April 19, 2016 - Hypoglycemia in Diabetes Flashcards
Acanthosis Nigricans
Can be a physical exam finding of excess insulin.

Typical Presentation of DM1
The 3 “P’s” - polyuria, polydipsia, polyphagia
Unexplained weight loss
Fatigue
+/- Blurred vision
+/- Candidiasis
Ketoacidosis (10-20%)
HbA1C
A long-term management tool used to look at how much sugar has coated the hemoglobin molecules in the blood.
This is NOT indicated at diagnosis.
Laboratory Investigations for Diabetes in Children
In the office, you should use a urine dip to test for glucose and ketones as well as measuring the meter glucose.
In the lab, you should do urinalysis R & M (routine and microscopy). Do a serum random glucose. Do serum electrolytes. Consider doing a blood gas.
Physical Exam (Diabetes less than 5 years)
Height / weight percentiles
Blood pressure and pulse
Thyroid palpation (hypothyroidism is fairly common in DM1)
Insulin injection sites (lipohypertrophy / lipoatrophy)
Other autoimmune diseases

Physical Exam (Diabetes longer than 5 years)
Fundi
Foot care (circulation, pulses, light touch with 10g monofilament, vibration senses, tendon reflexes)
HbA1C Targets
Non-diabetic = 4.3-6.1%
Adults < 7.0%
Young Kids < 8.5%
When to Initiate Complication Screening
Duration of diabetes > 5 years
AND
Chronological age > 15 years
OR
Abnormal foot/nuero exam, abnormal albumin/creatinine ratio, or abnormal eye exam
Insulin Formulations
Very short-acting analogs (5m, 1h peak, 4h duration)
Short-acting “regular” analogs (30m, 3-4h peak, 7-8h duration)
Intermediate-acting analogs (2h, 7-8h peak, 12-16h duration)
Long-acting, “flat-ish” analogs (2h, no peak, 18-24h duration)
These have modified side-chains that allow it to escape at different rates from the subcutaneous tissue. Regardless of the type of insulin, if you administer it through an IV, it will be a very short acting analog because it gets into circulation immediately.
Basic Insulin Regimens
Usually a long-acting insulin to maintain a steady level of insulin
COMBINED WITH
Short-acting insulin at meals to combat blood glucose
Insulin/Carb Ratio
Modified for each person based on their resistance profile, but important to know.
For a toddler, it might be 1 unit for 30g of carbs
For an overweight teenager, it might be 1 unit for 3g of carbs
Classic Triad for Hypoglycemia
- Autonomic or neuroglycopenic symptoms
- Low plasma glucose level
- Relief of symptoms with administration of carbohydrates
Symptoms of Hypoglycemia
Headache
Sweatiness
Blurry vision
Ringing in the ears
Increased heart rate
Hunger
Trembling
Feeling anxious
Irritability
Weakness or tiredness
Physiologic Response to Hypoglycemia
At a sugar reading of 4… decreased insulin secretion
At a reading of 3.5… secretion of glucagon is triggered by a decrease in insulin which increases glycogenolysis and gluconeogenesis in the liver
At a reading of 3.0… secretion of epinephrine which further increases glycogenolysis, further increases gluconeogenesis, and decreases peripheral glucose uptake
At a reading of 2.5… secretion of growth hormone and cortisol as a last-ditch effort but really are too late to help
Getting “Too Many Lows”
Getting too many episodes of hypoglycemia can blunt your body’s response to getting symptoms. Your body gets a less dramatic counter-regulatory response, and oftentimes symptoms won’t even appear until the blood sugar is dangerously low and about to go into a coma.
This is known as hypoglycemia unawareness in which the threshhold for autonomic symptoms becomes lower thanthe threshold for neuroglycopenic symptoms.
Hypoglycemia Unawareness
When a patient consistently experiences too many lows and their body becomes blunted to the counter-regulatory response.
When a patient is hypoglycemically unaware, the threshhold for developing autonomic symptoms (which would allow them to realize their blood sugar is low) becomes lower than the threshold for neuroglycopenic symptoms.
Relationship Between HbA1C and Hypoglycemia
An inverse relationship
The better control of your HbA1C, the higher risk you are for developing complications relating to hypoglycemia.

Risk Factors for Severe Hypoglycemia
In DM1 Patients…
Adolescence, children unable to detect or treat mild hypoglycemia, HbA1C <6.0%, long duration of diabetes, prior episodes of severe hypoglycemia, hypoglycemia unawareness, and autonomic neuropathy
In DM2 Patients…
Elderly, poor health literacy, food insecurity, increased HbA1C, duration of insulin therapy, seere cognitive impairment, renal impairment, and neuropathy.
Treatment of Hypoglycemia
For mild and moderate hypoglycemia, administer 15 grams of carbohydrates orally (preferably glucose tablets) and wait 15 minutes to retest them before administering another treatment.
For severe episodes of hypoglycemia, if they are conscious, administer 20 grams of oral carbohydrates. If unconscious, administer 1mg of glucagon OR 10-25 grams of IV glucose. Hospitalization is not required but should be discussed.
Hypoglycemia and Driving
Potential harm to the individial and to others (this is an issue of public safety vs. individual rights).
Exclusion criteria for commercial driving includes any severe hypoglycemic episode in the last 2 years, hypoglycemia unawareness, HbA1C > 2x normal, more than 10% of blood glucose values less than 4 mmol/L, or inadequate self-monitoring.
Safe blood glucose prior to driving is > 5 mmol/L
Need to re-check blood glucose every 4 hours of continuous driving and carry simple carbohydrate snacks.