Hypoglycaemia & Funny Hypoglycaemia & Funny turnsturns

Ali ChakeraAli Chakera

What is a hypo?What is a hypo?

Symptoms?Symptoms?

A blood sugar level?A blood sugar level?

What the patient says it is?What the patient says it is?

What do you tell to patients who What do you tell to patients who are having a hypo?are having a hypo?

Take some sugar?Take some sugar?

Take some lucozade?Take some lucozade?

Quick or slow actingQuick or slow acting

BothBoth

Does it matter?Does it matter?

What do others say?What do others say?

DAFNE:DAFNE:– A hypo is when your sugar drops below A hypo is when your sugar drops below

3.5mmol/l3.5mmol/l– Treat with lucozade 100-120 mlTreat with lucozade 100-120 ml– Fruit juice 150-200 mlFruit juice 150-200 ml– Cola 150-200ml (not diet)Cola 150-200ml (not diet)– Glucose tablets – may take a little longer 5-6 Glucose tablets – may take a little longer 5-6

tabletstablets

What do others dayWhat do others day

Lilly:Lilly:– Sugar in water – two teaspoonsSugar in water – two teaspoons– 3 dextrose tablets3 dextrose tablets

What do others say?What do others say?

NovoNordisk:NovoNordisk:– If your symptoms are not too severe, then If your symptoms are not too severe, then

taking sugar in the form of a biscuit or a piece taking sugar in the form of a biscuit or a piece of fruit may be enough. If you do need to take of fruit may be enough. If you do need to take sugar then make sure it is in a form which will sugar then make sure it is in a form which will work quickly. Liquid sugar is absorbed more work quickly. Liquid sugar is absorbed more quickly than solid, so sugary drinks are useful. quickly than solid, so sugary drinks are useful. Remember that, because of its fat content, Remember that, because of its fat content, chocolate will be absorbed more slowly so it chocolate will be absorbed more slowly so it may not relieve your symptoms quickly.may not relieve your symptoms quickly.

What others say?What others say?

Diabetes UK:Diabetes UK:– ‘‘hypo’ occurs when glucose is under 4 mmol/l.hypo’ occurs when glucose is under 4 mmol/l.– Treatment is usually very simple and requires taking Treatment is usually very simple and requires taking

some fast acting carbohydrate, such as a sugary drink some fast acting carbohydrate, such as a sugary drink or some glucose tablets, and following this up with or some glucose tablets, and following this up with some longer acting carbohydrate, such as a cereal some longer acting carbohydrate, such as a cereal bar, a sandwich, piece of fruit, biscuits and milk or the bar, a sandwich, piece of fruit, biscuits and milk or the next meal if it is due. next meal if it is due.

– In the vast majority of cases the body will release its In the vast majority of cases the body will release its own stores of glucose and raise the blood glucose own stores of glucose and raise the blood glucose level to normal, though this may take several hours. level to normal, though this may take several hours.

– Many people have hypos while they are asleep and Many people have hypos while they are asleep and come to no harm. come to no harm.

Is there any evidence?Is there any evidence?

None that I could find.None that I could find.

Suggestion that 15g glucose results in a Suggestion that 15g glucose results in a rise of glucose by 2.1 mmol/l within 20 rise of glucose by 2.1 mmol/l within 20 minutesminutes

Some cases...Some cases...

23 T1DM23 T1DM– Poor controlPoor control– T1DMT1DM– Semi-planned pregnancySemi-planned pregnancy– Starts to tighten controlStarts to tighten control– Severe hypo and paramedics called outSevere hypo and paramedics called out

But didn’t bring patient back into hospitalBut didn’t bring patient back into hospital

......

34 Italian woman34 Italian woman– Accompanied by UncleAccompanied by Uncle– He’s not sleeping because she’s getting hypo He’s not sleeping because she’s getting hypo

all the timeall the time– Basal-bolus insulin (single figures)Basal-bolus insulin (single figures)

......

45 T1DM45 T1DM– Post DAFNEPost DAFNE– Getting hypo in the middle of the morning, Getting hypo in the middle of the morning,

afternoon and nightafternoon and night– HbA1c improved from 6.5% to 7.5%HbA1c improved from 6.5% to 7.5%

65 year old male65 year old male– Relatively motivatedRelatively motivated– Decision to improve controlDecision to improve control

Switch to basal-bolus analogue insulinSwitch to basal-bolus analogue insulin

– Admitted a week later with a severe Admitted a week later with a severe hypoglycaemic eventhypoglycaemic event

What about recurrent hypos?What about recurrent hypos?

HistoryHistory

Glucose diaryGlucose diary

ExaminationExamination

LifestyleLifestyle

What do you say to the patient?What do you say to the patient?

Options for disabling Options for disabling hypoglycaemiahypoglycaemia

CSIICSII– NICE: NICE: attempts to achieve target HbA1c

levels with multiple daily injections result in the person experiencing disabling hypoglycaemia.

Islet cell transplantsIslet cell transplants– NICE: NICE: In a few people, hypoglycaemia occurs

without warning (‘hypoglycaemia unawareness’), with life-threatening consequences.

Is it always a hypoIs it always a hypo

Case 1Case 1– 54 year old man54 year old man– Happened to come on to our ward at TorbayHappened to come on to our ward at Torbay– Lots of follow-up in gastro and neurology for Lots of follow-up in gastro and neurology for

collapses and seizures and recurrent episode collapses and seizures and recurrent episode of vomiting and being unwell. Erratic sugars.of vomiting and being unwell. Erratic sugars.

– Presumed to be hypo’s/hyper’sPresumed to be hypo’s/hyper’s– What is the diagnosis?What is the diagnosis?

Autonomic neuropathyAutonomic neuropathy

Symptoms:Symptoms:– PosturalPostural– GastricGastric– ErectileErectile

Signs:Signs:– Postural BPPostural BP– Beat-to-beat variability with valsalvaBeat-to-beat variability with valsalva