Transcript Insulin treated patients who recover quickly from hypoglycaemic

Hypoglycemia
Workshop
Hypoglycaemia and
its management
Dubai February 2014
Hypoglycaemia
• Formal definition
– Blood glucose <70-mg/dl
• Causes
– Too much insulin?
– Too little food?
– Unusual exercise?
• FOUR IS THE FLOOR
WHICH PATIENTS WITH HYPOGLYCAEMIA SHOULD BE
ADMITTED TO HOSPITAL FROM A & E FOLLOWING
HYPOGLYCAEMIC COMA?
• Insulin treated patients who recover quickly from
hypoglycaemic coma and who are otherwise well and able to
eat normally may not need to be admitted to hospital.
Admission is advised for:
– Any insulin treated patient who is slow to recover
– Large amounts of insulin injected in error or with suicidal intent
– Insulin treated patients who are drunk - alcohol may precipitate or
prolong hypoglycaemia
– Insulin treated patients with hypopituitarism, hypoadrenalism or
chronic renal failure
– Elderly patients on sulfonylureas
Clinical features of hypoglycaemia
Adrenergic symptoms
• Tachycardia
• Palpitations
• Tremor
Neuroglycopenia
• Faintness
• Feeling of hunger
• Headache
• Abnormal behaviour
• Anxiety
• Altered consciousness
• Sweating
• Eventually, coma
Flight or fright symptoms
Lack of glucose to brain
Hypoglycemia unawareness
Autonomic:
tremor, sweating,
hunger, heart
palpitations,anxiety.
Neuroglycopenic:
confusion, difficulty
concentrating, blurred
vision, weakness,
drowsiness, irritability.
COUNTER-REGULATORY MECHANISM ACTIVATED BY
HYPOGLYCAEMIA
Glucagon
release
Fall in blood
glucose
Vagal
stimulation
Parasympathetic
Adrenal
medulla
stimulation
Sympathetic
Neuroglycopenia
Stimulates
glycogen
breakdown in
liver
Adrenaline
release
HYPOGLYCAEMIC COMA IN DIABETIC PATIENT
IMMEDIATE MANAGEMENT
Hypoglycaemic reaction (‘hypo’) in a diabetic patient on insulin can result from excessive insulin dosage,
excessive exercise or decreased carbohydrate intake due to missed or delayed meal. It can also occur in
elderly patients due to sulfonylurea therapy
• Patient’s skin feels moist and sweaty
Diagnosis
• Reflexes may be brisk with extensor plantar response
• Confirm with plasma glucose <3 mmol/L
• If conscious, sugar or sweet drinks e.g. 75g glucose or 250mls lucozade
Treatment
• If drowsy, HYPOSTOP gel
• If unconscious:
• Glucagon* 1mg i.v., i.m. or s.c.
Restores consciousness in 10-15 mins
• 20ml 50% dextrose i.v.
and/or
Restores consciousness within 5 mins
Severe hypoglyceamia with no response to glucagon or dextrose - ? cerebral oedema
• high dose steroids e.g. 2 mg dexamethasone i.v. 4-6 hourly
• 200ml 20% mannitol over 20-30 mins
• high flow oxygen
• dextrose infusion 10% or 20%, 0.5 litre 2-4 hourly
• consider ITU for ventilation
* If hypoglycaemia is precipitated or associated with excess alcohol intake, glucagon may be ineffective as alcohol
blocks glycogenolytic action of glucagon
Hypoglycaemia: Treatment
Exercise
Diabetes
Equilibrium
Insulin
Diet
Sulphonylurea induced
hypoglycaemia
• Sulphonylureas cause release of insulin from the
pancreatic  cells
• Continued production of insulin without adequate
carbohydrate
HYPOGLYCAEMIA
• Check blood glucose to confirm hypoglycaemia
• Treatment iv dextrose
• May need prolonged infusion
Hypoglycemia
Glucose-lowering agents classified
by risk of hypoglycaemia in type 2
diabetes
High risk1
Low risk1,2
Insulin
Metformin
Sulphonylureas
α-glucosidase inhibitors
Meglitinides
Thiazolidinediones
GLP-1 receptor agonists
DPP-4 inhibitors
1. Nathan DM, et al. Diabetologia. 2009;52:17-306. 2. Cefalu WT. Nature. 2007;81:636-49.
UK Hypoglycaemia Group Study: Frequency
of Severe Hypoglycemia
50
Annual
prevalence of
severe
hypoglycemia
(%)
(Severe: requiring
external
assistance)
40
Type
Type
Type
Type
Type
2 DM Sulfonylureas (n = 103)
2 DM <2 years insulin (85)
2 DM >5 years insulin (75)
1 DM <5 years (46)
1 DM >15 years (54)
30
20
10
0
T2DM
SU
T2DM
< 2 yrs
T2DM
> 5 yrs
T1DM
< 5 yrs
T1DM
> 15 yrs
Error bars = 95% confidence intervals
Adapted from: UK Hypoglycaemia Study Group (2007) Diabetologia; 50: 1140
Holstein A et al. Exper Opin Drug
Holstein A et al. Exper Opin Drug Saf 2010
Holstein A et al. Exper Opin Drug Saf 2010
Morbidity of Hypoglycaemia in
Diabetes
Brain
Blackouts, seizures,
coma
Cognitive dysfunction
Psychological effects
Cardiovascular
Myocardial ischaemia
(angina and infarction)
Cardiac arrhythmias
Musculoskeletal
Falls, accidents (&
driving accidents)
Fractures, dislocations
Outcomes of Hypoglycaemia
DeSouza CV, et al. Diabetes Care 2010; 33: 1389.
75
240
70
220
65
200
60
180
55
160
50
140
45
120
40
100
0
R
R+30
R+60
R+90
Time from autonomic reaction (R) in minutes
Left ventricular ejection fraction
Cardiac output
Fisher et al (1987) Diabetologia; 30: 841
Hilsted et al (1984) Diabetologia; 26: 328
Cardiac output (% of basal)
Left ventricular ejection fraction (%)
Cardiac function during hypoglycaemia
OTHER POINTS TO NOTE RE PATIENTS
WITH HYPOGLYCAEMIC COMA
• Hypoglycaemia may cause hypothermia
• Hypoglycaemic fitting can cause vertebral and
occasionally long bone fractures
• Watch for ‘delayed’ hypoglycaemia due to
excessive exercise
KEY TEACHING POINTS
• Always consider hypoglycaemia in any person whose behaviour or
conscious level is abnormal.
• Hypoglycaemia can present with fitting.
• Even close colleagues may not be aware that the patient is on
insulin.
• Neurological signs will disappear quickly with correction of
hypoglycaemia.
• Prolonged hypoglycaemic coma can cause irreversible
neurological damage.