management of diabetic emergencies:...

Management of

Diabetic

Emergencies:

Hypoglycaemia

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.

3

Symptoms of Hypoglycaemia

Autonomic Neuroglycopenic

Trembling

Palpitations

Sweating

Anxiety

Hunger

Nausea

Tingling

Difficulty concentrating

Confusion

Weakness

Drowsiness

Vision changes

Difficulty speaking

Headache

Dizziness

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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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

Hypoglycaemic Symptoms Based on Blood Glucose Levels

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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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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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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

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

Hypoglycemia Outcomes

VADT, ACCORD,

ADVANCE

Risk factors for hypoglycaemia:

• Advancing age

• Severe cognitive impairment

• Poor health knowledge

• Increased A1c

• Hypoglycaemia unawareness

• Long standing insulin therapy

• Renal impairment, Neuropathy

• 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

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

• 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

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.

• 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

• 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.