is due at that
time of the day to prevent repeated hypoglycaemia.
• Patients receiving anti-diabetic agents that may cause
hypoglycaemia should be counselled on:
• strategies for prevention,
• recognition, and
• treatment of hypoglycaemia.
• Individuals on insulin may need to have their insulin
regimen adjusted appropriately to lower their risk.