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Leaming Objectives

. ldentify the causes ol hypoglycemia

. Review the signs and symptoms of hypoglycemia

. ldentify the risks associated with hypoglycemia

. OLrtline strategies to prevent hypoglycemia

Definitions of Hypoglycemia
I*r _

. Whipple'striad: .

- Bymptome ol hypoglycemh
_ LtrPG
- Slmptom reliet with tr€atment
. Ho,t€\rer..-
- Somc patlenB with dhbebs may cxparionca symptoms of tm
BG with normal BG reeults by metar

- Nota[ patimt8 with dbbeEs expertmo symptoms ot

hypogryc.mb e\,3n wlth lil BG by motcr
 I

712512014

Hypoglycemia Unawareness

Definition

A reduction in the serum glucose

concentration with reduced or no
a uto n omi c warn ing sYmPtoms
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,, Classification of Hypoglycemia

. Symptomatic HypoglYcemia

- Charac,terized by a plasma glurce

<50 mgtrdL in association with typhal
adrenergic symptoms

Classif ication of Hypoglycemia

. Asymptomatic HypoglYcemia

- Plasma glucose <60 mg/dL not accompanied

by typical adrenergic symptoms

Classification of Hypoglycemia

. Severe Hypoglycemia

- An event requiring the assistance of another

person to actively administer carbohydrate,
glucagon or other resuscitatMe action
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Glassification of HYPoglYcemia

. Relative HYPoglYcemia

- An event during which the person with

diabetes reports symPtoms of hypoglycemia
that improves with ingestion of carbohydrate
but plasma glucce is >60 mg/dL

lnsulin tele reo

-----
Glucffe int.gduced -,+
intoboaY \
,/ glutme ?ntsrr {2115
Blood $uco!e {e!eit t:lt

,typt?l!{tmitr d!eei0P5

6lu{aqoo IPle}5!d
f arilieilegiii aitil iloimoilts le;ea5td

Signs and SymPtoms of

Hvooolvcemia in the Adult

99m Al0n
 Causec of Severe Hypoglycemia

. ]]ghtglycomlc contol . HyPoglycamb uDemffi

' R€cunsnthypog[camb . EndstagoR6nalDbaasc

. L6otglrcagpn r!spo{r!. to . Li/6r (&sas

hypoglyemb wlthh 5 Fars ot
TIDM dbgnotb Malnudtion

. AtianuationdEn, NE,grciilth . Alcohol ingestbnwithout

homons,cot0solt6ponr6 apploprhbf@d

. Aubnomlc naurop€thy

m:asM|h

Glucose Homeostatis

Studies in subiectswithout dtabetes who are made

hvomlvcemic
rriS r6#arch setting reveals that when

. PG approaches 80 mg/dl, endogenous rnsulrn secretpn

decreases

- PG d6lins to 6t70 mg/dl, glucagon and epinephrine

sretion rises
. PG d*lines to 5&55 mg/dl grov4h honnone secretion ,ses

. PG declin6 to < 60 mg/dl. cortisol *cretDn rises

90
&l Couls{gllldls
70 A1i6mlc syrp(ms
5a
NswogNycopenlc syrEms
50
40
30
Cma
20
10 Pernaort danagg
0 Dedl

5
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Approach to the
With Hypoglycemia

. t-'lypoglycemia is lhe leading limitingfaclor

in the glycemic managemanl of Tl & T2DltI

. lilo6tly related to insulin troatmsnl

. Urgenltreatment isoflen noc€ssary
. Blood should be drawn, whenever possible'
before the adminislralion of glucose.te allour
blood glucose documentation
. When lhe c'auses of trypoglycemia is obscure,
additional assays should include glucoae, insulin,
Gpeptide, cortisol, ethanol, and sutfonylurca level

to Address Hypoglycemia
1. Recognize aulonomic or neuroglycopenic symploms
t 1

iz. conrirm if possible totooYg2lucoce <6omg/dl)

3.
/'
Treat wiih 'fast sugar" (simple carbohydrate) (15 g) to
relieve symptoms

i4. Retest in 15 minutes to ensure the BG >4.0 mmolll and

, retreat (see above) it needed

r 5. Eai usual snack or meal due al that time of day or a

; snackurith 15 g carbohydrate plus prolein

Examplesof 15 g Simple Carbohydrate

' 15 g of glucose in lhe form of glucose

tablets
. 1 5 mL (3 teaspoons) or 3 packets of augar

dissolved in water og
. 175 mL (3/4 cup) of juice or regular soff
drink
. 6 Lifesavers (1=2.5 gof carbohydrate)
. 15 mL (1 tablespoon) o{ honeY
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Recognize Risk Factors for Severe

nft A"lo- ln IYP.2 Dl,

6hildrsn unabh b dstact and'or

Treatment of SEVERE Hypoglycemia in

Person

fr."t *itn oral Tast sugar" (simple Garbohydrale) i;;l"i I

I
i

v
Retest in 15 minutes to ensure lhe BG> 60
mg/dl
I

anO refreat wnn a further 15 g ofcarbohydrate

if 1

i
needed
< -,,
. Eat usual snack or meal due at that time ol day
or '

a snack wilh 15 g carbohydrate plus

prolein :

Treatment of SEVERE Hypoglycemia in

Person with lV Access
glucose
1. Treat with 1G25 g (2e50 co of D4Oo/o) of
intravenously over 1-3 minutes
J1
\,/ >60 mg/dl
2.
-' Retest in 3O minutes ld ensure the BG
rnJt ft""f *ilhafurlher D4O%25'5O ccort5gof
carbohYdrale if needl!
\-7
due at that
3.
-' Once conscious, eat usual snack or meal
plus
time ot Oay or a snack with 15 g carbohydrate
protein
 Recommendations f or Treatment

. Trcatment of hYPoglYcemia
(pbema glurce 60 mgddl) require ingestion
of glucose-carbohydrate-containing foods'

. The acute glycemic response conelates

befier with the glucose content than with
the carbohydrate content of the food'

Recommendations for Trcatment

. Afthough pure glucose isthe prefened

treatment, any form of carbohydrate that
contains glucose will raise blood glucose'
. Added fat may retard and then prolong
the acute glYcemic resPonse.

Recommendations for Treatment

Glucose (1S-20 g) is the prefened treatment for the

conscious individual with hypoglycemia
- lf SMBG 15 min after treatment shoitrs continued
hypoglyoemia, the treatment should be repeated'

- Once SMBG glucose returns to normal, the indMdual

should consume a meal or snack to prevent recunence
of hypoglycemia.
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Recommendations f or Treatment

. Glucagon (not availebE in lndonesia) should

be prescribed for
iii"iiaiilliia risk d severe hvposlvcemia' and
.l*ir!,i "i a;iti members of these indMduals should be
"isnificant
instructed in its adminbtration'

. lrdMduals with hypoglycsmia una /areness

zl episod6
;iJ;;hvp"slvderiiishould be advised to raise their
;i";;i;ffi;6i" stic-tlv avoid ftJrther hvposlvcemia for
:ffi ;;;;i r*l* to'partialtv rarerse nvpogl)'cetnia
unavrareness and educe risk cf fiJture episooes'

Pattern Management HYPoglycemia

a6te6.r4@r$t l! l!r%:vri'
'fid'.5v

Urgent Treatment

. lf neuroglycopenia precludes oral feeding'

parenteral therapy
is necessary'
by constant
- 25 I glucce l.v using 4096 eltrtion folbrred
infulion ol5 or 1o% dextr@ elution
lf i.v treatment i9 not Ptactiml, glucagon
s c or i m 6n be u*d
-
. Severe hypoglycemia should be treated using
emergency
glucagon kits
Those in cbffi contact with, or havlng custodial
t?* 9f'.Pl!
- use
*itt ttypogty""ri*prone dhbetes) should be instucted ln
of such kib.

. Glucaoon is inefiecti\E in glycogen'depleted

individuals and
may aiso stimulated insulin release )
less userul rn I luM
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Glucagon EmergencY Kit

Not available in lndonesia

Prevention of HYPoglYcemia

, Discontinue or reduce offending medication

. Treat underlying critical illnesses
. Promote hypoglycemia awareness in patients
treated with insulin or insulin secretagogues

. Patients with >1 episodes of severe

hypoglycemia may benefit from at least
short-term relaxation of glycemic targets'

Prevention of HYPoglYcemia

. Patient education:
- Symptoms
- Treatment
- Peak times for insulin (or oral agent action)
- Home glucose monitoring
 Prevention of HYPoglYcemia

. Adiust regimen for exercise or food intake:

- lnsulin-treated psti€nl: d€craaso prandial insulin
1-2 units for meals precedinglfollowing exercise

- Patient with insulin pump: program lemporary

2$50% roduction in bassl rate during exarcisa

- Patient treated with sulfonylurea: reduce dose'

exerciso in a.m. and tako lhe medication folloadng
exercise, OR snack before exeroising

Summary

. Mild hypoglycemia is a common complication of

therapy in patients with diabetes

. Severe hypoglycemia is a potentially preventable

complication of diabetes theraPy

- AdJusttherapy forglucose levels' meals, exercise

- Educate oatients about symPtoms
- Encourage patientsto always carry a glucose source
- Provide a glucagon kit with instructions

Case 1

Mr. Y., a 64-year-old man, was diagnosed with diabetes during

a medical checkup one week ago. After consulting with a friend
who also has diaretes, he stafted taking glybenclamide
5mg TlD.

After a long day at work, he did not eat dinner wlren he

got
home. ln the morning, his family found him unresponsive and
sw€ating profusely.

They immediately measured his blood glucose, found it to be

rt8 ms/dl, and took him - unconscious- to the nearest hospital
 7125120L4

Gase I Questions
. Whatis the petientb stdue?

. Whatis the pooeibb cause of hie hlpoglycemb?

. Ho,rr is hypoglycemia managed in the

hoapital se$ing?

. Whateducational materiale ehorH pu provide

tothe patienUpalient'e family?