References

1.Yale J-F, Begg I, Gerstein H, et al. 2001 Canadian Diabetes Association clinical practice guidelines for the prevention and management of hypoglycemia in diabetes. Can J Diabetes, 2002; 26:22-35. 2. Meltzer S, Leiter L, Daneman D, et al. 1998 clinical practice guidelines for the management of diabetes in Canada. CMAJ.1998;159 (Suppl 8):S1-S29.

UPDATE ON

Prevention Management of Hypoglycemia in Diabetes

HIGHLIGHTS FOR HEALTHCARE PROFESSIONALS

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This document highlights key messages, revised recommendations and new recommendations from the 2001 Canadian Diabetes Association Clinical Practice Guidelines for the Prevention and Management of Hypoglycemia in Diabetes.(1) Readers are referred to the complete guideline document for evidence-based grading, complete references and exact wording.
Denitions Severe hypoglycemia

The denition of hypoglycemia continues to be debated, but can be classied as: Mild: autonomic-mediated symptoms, patient can self-treat (blood glucose 4.0 mmol/L); Moderate: autonomic and neuroglycopenic-mediated symptoms, patient can self-treat; Severe: patient may be unconscious or require assistance (blood glucose < 2.8 mmol/L).
Incidence and causes

Major risk factors for severe hypoglycemia include: prior episode of severe hypoglycemia, current low HbA1c, hypoglycemia unawareness, long duration of diabetes, and autonomic neuropathy. Severe episodes are reported to occur mostly at night. Adolescents are found to have a higher incidence of nocturnal hypoglycemia.To reduce the risk of asymptomatic nocturnal hypoglycemia patients on intensive insulin therapy should periodically monitor overnight blood glucose levels at a time that corresponds to the peak action of their overnight insulin. The potential long-term complications of severe hypoglycemia are mild intellectual impairment and permanent neurologic sequelae. Research indicates a more consistent negative effect in children, especially those under age 5, exacerbated by early onset of diabetes.These children are more likely to have frequent episodes of hypoglycemia.

The incidence of hypoglycemia with the use of antihyperglycemic agents is probably underestimated, occurring in up to 20% of patients. Sulfonylureas, repaglinide and/or combination therapy increases the risk of hypoglycemia, so patient education is essential. Reports that 85% of hypoglycemic episodes are related to self-care activities (such as less food, more insulin, and more activity) stress the need to educate patients, on both traditional and intensive therapies, to make appropriate adjustments based on blood glucose levels. Patients on lispro insulin are at higher risk of exercise-induced hypoglycemia,and must be educated on prevention.

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Treatment

Revised Recommendations

Little evidence is available to support the widely recommended treatment of 10 g of fast-acting CHO. Newer research suggests that 15 g of glucose (monosaccharide) is required to produce a blood glucose rise of approximately 2.1 mmol/L within 20 minutes.Twenty grams (20 g) oral glucose will produce a glucose rise of approximately 3.6 mmol/L at 45 minutes. Milk and orange juice are slower to raise blood glucose levels. Glucose gel is quite slow less than 1 mmol/L rise at 20 minutes and must be swallowed to have a signicant effect.There is no evidence to support the practice of administering glucose gel buccally, since absorption through the mucosa is minimal, if any.
New Recommendations

Mild to moderate hypoglycemia should be treated with 15 g of carbohydrate, preferably as glucose or sucrose tablets. In smaller children,10 g of glucose may be used initially. Severe hypoglycemia in a conscious person should be treated with 20 g of carbohydrate, preferably as glucose tablets or equivalent. Retreat with another 15 g glucose if blood glucose remains < 4.0 mmol/L after 15 minutes. Severe hypoglycemia in an unconscious person in the home situation should be treated with 1 mg glucagon subcutaneously or intramuscularly. In children 5 years of age or younger, a dose of 0.5 mg should be used. For severe hypoglycemia with unconsciousness, IV glucose, 10 to 25 g (20 to 50 cc D50W) given over 1 to 3 minutes, is the standard medical and paramedical treatment. Once hypoglycemia is reversed, the person should have their usual meal or snack.A snack including 15 g of carbohydrate and a protein source is recommended if a meal is more than 1 hour away and in the absence of complicating factors. A PRN order for glucagon should be considered for any hospitalized patient at risk for severe hypoglycemia.

To ensure integration, the numbering system below refers to the numbered recommendations in the 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada.(2) The following are highlights of revised recommendations.Unchanged recommendations are not included. Readers are referred to the 1998 guidelines and hypoglycemia guidelines for evidence-based grading and complete wording.

Aspart/Lispro insulin has been associated with lower rates of hypoglycemia compared to human regular insulin. Patients experiencing frequent hypoglycemic episodes on regular insulin should be tried on rapidacting insulin analogues. (Recommendation #36) Extreme caution is required to avoid hypoglycemia in children age 5 years or less because of the permanent cognitive decit that may occur in this age group. (Recommendation #41) Gliclazide may be preferred over glyburide if a sulfonylurea is to be used, as it is associated with a reduced frequency of hypoglycemic events compared to glyburide. (Recommendation #48)

General advice regarding physical activity includes: - for those on insulin or insulin secretagogues, ingest rapidly absorbed carbohydrate if preexercise glucose level is < 5 mmol/L - for those on insulin injections, administer insulin into a site away from the most actively exercising extremities. (Recommendation #30)

The full document contains 16 new recommendations focused on insulin use in type 1 diabetes and treatment of hypoglycemia.
Highlights include:

Strategies to reduce the risk of nocturnal hypoglycemia. Identication of risk factors for severe hypoglycemia and strategies to prevent hypoglycemia. Strategies for individuals with hypoglycemia unawareness.

Meformin should be considered as initial therapy for obese patients with type 2 diabetes.To avoid unnecessary hypoglycemia, metformin, alpha-glucosidase inhibitors and/or thiazolidinediones should be considered before using the insulin secretagogues (sulfonylureas and meglitinides) in patients at high risk of hypoglycemia. (Recommendation #32)