April 19, 2016 - Hypoglycemia in Diabetes

Question 1

Acanthosis Nigricans

Answer 1

Can be a physical exam finding of excess insulin.

Question 2

Typical Presentation of DM1

Answer 2

The 3 “P’s” - polyuria, polydipsia, polyphagia

Unexplained weight loss

Fatigue

+/- Blurred vision

+/- Candidiasis

Ketoacidosis (10-20%)

Question 3

HbA1C

Answer 3

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.

Question 4

Laboratory Investigations for Diabetes in Children

Answer 4

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.

Question 5

Physical Exam (Diabetes less than 5 years)

Answer 5

Height / weight percentiles

Blood pressure and pulse

Thyroid palpation (hypothyroidism is fairly common in DM1)

Insulin injection sites (lipohypertrophy / lipoatrophy)

Other autoimmune diseases

Question 6

Physical Exam (Diabetes longer than 5 years)

Answer 6

Fundi

Foot care (circulation, pulses, light touch with 10g monofilament, vibration senses, tendon reflexes)

Question 7

HbA1C Targets

Answer 7

Non-diabetic = 4.3-6.1%

Adults < 7.0%

Young Kids < 8.5%

Question 8

When to Initiate Complication Screening

Answer 8

Duration of diabetes > 5 years

AND

Chronological age > 15 years

OR

Abnormal foot/nuero exam, abnormal albumin/creatinine ratio, or abnormal eye exam

Question 9

Insulin Formulations

Answer 9

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.

Question 10

Basic Insulin Regimens

Answer 10

Usually a long-acting insulin to maintain a steady level of insulin

COMBINED WITH

Short-acting insulin at meals to combat blood glucose

Question 11

Insulin/Carb Ratio

Answer 11

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

Question 12

Classic Triad for Hypoglycemia

Answer 12

1. Autonomic or neuroglycopenic symptoms
2. Low plasma glucose level
3. Relief of symptoms with administration of carbohydrates

Question 13

Symptoms of Hypoglycemia

Answer 13

Headache

Sweatiness

Blurry vision

Ringing in the ears

Increased heart rate

Hunger

Trembling

Feeling anxious

Irritability

Weakness or tiredness

Question 14

Physiologic Response to Hypoglycemia

Answer 14

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

Question 15

Getting “Too Many Lows”

Answer 15

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.

Question 16

Hypoglycemia Unawareness

Answer 16

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.

Question 17

Relationship Between HbA1C and Hypoglycemia

Answer 17

An inverse relationship

The better control of your HbA1C, the higher risk you are for developing complications relating to hypoglycemia.

Question 18

Risk Factors for Severe Hypoglycemia

Answer 18

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.

Question 19

Treatment of Hypoglycemia

Answer 19

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.

Question 20

Hypoglycemia and Driving

Answer 20

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.