NICE clinical Guideline 181 guidance.nice.org.uk/cg181 NICE

Hypoglycemia

Dr Shahjada SelimAssistant ProfessorDepartment of Endocrinology Bangabandhu Sheikh Mujib Medical UniversityEmail: selimshahjada@gmail.com

This guideline offers best practice advice on the care of people at risk of cardiovascular disease.1

HypoglycemiaHypoglycemia is a clinical syndrome with diverse causes in which low plasma glucose concentrations lead to symptoms and signs, and there is resolution of thesymptoms/signswhen the plasma glucose concentration is raised .

Hypoglycemia

In patients with Diabetes, hypoglycemia is defined as : All episodes of an abnormally low plasma glucose concentration (with or without symptoms) that expose the individual to harm.

The diagnosis of hypoglycemia is not based on an absolute blood glucose level; it requires fulfillment of the Whipple triad:

I) Signs and symptoms consistent with hypoglycemia2) Associated low glucose level3) Relief of symptoms with supplemental glucose

People with diabetes should become concerned about the possibility of hypoglycemia at a self-monitored blood glucose (SMBG) level 70 mg/dL (3.9 mmol/L).

This cut-off value has been debated, with some favoring a value of 70 mg/dL (3.9 mmol/L) as glucose levels decline into the physiological range.

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HypoglycemiaClinical classification4-Oct-16Hypoglycemia by Selim16

Probable symptomatic hypoglycemia Typical symptoms without plasma glucose determination (presumed)

Relative hypoglycemia : Typical symptoms but withPlasma glucose > 70 mg/dL (3.9 mmol/L) Example?

Severe hypoglycemia An event requiring the assistance of another person to actively administer carbohydrate, glucagonor other resuscitative actions is classified as a severe hypoglycemic event. Plasma glucose measurements may not be available during such an event, but neurological recovery attributable to restoration of plasma glucose to normal is considered sufficient evidence that the event was induced by a low plasma glucose concentration.Documented symptomatic hypoglycemia An event during which typical symptoms of hypoglycemia are accompanied by a measured (typically with a monitor or with a validated glucose sensor) plasma glucose concentration 70 mg/dL (3.9 mmol/L) is classified as a documented symptomatic hypoglycemic event.Asymptomatic hypoglycemia Asymptomatic hypoglycemia is classified as an event not accompanied by typical symptoms of hypoglycemia but with a measured plasma glucose concentration of 70 mg/dL (3.9 mmol/L).Probable symptomatic hypoglycemia Probable symptomatic hypoglycemia is classified as an event during which typical symptoms of hypoglycemia are not accompanied by a plasma glucose determination (but that was presumably caused by a plasma glucose concentration 70 mg/dL [3.9 mmol/L]).Relative hypoglycemia Relative hypoglycemia is classified as an event during which the person with diabetes reports typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but with a measured plasma glucose concentration >70 mg/dL (3.9 mmol/L). This category reflects the fact that patients with chronically poor glycemic control can experience symptoms of hypoglycemia at plasma glucose levels >70 mg/dL (3.9 mmol/L) as glucose levels decline into the physiological range.

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4-Oct-16Hypoglycemia by Selim17

Hypoglycemia : S & S4-Oct-16Hypoglycemia by Selim18Hyper-adrenergic Plasma Glucose < 70 mg/ dL (3.9 mmol/L)

Diaphoresis (Sweating) Tachycardia (Rapid heartbeat )/Palpitation Anxiety Tremor /ShakingTachypnea Vomiting Dizziness Hunger

Hypoglycemia : S & S4-Oct-16Hypoglycemia by Selim19Neuro-glycopenic Plasma Glucose < 50 mg/dL (2.8 mmol/L)

Slurred speech Cognitive impairment Inattention and confusion Focal neurologic deficits SeizuresBehavioral/ Irritability/ Sudden moodinessChange in personality Lack of coordination

Severe and prolonged hypoglycemiaLOC/Coma Irreversible brain injury

Hypoglycemia

Why does it matter ?4-Oct-16Hypoglycemia by Selim20

Hypoglycemia it matters 4-Oct-16Hypoglycemia by Selim21 The major limiting factor for achieving strict control in DM patients

Still , it is an expected price for adequate control

Hypoglycemia it matters 4-Oct-16Hypoglycemia by Selim22Bad impact on: Quality of life: Fear / Psych

Satisfaction

Compliance; to diet and Rx

Achieving proper targets ?

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Hypoglycemia it matters 4-Oct-16Hypoglycemia by Selim23Disturbing S & S

-Anxiety / Embarrassment -Risk of accidents with impaired LOC-Limitation of performance -Rebound /Reaction-Weight gain ?

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Hypoglycemia is common4-Oct-16Hypoglycemia by Selim24 Common ; up to 30- 60% in DM patientsType 1 > Type 2 But !

Intensive DM control (lower HbA1c?)Elderly Duration of diseaseAsymptomatic in 50% + Unawareness !Nocturnal very common !

Risk of hypoglycemia is more related to treatment used rather than to the A1c level;i.E : Metformin or TLC have very low risk or none Vs SU / insulin even with same A1c of 6.8%24

Hypoglycemia : Setting / Causes4-Oct-16Hypoglycemia by Selim25

Setting for hypoglycemia4-Oct-16Hypoglycemia by Selim30

Identification of the precipitating factors is important to prevent future events

Alcohol use (which suppresses hepatic glucose production)

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HypoglycemiaSetting4-Oct-16Hypoglycemia by Selim31

Common with Diabetics who are treated withInsulin releasing pills (sulfonylureas, Meglitinides, or Nateglinide) Insulin

Very unlikely with Lifestyle changes (TLC) onlyUsing alone medications like :( ex: Metformin ,DPP4I, GLP-1 + ,SGLT2 -)

Setting for hypoglycemiaFood intake 4-Oct-16Hypoglycemia by Selim32Skipped 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

Setting for hypoglycemia4-Oct-16Hypoglycemia by Selim33Unplanned / Excess exercisewithout snack / Rx adjustment

Excessive insulin / OHA dosesOrgan Failure MedicationsAlcohol use

Identification of the precipitating factors is important to prevent future events

Alcohol use (which suppresses hepatic glucose production)

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HypoglycemiaCauses4-Oct-16Hypoglycemia by Selim34Organ failure :

Renal Hepatic Cardiac Endocrine Failure:

Adrenal GlucagonCortisol Pituitary (ACTH/GH..)

Insulin excess-Absolute or relative 4-Oct-16Hypoglycemia by Selim35Excess insulin (Secretagogues) Doses, ill-timed /wrong type

Reduced exogenous glucose influx (Fasting /missed meals)

Increased insulin-independent glucose utilization (During and shortly after exercise)

Increased sensitivity to insulin (Hours after exercise, weight loss, nocturnal ,after improved control)

Reduced endogenous glucose production (Alcohol ingestion)Reduced insulin clearance (Renal failure)

hypoglycemic unawareness4-Oct-16Hypoglycemia by Selim36

Longer duration of DM and Autonomic Neuropathy

The brain has a trigger point at which it leads to releasestress hormones (Counter Regulatory Hormones)

With frequent low blood sugars, this set point gets reprogrammed to lower and lower blood sugar levels.

Stress hormones arent released until the blood sugar is dangerously low

hypoglycemic unawareness4-Oct-16Hypoglycemia by Selim37What causes hypoglycemic unawareness?Loss of the ability to detect a low blood sugar

Patient needs to be vigilant; Do frequent monitoring

It may not be a permanent conditionManaged by easing the strict control for 2-3 weeks of more

4-Oct-16Hypoglycemia by Selim38

HypoglycemiaManagement4-Oct-16Hypoglycemia by Selim39

Hypoglycemia Management 4-Oct-16Hypoglycemia by Selim40Prevention = Education

Hypoglycemia-Prevention4-Oct-16Hypoglycemia by Selim41Patient education and empowerment

Frequent self-monitoring of blood glucose (SMBG)

Flexible and rational insulin (and other drug) regimens

Individualized glycemic goals

Professional guidance and support.

Hypoglycemia-Prevention4-Oct-16Hypoglycemia by Selim42

Self-monitoring of blood glucose (SMBG)

Keeping some sugar or sweet handy

Teach patient/care-giver

Medical alert identification

Glucagon Emergency kit.

ADA-20154-Oct-16Hypoglycemia by Selim43

A1C Vs Average Glucose

A1C (%) Mean plasma glucose mg/dl

6 120 7 150 8 180 9 210 10 240 11 270 12 300 4-Oct-16Hypoglycemia by Selim44ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table 8

These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.

*07/16/96*##

ADA EASD Consensus:(June 2012)

4-Oct-16Hypoglycemia by Selim45

4-Oct-16Hypoglycemia by Selim46Diabetes in Elderly

< 7.5 %

< 8.0 %

< 8.5 %

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Hypoglycemia Management 4-Oct-16Hypoglycemia by Selim47

Recognize & Treat

Hypoglycemia Recognition & Treatment4-Oct-16Hypoglycemia by Selim48

Recognize S & S

Document /Measure the glucose by finger stick If < 70 mg/dl

Conscious Vs Unconscious patient/ unable to swallow

Role of 15 minutes 4-Oct-16Hypoglycemia by Selim49

Hypoglycemia Treatment 4-Oct-16Hypoglycemia by Selim50Conscious patientRapidly absorbed CHO ( glucose- or sucrose-containing foods) orally

Unconscious patient/ unable to swallow IV dextrose orIM glucagon

HypoglycemiaTake control

4-Oct-16Hypoglycemia by Selim51+ve mild symptoms Check blood sugar - Takefast acting CHO

cup of fruit juice or low fat / fat-free milk, Regular soda 3 glucose tablets 2 tbsp of raisins, 1 tbsp of honey or 2 tbsp of jam

About 15-20 grams of glucose

HypoglycemiaTake control

4-Oct-16Hypoglycemia by Selim52+ve mild symptoms

You will need more glucose if the blood sugar is very low

Check your blood sugar again after 15 minutes.Repeat same dose if the sugar is still low (