adnep hypoglycemia

8/7/2019 ADNEP Hypoglycemia

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Danilo F. Baldemor, MD, MS, DPCPInternist - Diabetetologist


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Magandang Hapon!Magandang Hapon!


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Tu rn me off!Tu rn me off!


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Level of Blood S u gar


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objectivesobjectives

Wh at is hyp ogl yc emia?Wh at is hyp ogl yc emia?

How do we diagnose hyp ogl yc emia?How do we diagnose hyp ogl yc emia?

How does hyp ogl yc emia ha pp ens?How does hyp ogl yc emia ha pp ens?

Wh at are t he causes of hyp ogl ycemia?Wh at are t he causes of hyp ogl ycemia?

Wh at are t he workWh at are t he work--ups for hyp ogl ycemia?ups for hyp ogl ycemia?

Wh ere to go from here?Wh ere to go from here?


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HYPOGLYCEMIAHYPOGLYCEMIAHYPOGLYCEMIAHYPOGLYCEMIA


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Wh at is H yp ogl yc emia?Wh at is H yp ogl yc emia?


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Backgro u nd:Hypogl ycemia is considered present w henserum glu cose level is


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Definitions of Hyp ogl yc emia p er P roto c olDefinitions of Hyp ogl yc emia p er P roto c oly Symptomatic

- Patient presents s ymp toms related to hyp ogl ycemia,confirmed b y BG (PG) < 72 mg/dL

y Severe- Patient presents s ymp toms related to hyp ogl ycemia

and requires assistan ce; asso c iated wit h PG < 56mg/dL; prom p t re cover y after oral carbo hydrate, IVglu cose, or glu cagon administration

y Noct u rnal- Asso c iated wit h PG < 72 mg/dL; o cc urs after bedtime

insulin inje c tion and before morning FBG monitoring,breakfast, or morning administration of oralanti hyp ergl ycemia agent

Riddle M. Rosensto ck J. Poster presented at: 62 nd S c ientific Sessions of t he ADA;June 14-18, 2002; San Fran cisco, Calif. Poster 457


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11) Severe hypoglycemia) Severe hypoglycemia

An event requiring assistan ce of anot her person An event requiring assistan ce of anot her personto a c tively administer carbo hydrate, glu cagons,to a c tively administer carbo hydrate, glu cagons,or ot her resus c itative a c tions. T hese e p isodesor ot her resus c itative a c tions. T hese e p isodes

ma y be asso c iated wit h suffi c ientma y be asso c iated wit h suffi c ientneurogl ycopenianeurogl ycopenia to indu ce seizure or coma.to indu ce seizure or coma.Plasma glu cose measurements ma y not bePlasma glu cose measurements ma y not beavailable during su ch an event, but neurologi calavailable during su ch an event, but neurologi cal

re cover y attributable to t he restoration of p lasmare cover y attributable to t he restoration of p lasmaglu cose to normal is considered suffi c ientglu cose to normal is considered suffi c ienteviden ce t hat t he event was indu ced b y a loweviden ce t hat t he event was indu ced b y a lowp lasma glu cose con centration.p lasma glu cose con centration.

AMERIC AN DIABE T ES ASSOCI AT IONWORKGROUP O N HYPOG L YCEMI A


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2 2 ) Doc u mented symptomatic) Doc u mented symptomatichypoglycemiahypoglycemia

An event during w h ich typ ical s ymp toms of An event during w h ich typ ical s ymp toms of hyp ogl ycemia are a cc om panied b y ahyp ogl ycemia are a cc om panied b y a

measured p lasma glu cose con centrationmeasured p lasma glu cose con centration70 mg/dl (3.9 mmol/l).70 mg/dl (3.9 mmol/l).

70


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33) Asymptomatic hypoglycemia) Asymptomatic hypoglycemia

An event not a cc om panied b y typ ical s ymp tomsof hyp ogl ycemia but wit h a measured p lasmaglu cose con centration 70 mg/dl.Sin ce t he gl ycemi c thres hold for a c tivation of glu cagon and e p ine ph rine se cretion as glu coselevels de c line is normall y 6570 mg/dl and sin ceante cedent p lasma glu cose con centrations of

70 mg/dl redu ce s ympat hoadrenal res ponses

to subsequent hyp ogl yc emia, t h is criterion setsthe lower limit for t he variation in p lasma glu cosein nondiabeti c , non pregnant individuals as t heconservative lower limit for individuals wit h diabetes.


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44) Probable symptomatic) Probable symptomatichypoglycemiahypoglycemia

An event during w h ich s ymp toms of hyp ogl ycemia are not a cc om panied b y a p lasmaglu cose determination (but t hat was presumabl y caused b y a p lasma glu cose con centration 70

mg/dl).Sin ce man y peo p le wit h diabetes ch oose to treats ymp toms wit h oral carbo hydrate wit hout a testof p lasma glu cose, it is im portant to re cognize

these events as probable hyp ogl yc emia. Su ch self-re ported e p isodes t hat are not confirmed b y a contem poraneous low p lasma glu cosedetermination ma y not be suitable out comemeasures for c linical studies t hat are aimed atevaluating t hera py , but t he y s hould be re ported.


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5 5 ) Relative hypoglycemia) Relative hypoglycemia An event during w h ich the person wit h diabetesre ports an y of the t yp ical s ymp toms of hyp ogl ycemia, and inter prets t hose as indi cative of hyp ogl ycemia, but wit h a measured p lasma glu cosecon centration 70 mg/dl.

Th is categor y refle c ts t he fa c t that patients wit h ch roni cally poor gl ycemi c control can ex perien ces ymp toms of hyp ogl ycemia at p lasma glu cose levels

70 mg/dl as p lasma glu cose con centrations de c linetoward t hat level. T houg h causing distress and

interfering wit h the patients sense of well-being, andpotentiall y limiting t he a ch ievement of o p timalglycemi c control, su ch e p isodes probabl y pose nodire c t harm and t herefore ma y not be a suitableout come measure for c linical studies t hat are aimed

at evaluating t hera py , but t he y s hould be re ported.


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HYPOG L YCEMI AHYPOG L YCEMI A

11) Severe) Severe2 2 ) Doc u mented symptomatic) Doc u mented symptomatic

33) Asymptomatic) Asymptomatic44) Probable symptomatic) Probable symptomatic5 5 ) Relative) Relative

AMERIC AN DIABE T ES ASSOCI AT IONWORKGROUP O N HYPOG L YCEMI A


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Food intakeFood intake {{ Drug intakeDrug intake

Hyp ogl yc emiaHyp ogl yc emia


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Whipples T riadWhipples T riad

1. S ymp toms com patible wit h hyp ogl yc emia,2. Low p lasma or blood glu cose con centration, and

3. Resolution of t hose s ymp toms after t he glu cosecon centration is raised to normal.


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Pathophysiology:The organ s ystems t hat manifest t he signsand s ymp toms of hyp ogl yc emia are t hecentral and autonomi c nervous s ystems.InsulinCounter regulator y hormones glu cagon &e p ine ph rine


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Mortality/Morbidity: Dela y in treatmentcan result in profound sequelae, in c luding

deat h . Acute sequelae in c lude coma, cardia c dysr hy thmia, and deat h .The risk of permanent neurologi c defi c its

increases wit h prolonged hyp ogl yc emia; su ch defi c its can in c lude hemi paresis, memor y impairment, diminis hed language skills,de creased abstra c t th inking ca pabilities, andataxia.

Be cause t he consequen ces of hyp ogl ycemiacan be devastating and an antidote is readil y available, diagnosis and treatment must bera p id in an y patient wit h sus pe c tedhyp ogl ycemia, regardless of t he cause.


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Sex: Females are affe c ted more t han

males.Age: Affec ts p redominantl y older adults.


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How does H yp ogl yc emiaHow does H yp ogl yc emiaha pp ens?ha pp ens?


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Normal physiological responses toNormal physiological responses tohypoglycemiahypoglycemia

The human brain primaril y uses glu cose as itssour ce of energ y.

Under normal conditions, t he brain is unable tos ynthesize or store glu cose and is exquisitel y vulnerable to glu cose de privation.

To prote c t the integrit y of the brain, severalphy siologi cal me ch anisms have evolved tores pond to and limit t he effe c ts of hypoglycemia .


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In humans, t he initial res ponse to a de c line inblood glu cose

su pp ression of endogenous insulin se cretion

release of counterregulator y hormones, of w h ich glu cagon and e p ine ph rine (adrenaline) are t he

most potent.


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Wh en blood glu cose falls in a nondiabeti c adult , these cretion of counterregulator y hormones and t heonset of cognitive, phy siologi cal, and s ymp tomati c ch anges o cc ur at re produ c ible blood glu cosethres holds wit h in a defined h ierar chy . Subje c tive

re cognition of t he s ymp toms of hypoglycemia isfundamental to effe c tive self-management and toprevent progression in severit y.

S ymp toms are generated at arterialized bloodglucose con centrations around 2.83.2 mmol/l (5058 mg/dl) and in young adults have been c lassifiedas neurogl ycopeni c , autonomi c , and malaise.Hypoglycemi c s ymp toms are idios yncrati c and ages pe c ific .


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Ne u rogenic (or a u tonomic ) symptoms

Ne u roglycopenic symptoms


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N eurogeni c (or autonomi c) s ymp toms are t he resultof the per ce p tion of phy siologi cal ch anges causedby the a c tivation of t he AN S triggered b y hyp ogl ycemia.

Althoug h all t hree efferent com ponents of t he AN S adrenomedullar y, s ympat hetic neural, andparas ympat hetic neural are a c tivated b y hyp ogl ycemia,

N eurogeni c s ymp toms are t houg h t to be caused b y s ympat hoadrenal a c tivation and mediated b y

nore p ine ph rine released from s ympat hetic adrenergi c postganglioni c neurons, t he adrenal medullae, or bot h ,by a cet ylch oline released from ch olinergi c s ympat hetic postganglioni c neurons andby e p ine ph rine released from t he adrenal medullae.


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Some neurogeni c s ymp toms, su ch astremulousness, palp itations, and anxiet y/arousal,

are adrenergi c (cate ch olamine mediated);

whereas ot hers, su ch as sweating, hunger, andparest hesias, are ch olinergi c .

Awareness of hyp ogl ycemia is largel y the result of the per ce p tion of neurogeni c s ymp toms and t here cognition t hat t he y are indi cative of hyp ogl ycemia.

Awareness of hyp ogl ycemia is a fun c tion of t heknowledge and t he ex perien ce of t he individual, aswell as t he phy siologi cal res ponses to low glu cosecon centrations.


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N eurogl ycopeni c s ymp toms are t he result of brain neuronal glu cose de privation.

The y inc lude sensations of warmt h , weakness,and fatigue as well as diffi culty th inking,confusion, be havioral ch anges (not infrequentl y confused wit h inebriation b y others), andemotional labilit y.

The y also in c lude seizures, loss of cons c iousness, and, if hyp ogl yc emia is severeand prolonged, brain damage and even deat h .


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Hypoglycemia UnawarenessHypoglycemia Unawareness

Some peo p le have no s ymp toms of hyp ogl ycemia. T he y ma y lose cons c iousnesswithout ever knowing t heir blood glu cose levelswere dro pp ing. T h is problem is calledhyp ogl ycemia unawareness .Hypogl ycemia unawareness tends to ha pp en topeo p le w ho have had diabetes for man y years. H ypogl ycemia unawareness does notha pp en to ever yone. It is more likel y in peo p lewho have neuro pat hy (nerve damage), peo p leon tig h t glu cose control, and peo p le w ho takecertain heart or h igh blood pressure medi c ines.


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Hypoglycemia UnawarenessHypoglycemia Unawareness

As t he years go b y, man y peo p le continue to haves ymp toms of hyp ogl yc emia, but t he s ymp tomsch ange. In t h is case, someone ma y not re cognize area c tion be cause it feels different.

These ch anges are good reason to ch e ck the bloodglu cose often, and to alert t he friends and famil y of thes ymp toms of hyp ogl yc emia.

Treat low or dro pp ing sugar levels even if t he p t. feelfine. And tell t he team if t he blood glu cose ever dro psbelow 50 mg/dl wit hout an y s ymp toms.


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FREQUE NCY OF HYPOG L YCEMI A WIT HDIFFERE NT T RE AT MENT MOD ALIT IES

O ral antidiabeti c agentspredominantl y asso c iated wit h the insulin se cretagogues.

not a common side effe c t of treatment wit h metformin,TZD, or AGI, alt houg h it has been o cc asionall y re ported

in asso c iation wit h metformin w hen food intake is limited.The frequen cy of hyp ogl ycemia is lower in peo p le treatedwith SU t han in t hose treated wit h insulin but is probabl y underestimated.

The risk of hyp ogl ycemia of ea ch sulfon ylurea relates toits ph arma cokineti c properties and is h ighest wit h long-a c ting sulfon ylureas su ch as ch lor propamide, gl yburide(gliben c lamide), and long-a c ting gli p izide.


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Alternative ins u lin regimensBasal insulins can be used safel y in combinationwith oral antidiabeti c agents in peo p le wit h type 2diabetes.

In a s ystemati c review of randomized controlledtrials com paring insulin monot hera py and

combination t hera py with oral agents, 13 of 14studies did not s how an y signifi cant differen ce inhyp ogl ycemia rates between t he different regimens.

In one stud y, 41 peo p le wit h type 2 diabetes treatedwith bedtime N PH (iso ph ane) insulin and oralantidiabeti c drugs, 49% had ex perien ced infrequentmild hyp ogl ycemia sin ce commen c ing insulin, wit h an in c iden ce of four e p isodes per patient per year and no e p isodes of severe hyp ogl ycemia.


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Alternative ins u lin regimensInsulin analogs a pp ear to limit hyp ogl yc emia. Insome studies, t he risk of hyp ogl yc emia has beenre ported to be lower wit h long-a c ting insulinglargine and insulin detemir w hen com paredwith N PH insulin. Glargine was also asso c iatedwith a lower frequen cy of hyp ogl yc emia t hanpremixed insulins.

Ra p id-a c ting insulin analogs, su ch as lis pro andglulisine, were also asso c iated wit h a lower

frequen cy of hyp ogl yc emia in peo p le wit h type 2diabetes w hen com pared wit h s hort-a c ting(soluble) regular insulins.


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Alternative ins u lin regimensStudies of alternative formulations of insulin,wh ich can be administered b y inhalation, in c ludea 6-mont h randomized trial of 299 parti c ipantswith type 2 diabetes in w h ich inhaled insulin wascom pared wit h sub cutaneous insulin. Gl ycemi c control was com parable and in haled insulin wasasso c iated wit h a relative risk of allhypoglycemia of 0.89 (95% CI 0.820.97) w hencom pared wit h sub cutaneous insulin.


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How do we diagnoseHow do we diagnoseHyp ogl yc emia?Hyp ogl yc emia?


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History

Patients often have a h istor y of diabetesmellitus. A h istor y of insulin usage or ingestion of an oral hyp ogl ycemi c agent ma y beknown, and possible toxi c ingestion s houldbe considered.Inquire if t he patient is taking an y newmedi cations.


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HistoryO btaining an a cc urate medi cal h istor y ma y be diffi cult if the patient's mental status isaltered.The medi cal h istor y ma y inc lude diabetes

mellitus, renal insuffi c ien cy /failure,alcoholism, he patic c irr hosis/failure, ot her endo crine diseases, or re cent surger y.


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History

The patient's medi cation and drug h istor y s hould be reviewed carefull y for potentialcauses of hyp ogl ycemia.

The so c ial h istor y ma y inc lude et hanolintake and nutritional defi c ien cy .

Review s ystems for weig h t redu c tion,fatigue, somnolen ce, nausea andvomiting, and heada ch e.Look for ot her s ymp toms suggestinginfe c tion.


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Central nervous s ystemHeada ch eConfusionPersonalit y ch anges

Cardiovas cular s ystem - Pal p itationsGI s ymp toms

Hunger N auseaBel ch ing

Adrenergi c s ymp tomsSweating

Anxiet y TremulousnessN ervousness

Pol yuria, polydipsiaN oc turia

History


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Physical

P hysical findings are nons pe c ific inhyp ogl ycemia and generall y are related to t hecentral and autonomi c nervous s ystems.

Assess VS for hyp othermia, ta chyp nea,ta chyc ardia, hyp ertension, and brad ycardia(neonates).

The HEE N T examination ma y indicate blurredvision, pup ils normal to fixed and dilated, i c terus(usuall y ch olestati c due to he patic disease), andparotid pain (due to endo crine causes).


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Physical

Cardiovas cular disturban ces ma y inc lude ta chyc ardia (brad ycardiain neonates), hyp ertension or hyp otension, and d ysr hy thmias.

Res p irator y disturban ces ma y inc lude d ys pnea, ta chyp nea, anda cute pulmonar y edema.

GI disturban ces ma y inc ludenausea and vomiting, d ys pe psia,and abdominal cram p ing.


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PhysicalSkin ma y be dia ph oreti c and warm or s how signs of de hydration wit h de creasein turgor.

N eurologi c conditionsinc lude coma, confusion,fatigue, loss of coordination, combative or agitated dis position, strokes yndrome, tremors,convulsions, and di p lop ia.


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Wh at are t heWh at are t he

Manifestations of Manifestations of Hyp ogl yc emia?Hyp ogl yc emia?


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S ymp tomsS ymp tomsh u nger h u nger nervo u sness and shakinessnervo u sness and shakinessperspirationperspiration

dizziness or lightdizziness or light- -headednessheadednesssleepinesssleepinessconf u sionconf u sion

diffic u lty speakingdiffic u lty speakingfeeling anxio u s or weakfeeling anxio u s or weak


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Wh at are t he Causes of Wh at are t he Causes of Hyp ogl yc emia?Hyp ogl yc emia?


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Causes of H yp ogl yc emiaCauses of H yp ogl yc emia

excessive doses of insu

lin or somediabetes medications, incl u ding SUs andmeglitinides ( AGIs, big u anides, and TZ Dsalone sho u ld not ca u se hypoglycemiab u t can when u sed with other diabetesmedicines. ) increased activity or exercise

excessive drinking of alcohol


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Ca u ses

Causes of hyp ogl yc emia are varied, but it isseen most often in diabeti c patients.

Hypogl ycemia ma y result from medi cationch anges or overdoses, infe c tion, diet ch anges,metaboli c ch anges over time, or a c tivity ch anges; however, no a cute cause ma y befound.


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Ca u ses

Earl y in the course of T ype 2 diabetes, patientsma y ex perien ce e p isodes of hyp ogl yc emiaseveral hours after meals. T he s ymp tomsgenerall y are brief and res pond s pontaneousl y.

Patients wit h no prior h istor y of hyp ogl yc emiarequire a com p lete worku p to find a potentiall y treatable disease.


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Ca u sesDr u gs that ma y be related to hyp ogl ycemia in c ludethe following: oral hyp ogl yc emi cs, sulfonamide,ph en ylbutazone, insulin, bis hydrox y coumarin,sali cy lates, p -aminobenzoi c a c id, p ropoxyph ene,halo peridol, stanozolol, et hanol, hyp ogl yc in, carbamateinse c tic ide, diso py ramide, isoniazid, met hanol,met hotrexate, pentamidine, sulfonamide, tri cyc lic antide pressants, cy totoxi c agents, organo ph os ph ates,propranolol p lus et hanol, didanosine, ch lor p romazine,quinine, sulfa drugs, fluoxetine, sertraline, fenfluramine,trimet hoprim, 6-mer ca p topurine, t h iazide diureti cs,th ioglycolate, tremetol, ritodrine, disodium

et hy lenediaminetetraa cetic a c id (EDTA), c lofibrate,angiotensin converting enz yme (ACE) in h ibitors, andlith ium.Factitio u s hypoglycemia or self-indu cedhyp ogl ycemia can be seen in healt h care workers or inrelatives w ho care for diabeti c famil y members at home.


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O ther causes in c lude t he following:GI surger yIdiopat h icHe patic diseaseIslet cell tumor/extra pan creati c tumor Exer c ise (in diabeti c patients)

Pregnan cyRenal gl ycosuriaKetoti c hyp ogl yc emia of ch ildhood

Adrenal insuffi c ien cyHypop ituitarism

Enz yme defi c ien cyLarge tumors (eg, mesen chy mal tumors, e p ithelial tumors,endot helial tumors)Se psisStarvation

Artifa c t

Ca u ses


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Differentials

Alcohol and Substan ce Abuse Evaluation Anorexia N ervosa Arthritis, R heumatoidHIV Infe c tion & AIDS

Hypop ituitarismHypothy roidism and M yxedema ComaN eo p lasms, Brain, Lung, S p inal CordPlant Poisoning, Gl ycosides CoumarinPlant Poisoning, H ypogl ycemi csS hock, Se p ticS ystemi c Lupus Er ythematosusToxi c ity, Beta-blo cker, Isoniazid, Lit h ium,O rgano ph os ph ate and Carbamate, Sali cy late


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Wh at are t he WorkWh at are t he Work--ups for ups for Hyp ogl yc emia?Hyp ogl yc emia?


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Laboratories

Treatment and dis position of hyp ogl yc emia areguided b y the h istor y and t he c linical p ic ture.Serum glu cose s hould be measured frequentl y and used to guide treatment, be cause c linicala pp earan ce alone ma y not refle c t the

seriousness of t he situation.

Hypogl ycemia is defined a cc ording to t hefollowing serum glu cose levels:


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Laboratories

If the cause of hyp ogl ycemia is ot her t han oralhyp ogl ycemi c agents or insulin in a diabeti c patient, ot her lab tests ma y be ne cessar y.

C- pe p tide measurement : T h is measurement is

elevated in insulinoma, normal or low wit h exogenousinsulin, and elevated wit h oral sulfon ylureas.

Che ck liver fun c tion tests, serum insulin, and cortisoland t hy roid levels.


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Laboratories

Sear ch for a sour ce of infe c tion. Studies s houldbe considered to rule out t he possibilit y of acon current o cc ult infe c tion contributing to t henew hyp ogl yc emi c e p isode.

Com p lete phy sical examinationChest radiogra phUrinal ysisBlood cultures


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LaboratoriesImaging St u dies:

Performing an abdominal CT s can or an ultrasound to ruleout an abdominal tumor ma y be a pp ropriate in t he patientwith new-onset hyp ogl yc emia and no c lear etiolog y.In diabeti c patients presenting wit h hyp ogl yc emia, performa ch est radiogra ph to rule out infe c tion.

Other T ests:Plasma glu cose overnig h t fasting -


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How do we treatHow do we treatHyp ogl yc emia?Hyp ogl yc emia?


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Emergency Department CareEmergency Department Care

The initial a pp roa ch s hould in c lude t he following: ABCs,intravenous (IV) a cc ess, ox ygen, monitoring, and

Acc uch e ck. Administration of glu cose as part of t he initialevaluation of altered mental status often corre c tshyp ogl ycemia.

Treatment s hould not be wit hh eld w h ile waiting for alaborator y glu cose value. Be cause t he brain usesglu cose as its p rimar y energ y sour ce, neuronal damagema y occ ur if treatment of hyp ogl yc emia is dela yed.

A hyp ergl ycemi c patient wit h an altered mental status ma y re ceive a bolus of glu cose. T h is procedure is unlikel y to harm t he

patient wit h h igh glu cose; however, t he dela y in giving glu cose tothe hyp ogl ycemi c patient ma y be detrimental.If an A cc uch e ck can be performed immediatel y, awaiting t heresults of t h is test (available wit h in 1 minute) before de c idingwhet her to administer glu cose is reasonable.


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Emergency Department CareEmergency Department Care

O nce t he diagnosis of hyp ogl ycemia is made,sear ch carefull y for t he cause in t he previousl y healt hy patient.

In the diabeti c patient, sear ch diligentl y for t hecause (eg, medi cation ch anges, dietar y ch anges, new metaboli c ch anges, re cent illness,occ ult infe c tion) of t he e p isode.


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Paano magamotang Hypoglycemia?


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Treatment of H yp ogl yc emiaTreatment of H yp ogl yc emia

For the u nconscio u s patient / thoseFor the u nconscio u s patient / thosewith sensorial changes:with sensorial changes:

Intravenous glu cagon or glu cose (50 cc Intravenous glu cagon or glu cose (50 cc in 50% dextrose followed b y 5in 50% dextrose followed b y 5--10%10%dextrose dri pdextrose dri p


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TreatmentTreatment

If you t h ink t he blood glu cose is too low, use ablood glu cose meter to ch e ck the level. If it is 70mg/dL or below, have one of t hese "qui ck fix"foods rig h t awa y to raise t he blood glu cose:

2 or 3 glu cose tablets1/2 cup (4 oun ces) of an y fruit juice1/2 cup (4 oun ces) of a regular (not diet) soft drink

1 cup (8 oun ces) of milk5 or 6 p ieces of hard cand y 1 or 2 teas poons of sugar or hone y


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How is hypoglycemia treated?The a cute management of hyp ogl ycemiainvolves t he ra p id deliver y of a sour ce of easil y absorbed sugar.

Regular soda, jui ce, lifesavers, table sugar, and

the like are good o p tions.In general, 10-15 grams of glu cose is used,followed b y an assessment of s ymp toms and ablood glu cose ch e ck if possible. If after 10

minutes t here is no im provement, anot her 10-15grams s hould be given. T h is can be re peated u p to 3 times. At that point, the patient sho u ld beconsidered as not responding to the therapyand an amb u lance sho u ld be called.


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The equivalen cy of 10-15 grams of glu cose(a pp roximate servings) are:

Ten lifesavers4 teas poons of sugar 1/2 can of regular soda or jui ce

Man y peo p le like t he idea of treatinghyp ogl ycemia wit h cake, cookies, and brownies.However, sugar in t he form of com p lexcarbo hydrates or sugar combined wit h fat andprotein are mu ch too slowl y absorbed to beuseful in t he a cute treatment of hyp ogl yc emia.

O nce t he a cute e p isode has been treated, ahealt hy , long-a c ting carbo hydrate to maintainblood sugars in t he a pp ropriate range s hould beconsumed. Half a sandwi ch is a reasonableop tion.


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TreatmentTreatment After 15 minutes, ch e ck the blood glu cose againto make sure t hat it is no longer too low. If it isstill too low, have anot her serving. Re peat t heseste ps until t he blood glu cose is at least 70.

Then, if it will be an hour or more before t henext meal, have a sna ck.If patient is taking insulin or a diabetesmedi cation t hat can cause hyp ogl yc emia,

alwa ys carr y one of t he qui ck-fix foods wit h them. Wearing a medi cal identifi cation bra celetor ne ckla ce is also a good idea.


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Exer c ise can also cause hyp ogl yc emia. C he ckblood glu cose before t he exer c ise.Severe hyp ogl yc emia can cause patient to losecons c iousness. In t hese extreme cases w henthe y lose cons c iousness and cannot eat,glu cagon can be inje c ted to qui ckly raise t heblood glu cose level.

Ask your healt h care provider if having aglu cagon kit at home and at work is a pp ropriate

for you. T h is is parti cularl y important if you havetype 1 diabetes. Your famil y, friends, and co-workers will need to be taug h t how to give you aglu cagon inje c tion in an emergen cy .

Dextrose (Glu cose-D) -- Monosa cch aride absorbed from intestine


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Dr u g Name

Dextrose (Glu cose D) Monosa cch aride absorbed from intestineand distributed, stored, and used b y tissues. Parenterall y inje c teddextrose is used in patients unable to obtain adequate oral intake.Dire c t oral absor p tion results in ra p id in crease of blood glu cosecon centrations. Effe c tive in small doses, and no eviden ce t hat itma y cause toxi c ity. Con centrated dextrose infusions provideh igher amounts of glu cose and in creased calori c intake wit h minimum fluid volume.Long-term management of hyp ogl ycemia is di c tated b y cause (eg,insulinoma).

Ad u lt Dose

Acute management: 50 mL of 50% dextrose IV bolus after blooddrawLong-term management: 10% glu cose IV infusion in water b y central venous line; avoid vein s c lerosis t hat ma y occ ur wit h periph eral infusion

Pediatric DoseN eonates: 200 mg/kg (2 mL/kg 10% glu cose in water) IV bolus

Ch ildren: 0.5 g/kg dextrose IV bolus

Contraindications

Diabeti c coma if blood sugar levels are extremel y h ighDo not administer con centrated solution if intras p inal or intra cranial hemorr hage present

Avoid in de hydrated patients, es pe c ially if severel y de hydrated or those wit h delirium tremens, he pati c coma, or glu cose-gala c tosemalabsor p tion s yndrome

Caution w hen administering parenteral fluids to patients re ceiving


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InteractionsCaution w hen administering parenteral fluids to patients re ceivingcorticosteroids or corticotro p in, es pe c ially if solution containssodium ions

Pregnancy A - Safe in pregnan cy

Preca u tions

Ma y cause nausea, w h ich also ma y occ ur wit h hyp ogl ycemia; IVsolutions ma y dilute serum ele c trolyte con centrations or result inover hy dration in fluid overload; caution in patients suffering from

congested states or pulmonar y edema; hyp ertoni c dextrose givenperiph erall y ma y cause t hrombosis (administer instead t hroug h central venous cat heter); caution in sub c linical diabetes mellitus or carbo hydrate intoleran ce; in creased risk of indu c ing signifi canthyp ergl ycemia or hyp erosmolar s yndrome if solution administeredra p idly, es pe c ially in patients wit h ch roni c uremia or carbo hy drate

intoleran ce; con centrated solutions s hould not be administered SCor IM; rates of dextrose infusion h igher t han 0.5 g/kg/ h ma y p rodu ce gl ycosuriaat infusion rates of 0.8 g/kg/ h , inc iden ce of glycosuria is 5%; monitor fluid balan ce, ele c trolyte con centrations,and a c id-base balan ce c losel y; dextrose administration ma y p rodu ce vitamin B- com p lex defi c ien cy

Dr u g Category: Glucose-elevating agents -- T hese agents can act in the


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pancreas or the peripheral tiss u es to increase blood gl u cose levels.

Dr u g Name

Glu cagon hydro ch loride -- Pan creati c alph a cells of islets of Langer hans produ ce t h is polyp e p tide hormone. Exerts effe c tsopp osite of insulin on blood glu cose. Elevates blood glu cose levelsby inh ibiting gl ycogen s ynthesis and en han c ing formation of glu cose from non carbo hydrate sour ces, su ch as p roteins and fats(glu coneogenesis).In creases hydrol ysis of gl ycogen to glu cose(glycogenol ysis) in liver. A cc elerates he pati c glycogenol ysis andlipolysis in adi pose tissue b y stimulating cyc lic AMP s ynthesis viaaden ylyl cyc lase and en han c ing ph os ph or ylase kinase a c tivity.Useful w hen IV a cc ess is problemati c . Ma y be administered as partof EMS proto col in patients wit h altered mental status and no IVa cc ess.

Ad u lt Dose 1-2 mg IV/IM/SC; dose ma y be re peated ever y few h

Pediatric Dose < 20 kg: 0.5 mg (0.5 U) or dose equivalent to 20-30 m cg/kg> 20 kg: 1 mg (1 U) IV/IM/SC

Dr u g Category: Glucose-elevating agents -- T hese agents can act in the


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pancreas or the peripheral tiss u es to increase blood gl u cose levels.

Contraindications Do cumented hyp ersensitivit y; ph eo ch romo cy toma

InteractionsMa y en han ce effe c ts of anti coagulants (alt houg h onset ma y bedela yed); monitor PT and for signs of bleeding in patients re ceivinganti coagulantsadjust dose a cc ordingl y

Pregnancy B - Usuall y safe but benefits must outweig h the risks.

Preca u tions

Monitor blood glu cose levels in hyp ogl ycemi c patients until t he y areas ymp tomati c ; effe c tive in treating hyp ogl ycemia onl y if suffic ientliver gl ycogen present, t herefore glu cagon has virtuall y no effe c tson patients in states of starvation, adrenal insuffi c ien cy, or ch roni c hyp ogl ycemia

Diazoxide (H yp erstat) -- Dire c t inh ibitor of insulin se cretion.


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Dr u g Name

Increases he patic glu cose out put and de creases cellular glu coseup take. Has ver y limited role in treating hyp ogl ycemia, but ma y beindicated in some cases of insulinoma or overdosage wit h oralhyp ogl ycemi c agents.

Hyp ergl ycemi c effe c t starts wit h in 1 h , lasting maximum of 8 h if renal fun c tion normal. Patients wit h refra c tor y hyp ogl ycemia ma y require h igh dosages.

Ad u lt Dose 200 mg PO q4 h

Infuse 300 mg IV over 30 min as adjun c t to glu cose infusion

Pediatric Dose 3-8 mg/kg/d divided bid/tid q8-12 h

Contraindications Do cumented hyp ersensitivit y; aorti c coar c tation;ph eo ch romo cy toma; arteriovenous s hunts; aorti c aneur ysm

InteractionsMa y de crease serum hydantoins, possibl y resulting in de creasedanti convulsant effe c ts; t h iazide diureti cs ma y potentiatehyp eruri cemi c and anti hyp ertensive effe c ts

Pregnancy C - Safet y for use during pregnan cy has not been establis hed.

Preca u tions

Patients wit h diabetes mellitus ma y require treatment for hyp ergl ycemia; w hen given prior to deliver y, ma y produ ce fetal or neonatal hyp erbilirubinemia, t hrombo cy topenia, alteredcarbo hydrate metabolism, and ot her adverse rea c tions


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Fu rther Inpatient CareFu rther Inpatient Care

Admission criteriaN o obvious causeO ral hyp ogl yc emi c agent

Long-a c ting insulinPersistent neurologi c defi c its

Dis ch arge ma y be considered after a h igh

carbo hydrate meal in t he ff. situations:O bvious cause is found and treated.Ep isode is reversed ra p idly.


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Fu rther O u tpatient CareFu rther O u tpatient Care

For patients on eit her s hort-a c ting insulin or hyp ogl ycemi c agents w ho have not eaten andhave had t heir hyp ogl ycemia reversed ra p idly, ah igh carbo hydrate meal prior to dis ch arge is

re commended.

A com petent adult w ho has been dire c ted tomonitor fingersti ck glu cose measurementsc losel y during t he remainder of t he da y s houlda cc om pan y the patient after dis ch arge.


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Patients must be counseled as to t he causesand t he earl y signs and s ymp toms of hyp ogl ycemia.

General out patient diabeti c edu cation or inpatient diabeti c tea ch ing is indi cated.

Deterrence/Prevention


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Prolonged hyp ogl yc emia ma y cause permanentneurologi c defi c it or deat h .

Unre cognized infe c tion causing hyp ogl yc emia indiabeti c patients ma y result in re currenthyp ogl ycemi c s pells or progression of t heinfe c tion.

Complications


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The prognosis for t h is condition is ex cellent if dete c ted and treated earl y.

Prognosis

Patient Ed u cationDiabeti c patients wit h e p isodes of hyp ogl yc emianeed edu cation in nutrition, ch e cking glu coselevels at home, and earl y signs and s ymp toms of hyp ogl ycemia.

Re cognition of earl y s ymp toms is paramount for self-treatment


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Preventing re curren ce of Preventing re curren ce of hyp ogl yc emiahyp ogl yc emia

Treatment of t he pre c ip itating eventwh ich caused t he hyp ogl ycemiaRedu c tion or adjustment of t heimp licated medi cationsRe p lacement of t he res pe c tivehormones ne cessar y

Eating meals at t he rig h t timeconsistentl y


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PreventionPrevention

To help p revent hyp ogl ycemia, you s houldkee p in mind several t h ings:Your diabetes medi cations. Some

medi cations can cause hyp ogl ycemia. Askhealt h care provider if yours can. Also,alwa ys take medi cations and insulin in t here commended doses and at t here commended times.

Wh at to Ask Your Do c tor AboutWh at to Ask Your Do c tor About


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Wh at to Ask Your Do c tor AboutWh at to Ask Your Do c tor AboutDiabetes Medi cationsDiabetes Medi cations

Co u ld my diabetes medication ca u seCo u ld my diabetes medication ca u sehypoglycemia?hypoglycemia?When sho u ld I take my diabetesWhen sho u ld I take my diabetes

medication?medication?How m u ch sho u ld I take?How m u ch sho u ld I take?Sho u ld I keep taking my diabetesSho u ld I keep taking my diabetes

medication if I am sick?medication if I am sick?Sho u ld I adj u st my medication beforeSho u ld I adj u st my medication beforeexercise?exercise?

N ormal and target blood glu cose rangesN ormal and target blood glu cose ranges


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Normal blood gl u cose levels in peoplewho do not have diabetes.

Upon waking (fasting ): 70 to 110After meals: 70 to 140

T arget blood gl u cose levels in peoplewho have diabetes.

Before meals: 90 to 130

1 to 2 ho u rs after the start of a meal:less than 180Hypoglycemia (low blood gl u cose ): 70 or below

g g gg g g(mg/dL)(mg/dL)

Wh t h ld I d h d t t h lt h


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Follow the healthy eating plan that yo u and yo u r doctor or dietitian have worked o u t.

Be active a total of 30 min u tes most days. Askyo u r doctor what activities are best for yo u .

T ake yo u r diabetes medicines at the same timeseach day.

Wh at s hould I do ea ch da y to sta y healt hy with diabetes?


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Ch l S h l Phil hCh l S h l Phil h


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Charles Sch u ltz PhilosophyCharles Sch u ltz Philosophy

T he following is the philosophy of Charles Sch u ltz, the creator of T he following is the philosophy of Charles Sch u ltz, the creator of the "Pean u ts" comic strip. Yo u don't have to act u ally answer thethe "Pean u ts" comic strip. Yo u don't have to act u ally answer theq u estions.q u estions.

1. Name the five wealthiest people in the world.1. Name the five wealthiest people in the world.2. Name the last five Heisman trophy winners.2. Name the last five Heisman trophy winners.

3. Name the last five winners of the Miss America.3. Name the last five winners of the Miss America.4. Name ten people who have won the Nobel or P u litzer Prize.4. Name ten people who have won the Nobel or P u litzer Prize.5. Name the last half dozen Academy Award winner for best actor 5. Name the last half dozen Academy Award winner for best actor and actress.and actress.6. Name the last decade's worth of World Series winners.6. Name the last decade's worth of World Series winners.

Ch l S h l Phil hCh l S h l Phil h


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How did you do?How did you do?

The point is, none of us remember t he headliners of The point is, none of us remember t he headliners of yesterda y. T hese are no se condyesterda y. T hese are no se cond--rate a ch ievers. T he y rate a ch ievers. T he y are t he best in t heir fields. But t he a pp lause dies. Awardsare t he best in t heir fields. But t he a pp lause dies. Awardstarnis h . Ach ievements are forgotten. A cc olades andtarnis h . Ach ievements are forgotten. A cc olades andcertificates are buried wit h their owners.certificates are buried wit h their owners.

Ch l S h lt Phil hCh l S h lt Phil h


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Here's another q u iz. See how yo u do on this one:

1. List a few teachers who aided yo u r jo u rney thro u gh school.

2. Name three friends who have helped yo u thro u gh a diffic u lt time.

3. Name five people who have ta u ght yo u something worthwhile.

4. T hink of a few people who have made yo u feel appreciated andspecial.

5. T hink of five people yo u enjoy spending time with.

Ch l S h lt Phil hCh l S h lt Phil h


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Easier?Easier?

Th e lesson:Th e lesson: T he people who make a difference inT he people who make a difference inyo u r life are not the ones with the most credentials,yo u r life are not the ones with the most credentials,the most money, or the most awards. T hey are thethe most money, or the most awards. T hey are theones that care.ones that care.

Ch l S h u lt Phil hCh l S h u lt Phil h


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Pass this on to those people who have made a difference inPass this on to those people who have made a difference inyo u r life. Yo u are receiving this beca u se yo u made a differenceyo u r life. Yo u are receiving this beca u se yo u made a differencein mine.in mine.

"Don't worry abo u t the world coming to an end today."Don't worry abo u t the world coming to an end today.

It's already tomorrow in Au stralia." (Charles Sch u ltz )It's already tomorrow in Au stralia." (Charles Sch u ltz )


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T hank Yo u !T hank Yo u !


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T hank Yo u !T hank Yo u !


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adnep hypoglycemia

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