hypoglycaemia

Question 1

most common SE of the following 2 drugs

Answer 1

insulin
SUs

Question 2

5 drugs that are unlikely to result in hypo when prescribed without insulin or SUs

Answer 2

metformin
pioglitazone
DDP4 inhibitors (gliptins)
SGLT2i inhibitors (flozins)
GLP1 receptor agonists (-tide)

Question 3

treatment of adults with symptoms of hypo who have BGC of >4mmol/L

Answer 3

small carb snack e.g. slice of bread or normal meal if due

Question 4

treatment of adult with BGC <4mmol/l with or without symptoms who is conscious and able to swallow

Answer 4

treat with fast acting carbohydrate by mouth

• lift glucose liquid
• glucose tabs
• glucose 40% gel (e.g. glucogel, dextrose gel, rapilose)
• pure fruit juice
• sugar dissolved in appropriate volume of water

Question 5

what type of forms are preferred in treatment of hypo and why

Answer 5

oral glucose forms because absorption occurs more quickly

Question 6

Treatment of hypoglycaemia in pt with BGC <4 with or without symptoms who are conscious and able to swallow need to be treated with a fast acting carbohydrate by mouth. This can include pure fruit juice.

However, avoid orange juice in the following people…

Answer 6

people following low potassium diet due to CKD

Question 7

Treatment of hypoglycaemia in pt with BGC <4 with or without symptoms who are conscious and able to swallow need to be treated with a fast acting carbohydrate by mouth. This can include sugar dissolved in appropriate volume of water.

However avoid sugar dissolved in water in the following pt

Answer 7

pt taking acarbose because this prevents the breakdown of sucrose to glucose

Question 8

Why should you avoid choc and biscuits if possible in pt who are being treated for hypo

Answer 8

they have lower sugar content and their high fat content can delay stomach emptying

Question 9

How many times can you repeat treatment for hypo

Answer 9

If necessary repeat treatment after 15 minutes up to a maximum of three treatments in total

Question 10

Once BGC is above 4 and the patient has recovered, will they need further treatment

Answer 10

Yes

Give a snack providing long acting carbohydrate to prevent blood glucose from falling again

Question 11

Once BGC is above 4 and the patient has recovered, give a snack providing long acting carbohydrate to prevent blood glucose from falling again.

What can this include

Answer 11

2 biscuits
1 slice of bread
200-300ml of milk (NOT soya or other forms of alt milk e.g. almond, cocunut)
Normal carb containing meal if due

do not omit insulin dose but dose regimen may need review

Question 12

define hypoglycaemia which does not respond

Answer 12

BGC that remains below 4 after 30 to 45 minutes or after three treatment cycles

Question 13

treatment of hypoglycaemia which does not respond (2)

Answer 13

IM Glucagon
Glucose 10% IV infusion

Question 14

treatment of hypoglycaemia which does not respond in alcoholic pt

Answer 14

Thiamine supplementation should be given with, or following, the administration of IV glucose to minimise the risk of Wernicke’s encephalopathy.

Question 15

what is glucagon and how does it work

Answer 15

polypeptide hormone produced by the alpha cells of the islets of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the liver

Question 16

Glucagon is ineffective in the following pt, therefore DO NOT GIVE

Answer 16

ineffective in patients whose liver glycogen is depleted, therefore should not be used in anyone who has fasted for a prolonged period or has adrenal insufficiency, chronic hypoglycaemia, or alcohol-induced hypoglycaemia

Question 17

Treatment of hypoglycaemia that does not respond in patient who takes a SU and why

Answer 17

Glucagon IM may also be less effective in patients taking a sulfonylurea; in these cases, intravenous 10% glucose will be required.

Question 18

In an emergency, if the patient has a decreased level of consciousness caused by hypoglycaemia, what can be given by a family member or friend

Answer 18

IM glucagon can be given by a family member or friend who has been shown how to use it.

If glucagon is not effective after 10 minutes, glucose 10% intravenous infusion should be given.

Question 19

when is hypoglycaemia an emergency

Answer 19

when it causes unconsciousness

Question 20

Hypoglycaemia which causes unconsciousness is an emergency. Patients who are unconscious, having seizures, or who are very aggressive, should have the following treatment

Answer 20

STOP any IV insulin

Treat initially with glucagon

If glucagon IM unsuitable (e.g. adrenal insufficiency, taking SU, alcohol induced hypo, fasted for long period of time, chronic hypoglycaemia) or if no response after 10mins, give glucose 10% IV infusion or alt glucose 20% IV infusion

Question 21

why is glucose 50% IV infusion not recommended

Answer 21

it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult.

Question 22

Once the patient has recovered, a long acting carb should be given ASAP and their BGC is above 4. (e.g. 2 biscuits, 1 slice of bread, 200-300ml milk that is not soya or alt forms of milk, or normal carb containing meal if due)

However, what is treatment in people who have received glucagon?

Answer 22

They need larger portion of LA carb to replenish glycogen stores

4 biscuits
2 slices bread
400-600ml milk
normal carb containing meal if due

Question 23

What must be given to pt who are nil by mouth

Answer 23

glucose 10% IV infusion

Question 24

after hypo, what should patients do who self manage their insulin pump

Answer 24

may need to adjust their pump infusion rate

Question 25

monitoring of hypoglycaemia caused by SU or LA insulin (degludec, detemir, glargine)

Answer 25

Hypoglycaemia caused by a sulfonylurea or long-acting insulin, may persist for up to 24–36 hours following the last dose, especially if there is concurrent renal impairment.

Blood-glucose monitoring should be continued for at least 24–48 hours.

Question 26

diabetic hypoglycaemia in the community - fast acting carb doses to give in adults

(5)

Answer 26

• 15-20g oral glucose liquid
• 4-5 glucose tabs
• 1.5-2 tubes of 40% oral gel
• 150-200ml pure fruit juice
• 3-4 heaped teaspoonfuls of sugar dissolved in appropriate volume of water

can be repeated after 15 mins if necessary up to 3 times before considered hypoglycaemia that does not respond, which will then require IM glucagon or IV glucose 10% infusion

Question 27

diabetic hypoglycaemia in the community - fast acting carb doses to give in adults via buccal administration if they are conscious but uncooperative

Answer 27

15-20g (1.5-2 tubes) glucose 40% oral gel, repeat after 15 mins if necessaey

Question 28

dose of glucagon IM 1mg/ml injection in children and adults

Answer 28

• 8 years and below, or body weight up to 25kg = 500mcg (0.5ml)
• 9-17 or body weight 25kg and over: 1mg (1ml)
• adult: 1mg (1ml)

Question 29

this is indicated for chronic hypoglycaemia

hint Nafisa

Answer 29

diazoxide