Hypoglycaemia

Section 4 | Part 1 of 2 Curriculum Module III-6 | Short-term complications

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Hypoglycaemia

Definition of hypoglycaemia

Curriculum Module III-6 Slide 2 of 38

When the level of glucose falls in the blood so that the cells in the

periphery, and eventually the

brain cells, do not get adequate

glucose to function

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Hypoglycaemia

The bodys response

Curriculum Module III-6 Slide 3 of 38

Endogenous insulin secretion suppressed

Release of glucagon, epinephrine, cortisol, growth hormone Autonomic response

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Hypoglycaemia

The bodys response

Curriculum Module III-6 Slide 4 of 38

Brain lacks glucose Temporary cognitive impairment Wide variation in symptoms

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Hypoglycaemia

Glucagon

Curriculum Module III-6 Slide 5 of 38

Hypoglycaemia stimulates release

It acts in the liver to increase glucose production

releasing stored glycogen

activating production of new glucose stimulating production of ketones
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Hypoglycaemia

Epinephrine

Curriculum Module III-6 Slide 6 of 38

Releases stored glycogen Activates production of glucose from protein Reduces uptake of glucose Reduces production of insulin

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Hypoglycaemia

Cortisol and growth hormone

Curriculum Module III-6 Slide 7 of 38

Reduce cellular uptake of glucose Stimulate breakdown of proteins to make glucose Stimulate breakdown of body fats

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Hypoglycaemia

Hypoglycaemia

Curriculum Module III-6 Slide 8 of 38

Symptoms Low blood glucose Relief of symptoms when blood glucose raised

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Hypoglycaemia

Symptoms of hypoglycaemia

Curriculum Module III-6 Slide 9 of 38

Mild
Capable of selftreating Tremors, palpitation, sweating, hunger, fatigue Adrenergic

Moderate
May require prompting Headache, mood changes, low attentiveness Neuroglycopenic

Severe
Not capable of selftreatment Conscious or unconscious

Neuroglycopenic

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Hypoglycaemia

Consequences of hypoglycaemia

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Mild-moderate fear anxiety affects selfcare social stigma prejudice

Severe injury seizures transient paralysis cognitive impairment death

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Hypoglycaemia

People at risk of hypoglycaemia

Curriculum Module III-6 Slide 11 of 38

Only those taking glucose-lowering medicines or insulin Increased risk: too little or wrong type of carbohydrate late or missed meal fasting or malnourishment too much insulin or insulin secretagogues prolonged or unplanned activity
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Hypoglycaemia

People at risk of hypoglycaemia

Curriculum Module III-6 Slide 12 of 38

Increased risk:
Recent severe hypoglycaemia Gastroparesis Liver disease or kidney failure Pregnancy

Injection-related
Over-correction of high BGL
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ACTIVITY

Hypoglycaemia
Curriculum Module III-6 Slide 13 of 38

How would you advise people to treat the following?

Mild hypoglycaemia Moderate hypoglycaemia Severe hypoglycaemia

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Hypoglycaemia

Management

Curriculum Module III-6 Slide 14 of 38

Mild or moderate Test if possible 15 g glucose; re-test Glucose tablets Fruit juice Soft drink Sugar Re-treat if level remains low
CDA 2003
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Hypoglycaemia

Management

Curriculum Module III-6 Slide 15 of 38

Severe 20 g glucose glucagon intravenous dextrose Manage seizure place person on their side if not too agitated

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Hypoglycaemia

Glucagon/IV dextrose options

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If unable to treat orally: Glucagon subcutaneously or intramuscular 1 ml for adult (0.5ml for child) blood glucose 3.0 to 11.8 in 45 min vomiting severe headache IV dextrose: 25-50 ml IV over 2-3 minutes immediate response
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Hypoglycaemia

Follow-up management Carbohydrate + protein

Next dose taken as usual Consider reducing insulin

Curriculum Module III-6 Slide 17 of 38

Assess cause
Prevent recurrence Avoid BGLs < 4 mM If BGL < 7mM before bed, eat a snack
CDA, 2003
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Hypoglycaemia

Other management strategies

Curriculum Module III-6 Slide 18 of 38

Glargine/levemir insulin Pump

Different injection sites

Depth of injection

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Hypoglycaemia

Relative hypoglycaemia

Curriculum Module III-6 Slide 19 of 38

Symptoms of hypoglycaemia without low blood glucose levels

Associated with: suboptimal control significant and sudden change in blood glucose

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Hypoglycaemia

Rebound hyperglycaemia

Curriculum Module III-6 Slide 20 of 38

After nocturnal hypoglycaemia Low levels in early hours

Fasting ketones may be present in prolonged hypoglycaemia

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Hypoglycaemia

Rebound hypoglycaemia

Curriculum Module III-6 Slide 21 of 38

Treatment options
Decrease evening intermediateacting insulin Intermediate insulin at bedtime Long-acting insulin analogue

Increase bedtime snack

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Hypoglycaemia

Frequency of hypoglycaemia

Curriculum Module III-6 Slide 22 of 38

Recognized hypoglycaemia twice a week Up to 50% unrecognized Increased frequency may decrease counter-regulatory response and awareness Asymptomatic nocturnal low blood glucose is common, often prolonged Risk of death
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Hypoglycaemia

Developing unawareness

Curriculum Module III-6 Slide 23 of 38

Glucagon response often lost after five years with type 1 diabetes Epinephrine response may be blunted and delayed Adrenergic symptoms blunted

Reliance on recognizing neuroglycopenic symptoms

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Hypoglycaemia

Managing hypoglycaemic unawareness

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Unawareness is reversible Encourage hypoglycaemia-free state Medical alert identification Test before potentially hazardous behaviour

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Hypoglycaemia

Increased risk of hypoglycaemia

Curriculum Module III-6 Slide 25 of 38

DCCT intensively treated group three times the number of severe hypoglycaemic episodes UKPDS 30% of intensively treated experienced hypoglycaemia; events rare in the conventional group Current research no increased risk with current medications, monitoring and appropriate education
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Hypoglycaemia

Alcohol

Curriculum Module III-6 Slide 26 of 38

Increased risk of hypoglycaemia

Decreased gluconeogenesis

Decreased ability to recognize symptoms

Safe drinking
Turner 2001
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Hypoglycaemia

Hypoglycaemia in older people

Curriculum Module III-6 Slide 27 of 38

Risk of injury from falls

May be missed or mistaken for dementia Malnutrition may increase risk of hypoglycaemia Avoid long-acting sulphonylureas in older people
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Hypoglycaemia

Driving type 1 diabetes

Curriculum Module III-6 Slide 28 of 38

Driving skills tested at three blood glucose ranges Driving impaired at all three ranges Preventive action

Cox, Gonder-Fredericks 2000

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ACTIVITY

Hypoglycaemia
Curriculum Module III-6 Slide 29 of 38

Are there any local regulations regarding driving and insulin use. For instance, can people on insulin hold a license to drive a tractor or fly an airplane? Are you required by law to report people who have frequent hypoglycaemia or unawareness?

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Hypoglycaemia

Summary

Curriculum Module III-6 Slide 30 of 38

Hypoglycaemia Common Frightening for person with diabetes and family Can usually be prevented Reduced through education, selfmonitoring and self-care Must be addressed at every visit to healthcare professional Treatment must be revised if recurrent
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Hypoglycaemia

Review question

Curriculum Module III-6 Slide 31 of 38

1. Which of the following symptoms are part of the autonomic response to hypoglycaemia?
a. b. c. d. Trembling, palpitations, drowsiness Hunger, sweating, confusion Palpitations, sweating, drowsiness Palpitations, trembling, hunger

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Hypoglycaemia

Review question

Curriculum Module III-6 Slide 32 of 38

2. Hypoglycaemia unawareness is thought to be caused by impaired counter-regulation due to:

a. b. c. d. Repeated hypoglycaemia Autonomic neuropathy Nephropathy Absent glucagon production

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Hypoglycaemia

Review question

Curriculum Module III-6 Slide 33 of 38

3. At what blood glucose level do neuroglycopenic symptoms generally begin to show?

a. b. c. d. Less Less Less Less than than than than 3.7mmol/L 3.1mmol/L 2.5mmol/L 2.0mmol/L (66mg/dL) (56mg/dL) (45mg/dL) (36mg/dL)

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Hypoglycaemia

Review question

Curriculum Module III-6 Slide 34 of 38

4. Glucagon secretion results in:

a. Increased production of glucose in the liver b. Increased sensitivity to glucose in the cells c. Decreased absorption of glucose from the gastrointestinal tract d. Decrease in glucose passed in the urine
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Hypoglycaemia

Review question

Curriculum Module III-6 Slide 35 of 38

5. Which would be the most appropriate to treat mild-to-moderate hypoglycaemia?

a. b. c. d. Cup of tea Chocolate bar Six crackers Glass of fruit juice

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Hypoglycaemia

Answers

Curriculum Module III-6 Slide 36 of 38

1. d
2. a 3. c 4. a 5. d

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Hypoglycaemia

References
1.

Curriculum Module III-6 Slide 37 of 38

Clarke WL, Cox DJ, Gonder-Frederick LA, Julian D, Schlundt D, Polonsky W. The relationship between nonroutine use of insulin, food, and exercise and the occurrence of hypoglycaemia in adults with IDDM and varying degrees of hypoglycemic awareness and metabolic control. Diabetes Educ 1997; 23(1): 55-8. Jones TW, Porter P, Sherwin RS, et al. Decreased epinephrine responses to hypoglycaemia during sleep. N Eng J Med 1998; 338: 1657-62. Frier BM, Ewing FM, Lindholm A, Hylleberg B, Kanc K. Symptomatic and counterregulatory hormonal responses to acute hypoglycaemia induced by insulin aspart and soluble human insulin in Type 1 diabetes. Diabetes Metab Res Rev 2000; 16(4): 262-8.

2. 3.

4.

The Diabetes Control and Complications Trial Research Group. Effects of intensive diabetes therapy on neuropsychological function in adults in the Diabetes Control and Complications Trial. Ann Intern Med 1996; 124: 379-88.
UKPDS. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patinets with type 2 diabetes (UKPDS 33). Lancet 1998; 352(9131): 837-53.

5.

6.

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003; 27(suppl 2).
Garg SK, Paul JM, Karsten JI, et al. Reduced severe hypoglycemia with insulin glargine in intensively treated adults with type 1 diabetes. Diabetes Technol Ther 2004; 6(5): 589-95.
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7.

Hypoglycaemia

References
8.

Curriculum Module III-6 Slide 38 of 38

Garb SK, Gottlieb PA, Hisamoti ME, et al. Improved glycemic control without an increase in severe hypoglycemic episodes in intensively treated patients with type 1 diabetes receiving morning, evening, or split doses insulin glargine. Diabetes Res Clin Pract 2004; 66(1): 49-56. Rosenstock J, Dailey G, Massi-Benedetti M, et al. Reduced hypoglycemia risk with insulin glargine: A meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care 2005; 28(4): 950-5. Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood glucose awareness training (BGAT-2): Long-term benefits. Diabetes Care 2001; 24(4): 637-42.

9.

10.

11.

Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001; 24(11): 1888-93.
Cox DJ, Gonder-Frederick LA, Kovatchev BP, Julian DM, Clarke WL. Progressive hypoglycaemia's impact on driving simulation performance. Occurrence, awareness and correction. Diabetes Care 2000; 23(2): 163-70.

12.

13.

Kalergis M, Schiffrin A, Gougeon R, Jones PJ, Yale JF. Impact of bedtime snack composition on prevention of nocturnal hypoglycaemia in adults with type 1 diabetes undergoing intensive insulin management using lispro insulin before meals: a randomized, placebo-controlled, crossover trial. Diabetes Care 2003; 26(1): 9-15.

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