MANAGEMENT OF DIABETES

EMERGENCY:
HYPOGLYCEMIA

Dr Hafizah binti Md Salleh

Pakar Perubatan Keluarga
KK Beranang
HOW MANY MINUTES IS THE AUDIENCE’S ATTENTION
SPAN?
Written by Brad Phillips @MrMediaTraining on August 23, 2012 – 6:04 AM
 3

TIMELINE

HYPERGLYCEMIC
INCIDENCE AND MOMENT!!
PATHOPHYSIOLOGY

EFFECTS OF MANAGEMENT OF
DEFINITION OF
HYPOGLYCEMIA HYPOGLYCEMIA
HYPOGLYCEMIA
DEFINITION OF HYPOGLYCEMIA
Low plasma glucose level (<4.0
mmol/L).
OR
Development of autonomic or
neuroglycopenic symptoms in
patients treated with insulin or
OADs which are reversed by
caloric intake.
CPG Diabetes Mellitus 5th edition 2015
Symptoms of hypoglycemia
(autonomic & neuroglycopenia)
Hypoglycaemic Symptoms Based on Blood Glucose Levels
 Classification of hypoglycemia

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.
True hypoglycemia Relative hypoglycemia

Blood sugar < 4mmol/L

VS Presence of typical
symptoms of hypoglycemia

Presence of typical Blood sugar > 4mmol/L

symptoms of hypoglycemia
Classification of hypoglycemia ADA
 1
0

TIMELINE

INCIDENCE AND
PATHOPHYSIOLOGY

DEFINITION OF
HYPOGLYCEMIA
Defective glucose counter regulation…....

T1DM & late T2DM associated Impaired awareness of

with defective counter regulation hypoglycemia associated with
(absence of glucagon response higher rate of SEVERE
and attenuated epinephrine HYPOGLYCEMIA
response
Hypoglycemia episodes
often unrecognised
Especially in insulin treated patient

63% & 47% 54% 74%

T1DM & T2DM had Nocturnal hypo- Occur at night
unrecognised hypoglycemia undetected

CGM, continuous glucose monitoring

Chico et al, Diabetes care 2003
Sleep blunts the counter-regulatory catecholamine response to
hypoglycaemia

Baseline was defined as mean plasma concentrations of the values at −20 and 0 min

Jones et al. N Engl J Med 1998;338:1657–62

Vicious circle of hypoglycemia unawareness
Hypoglycemic events lead hypoglycaemic events

Frequent Symptoms of hypo

hypoglycemia - weaker
< 4.0 mmol/l - appear later
- change

Awareness of hypoglycemia
- more difficult & less reliable
 Who are at risk of hypoglycemia

01 Advancing age 04 Increase A1c

02 Cognitive impairment 05 Hypoglycemia

unawareness

03 Poor health knowledge 06 Long standing insulin

therapy

07 Presence of target
organ damage
 1
8

Causes of hypoglycemia

Meal related Medicine related

delayed or inadequate or too much or over dosage
missed

Exercise Drug or alcohol intake

Insulin related
increase sensitivity or
reduce insulin clearance
 1
9

TIMELINE

INCIDENCE AND
PATHOPHYSIOLOGY

EFFECTS OF
DEFINITION OF
HYPOGLYCEMIA
HYPOGLYCEMIA
Hypoglycemia in T2DM: increase CV event

Increase of
76% medication non
adherence

01 Hemodynamic changes
10-50 fold increase
adrenaline and noradrenaline

02 ECG changes
prolonged QT, hypokalemia

03 Hematological changes
Platelet activation & increase
viscosity
Evidence of hypoglycemia outcome

01 02 03
 Complications and Effects of Severe
Hypoglycemia
Plasma glucose level

110
6

100

5 90

80
Increased Risk of Cardiac Progressive
4
70
Arrhythmia1 Neuroglycopenia2

60
 Abnormal prolonged cardiac  Cognitive impairment
3 repolarization—  Unusual behavior
50 ↑ QTc and QTd
 Seizure
 Sudden death
2
40
 Coma
30  Brain death

1 20
mmol/L

10
mg/dL

1. Landstedt-Hallin L et al. J Intern Med. 1999;246:299–307.

2. Cryer PE. J Clin Invest. 2007;117(4):868–870.
Severe Hypoglycemia Causes QTc Prolongation

450 P=0.0003
Mean QT interval, ms 440
430
420 P=NS

410
400
390
380 Significant QTc prolongation
370 during
360 hypoglycemia
0
Euglycemic clamp Hypoglycemic clamp
(n=8) 2 weeks after
glibenclamide withdrawal
Baseline (t=0)
End of clamp (t=150 min)
(n=13)
ACCORD?

Landstedt-Hallin L et al. J Intern Med. 1999;246:299–307.

Patient fear of hypoglycemia
increases with history
p < 0.0001
of hypoglycemia 20 19
18
16
Represent psychological barrier
14
to patient and physician and may impede diabetes
management 12
10.2
10
8
Some patient intentionally maintain 6
hyperglycemia state 4
To avoid hypoglycemia
2
0
Significantly associated with lower No hypoglycemia History of
hypoglycemia
treatment satisfaction & barrier to
Mean HFS-II worry score
adherence
Fear may also extend to family members

Vexiau et al, Diabetes Obes Metab 2008

Nakar et al. J Diabetes Complications 2007;21:220–6; 2. Frier. Diabetes Metab Res Rev 2008;24:87–92; 3.
Alvarez Guisasola et al. Diabetes Obes Metab 2008;10(Suppl. 1):25–32
 Klinik XXX
Management of
Aim of treatment
hypoglycemia
• 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.
 Rule of 15

In management of hypoglycemia

Give 15g glucose or fast acting

CHO containing food

Wait 15 minutes

Recheck blood glucose, repeat treatment

if necessary another 15g
Examples of 15 g Simple Carbohydrate
• 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
 Once hypoglycemia reversed…..

01 Take usual meal or snack at 03 Education on

the time of the day to prevent recognition
recurrent of symptoms and
treatment

02 Counselling on strategies for 04 May need to adjust

prevention of hypoglycemia insulin regime
to lower the risk
Recharged!!!
Case Studies
Case 1
• A 76-year-old female patient was admitted to the
orthopedic unit for right hip replacement.

• She has diabetes for 15 years and had been treated with
glibenclamide 5 mg twice daily and metformin 1
g/day.

• In the morning of the admission day and after she had

taken her diabetes medications at home, she complained
of nausea, vomiting, and diarrhoea and refused any food
intake.
Case 1

• In the afternoon the patient was found comatose in bed.

• What is the possible reason for her unconsciousness?

• What would you do?

Case 1

• Computed tomography of the brain was normal.

• Blood was sent to the laboratory for biochemical analysis;

after about 2 hours the laboratory informed the unit that
the patient’s blood glucose was 20 mg/dL (1.1 mmol/L).
Case 1
• What was wrong with this patient?

• Glibenclamide (glyburide) is a well-known sulphonylurea

that may cause severe hypoglycemia more often than
other sulphonylureas due to the prolonged duration of
action of the medication and its metabolites.

• The relatives should have been informed about the risk of

hypoglycaemia with glibenclamide (glyburide) and they
should have informed the personnel of the unit that the
patient had taken her medications before admission.
Case 1

• Blood glucose should have been closely monitored in the

hospital and, if it was low, intravenous glucose infusion
should have begun.

• In addition, every unconscious patient should be

considered as hypoglycaemic, especially if the patient
has diabetes, until immediate estimation of the blood
glucose levels rules out hypoglycaemia. Thus the patient
should have been managed as having been in
hypoglycaemic coma until the results of the blood test
were available.
Case 1

• How will you manage this patient?

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
Thank you
• somogyi vs dawn
• exercise in diabetes
• close monitoring
• sugar < 5.6 take 20g CHO