Hypoglycemi for dm educators
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HYPOGLYCEMIA IN DIABETIC PATIENTS
FOR DIABETES EDUCATORS
DR. MOHAMMAD DAOUDCONSULTANT ENDOCRINOLOGIST
KAMC-NGHA JEDDAH
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HYPOGLYCEMIAOBJECTIVES
Basic physiologyDefinitions
Clinical PictureManagement
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HYPOGLYCEMIAFACTS
Carbohydrates (Glucose) are the first/ main calorie resource for our body
Extra CHO are stored as glycogen in liver and muscles Or shifted to fat
The Brain and RBCs .. only glucose as a fuel
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HYPOGLYCEMIADEFINITIONS
Hypoglycemia : “All episodes of an abnormally low plasma glucose concentration (w or w/o symptoms) that expose the
individual to harm”Low blood sugar, occurs when brain and body are
not getting enough sugar.
Hypoglycemia …. < 70 mg/dl (< 3.9 mmol/L)
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WHAT IS HYPOGLYCEMIA ?
For Non Diabetic patientGlucose value < 50 mg/dl (2.8mmo/L)
For Diabetic patientGlucose value < 70 mg/dl (3.9 mmo/L)
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HYPOGLYCEMIADEFINITIONS
Mild Hypoglycemia : Can be managed by patient him self
Severe Hypoglycemia : Need assistance /Hospital visit
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HYPOGLYCEMIAFACTS
The brain relies almost exclusively on glucose
So … Adequate uptake of glucose from the plasma is essential for
normal brain function and survival
Luckily …Very effective physiological and behavioral mechanisms
normally prevent or rapidly correct hypoglycemia
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HYPOGLYCEMIA – PATHO-PHYSIOLOGY
Glycogen Breakdown -Liver Increased Glucagon
Energy Fat Synthesis
Glycogen Synthesis
Glucose release to blood
(+) Pancreas secretion of Glucagon
Blood Glucose
Pool(+) Pancreas
secretion of Insulin
(+) Circulating Insulin
Uptake of glucose by cells
Decrease blood glucose
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HYPOGLYCEMIA
Counter-regulatory Hormones
Plasma glucose Response
65-70 mg/dl ( 3.6-3.9 mmol/L) Stop Insulin Secretion + Glucagon and Epinephrine
60-65 mg/dl ( 3.3-3.6 mmol/L) + GH <60 mg/dl ( 3.3 mmol/L) + Cortisol
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HYPOGLYCEMIACLINICAL CLASSIFICATION
Severe hypoglycemia = Requiring assistance
Documented symptomatic hypoglycemia = Symptoms + plasma glucose ≤70 mg/dL (3.9 mmol/L)
Asymptomatic hypoglycemia…Unawareness No typical symptoms but…Plasma glucose ≤70 mg/dL (3.9 mmol/L) …STOP !!
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HYPOGLYCEMIACLINICAL CLASSIFICATION
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 ?
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HYPOGLYCEMIA : S & S
Hyper-adrenergic Plasma Glucose < 70 mg/ dL (3.9 mmol/L)
Diaphoresis (Sweating) Tachycardia (Rapid heartbeat )/Palpitation
Anxiety Tremor /ShakingTachypnea Vomiting
Dizziness Hunger
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HYPOGLYCEMIA : S & S
Neuro-glycopenic Plasma Glucose < 50 mg/dL (2.8 mmol/L)
Slurred speech Cognitive impairment Inattention and confusion
Focal neurologic deficits SeizuresBehavioral/ Irritability/ Sudden moodiness
Change in personality Lack of coordination
Severe and prolonged hypoglycemiaLOC/Coma Irreversible brain injury
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HYPOGLYCEMIA
WHY DOES IT MATTER ?
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HYPOGLYCEMIA IT MATTERS …
The major limiting factor for achieving strict control in DM patients
Still , it is an expected price for adequate control
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HYPOGLYCEMIA IT MATTERS …
Bad impact on: Quality of life: Fear / Psych
Satisfaction
Compliance; to diet and Rx
Achieving proper targets ?
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HYPOGLYCEMIA IT MATTERS …
Disturbing S & S
-Anxiety / Embarrassment -Risk of accidents with impaired LOC
-Limitation of performance -Rebound /Reaction
-Weight gain ?
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HYPOGLYCEMIA …IS COMMON
Common ; up to 30- 60% in DM patientsType 1 > Type 2 …But !
Intensive DM control (lower HbA1c…?)Elderly
Duration of disease
Asymptomatic in 50% + …Unawareness !Nocturnal …very common !
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HYPOGLYCEMIA : SETTING / CAUSES
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SETTING FOR HYPOGLYCEMIA
Identification of the precipitating factors is important to prevent future events
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HYPOGLYCEMIASETTING
Common with Diabetics who are treated with
Insulin releasing pills (sulfonylureas, Meglitinides, or Nateglinide)
Insulin
Very unlikely with Lifestyle changes (TLC) only
Using alone medications like :( ex: Metformin ,DPP4I, GLP-1 + ,SGLT2 -)
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SETTING FOR HYPOGLYCEMIAFOOD INTAKE
Skipped or delayed meals(ex: Fasting Ramadan)
Vomiting after meal & meds intake
Mismatch:Wrong dose or too high a dose of medications
for the amount of food;Too little carbohydrate
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SETTING FOR HYPOGLYCEMIA
Unplanned / Excess exercisewithout snack / Rx adjustment
Excessive insulin / OHA dosesOrgan Failure Medications
Alcohol use
Identification of the precipitating factors is important to prevent future events
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Risk factors for hospital hypoglycemia
Reduction of oral intake Interruption of feeding/
New NPO statusReduction of of Dextrose-IVF
Eemesis
Others: Malignancy, infection, or sepsis.
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Risk factors for hospital hypoglycemia
Sudden reduction of corticosteroid dose
Altered ability of the patient to report symptoms
Rx Timing:Inappropriate timing of short- or rapid-acting insulin
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HYPOGLYCEMIACAUSES
Organ failure :
Renal Hepatic Cardiac
Endocrine Failure:
Adrenal GlucagonCortisol
Pituitary (ACTH/GH..)
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INSULIN EXCESS -ABSOLUTE OR RELATIVE
Excess insulin (Secretagogues) Doses, ill-timed /wrong type
Reduced exogenous glucose intake (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)
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HYPOGLYCEMIC UNAWARENESS
Longer duration of DM and Autonomic Neuropathy
The brain has a trigger point at which it leads to release stress hormones (Counter Regulatory Hormones)
With frequent low blood sugars, this set point gets reprogrammed to lower and lower blood sugar levels.
Stress hormones aren’t released until the blood sugar is dangerously low
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HYPOGLYCEMIC UNAWARENESS
What 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
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HYPOGLYCEMIAMANAGEMENT
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HYPOGLYCEMIA -MX
Prevention
Recognition and Treatment
Addressing underlying cause
Intervention to prevent recurrence
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HYPOGLYCEMIA MANAGEMENT
Prevention = Education
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HYPOGLYCEMIA-PREVENTION
Patient/care-giver education; Empower
Frequent self-monitoring of blood glucose (SMBG)
Flexible and rational insulin (and other drug) regimens
Individualized glycemic goals
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HYPOGLYCEMIA-PREVENTION
Medical alert identification
Keeping some sugar or sweet handy
Glucagon Emergency kit
Professional guidance and support.
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ADA-2015
7.5-8.5%
100-150
150-200
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A1C VS AVERAGE GLUCOSE
ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table 8
A1C (%) Mean plasma glucose mg/dl
6 120 ̴ 7 150 ̴ 8 180 ̴ 9 210 ̴ 10 240 ̴ 11 270 ̴ 12 300 ̴
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ADA – EASD Consensus:(June 2012)
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HYPOGLYCEMIA MANAGEMENT
Recognize & Treat
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HYPOGLYCEMIA RECOGNITION & TREATMENT
Recognize S & S
Document /Measure the glucose by finger stick If < 70 mg/dl…
Conscious Vs Unconscious patient/ unable to swallow
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Role of 15; Minutes/Gms
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HYPOGLYCEMIA TREATMENT
Conscious patientRapidly absorbed CHO ( glucose- or sucrose-
containing foods) orally
Unconscious patient/ unable to swallow IV dextrose orIM glucagon
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HYPOGLYCEMIATAKE CONTROL+ve mild symptoms
Check blood sugar - Take fast acting CHO
½ 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
3 dates
About 15-20 grams of glucose
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HYPOGLYCEMIATAKE CONTROL+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 (<70mg/dl)
Double Dose if getting lower
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If blood glucose is getting lower than base line
Double the amount
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HYPOGLYCEMIATAKE CONTROL
+ve severe symptoms :Call for help
Emergency IM glucagon by someone trained to do so (SC/ IM injection) of 0.5 to 1.0 mg
Recovery of consciousness within 10 to 15 minutes
Glucagon may cause nausea or vomitingCheck blood sugar
Don’t wait for the emergency personnel arrival
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HYPOGLYCEMIATAKE CONTROL
+ve severe symptomsPatients in the hospital
Give 15-20 g of 50% glucose (dextrose) intravenously
A subsequent glucose infusion (or food, if patient is able to eat) is often needed, depending upon the cause of the hypoglycemia
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ADA 2015 - HYPOGLYCEMIA
Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each
encounter. C
Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient,
and caregivers if low cognition and/or declining cognitionis found. B
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ADA 2015 - HYPOGLYCEMIA
Glucose (15–20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of CHO that
contains glucose may be used
15-minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated.
Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. E
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ADA 2015 - HYPOGLYCEMIA
Glucagon
Prescribe for all patients with increased risk of severe hypoglycemia
Keep it handy !!
Make sure about :Proper storage /Refrigerator/ No direct light /
Expiration date
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ADA 2015 - HYPOGLYCEMIA
Glucagon
Caregivers or family members (not limited to health care professionals)
Should be instructed on its proper mixing and administer immediately
Glucagon can cause vomiting Risk of aspiration when unconscious
Keep patient on his side
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ADA 2015 - HYPOGLYCEMIA
Hypoglycemia unawareness or one or more episodes of severe hypoglycemia
should trigger reevaluation of the treatment regimen. E
Action: Raise their glycemic targets
to avoid further hypoglycemia for at least several weeks Aiming to partially reverse hypoglycemia unawareness and reduce
risk of future episodes. A
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HYPOGLYCEMIA MANAGEMENT
Address Underlying Cause / Setting&
Intervene to Prevent Recurrence
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HYPOGLYCEMIA MANAGEMENT
Verify etiology & Prevent
Diet Medication
Safe activities Precautions : ID
Be equipped :CHO /Glucagon…..
Educate …Educate …Educate
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Risks associated with FASTING in patients with diabetes
Diabetes Care, volume 28, NUMBER 9, September 2005
1. Hypoglycemia
2. Hyperglycemia : DKA / HHS
3. Dehydration and thrombosis
4. Hospitalizations
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DM and FastingBGM
Frequent monitoring of glycemia: esp. in the first few days esp. with Insulin use or insulin secretagogues
To verify Safe DM control:Early morning , noon ,late afternoon , before sunset
To verify Adequate DM control:After Iftar , late night and before Sohour
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Nutrition in RamadanAim to not overeat
-Healthy and balanced diet-Avoid large quantities of fried foods and CHO-meals
- Sohour (pre-dawn meal): - Delay as late as possible - Use “complex” carbohydrates
-Aim at maintaining a constant body mass
- Plenty of fluid during non-fasting hours
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TAKE HOME MESSAGES
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HYPOGLYCEMIATAKE HOME MESSAGES
All episodes of an abnormally low plasma glucose that expose the individual to harm) ;
PG <70 mg/dL (3.9 mmol/L)
Occurs in both type 1 DM and patients with type 2 DM (Insulin and SU …highest risk)
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HYPOGLYCEMIATAKE HOME MESSAGES
Hypoglycemia can occur at any level of glycemic control / HbA1c level ,
but the risk increases with more intensive therapy
It is a major limiting factor for intensive DM control
Hypoglycemia : Cost / M &M
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HYPOGLYCEMIATAKE HOME MESSAGES
Know the risk factors /setting
Beware of nocturnal , exercise-induced and unawareness forms
Treat and try to prevent recurrence
Educate your self , your patients and their families
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سكر اآلنسة
https://www.youtube.com/watch?v=Ao9iNysZG2g
لالطفال ... فلم السكر
https://www.youtube.com/watch?v=jkQoQxJubJg