Hypoglycemia

Question 1

Define Hypoglycemia

Answer 1

Abnormally low plasma glucose that exposes the patient to potential hard

Question 2

Common Precipitating Factors Found

Answer 2

 Meal-related problems (not eating enough or skipping meals)
 Wrong insulin product administered (long vs rapid)
 Wrong dose or confuse dosing units

Question 3

Pathophysiology

Answer 3

o Decreased glucose acting on the pancreas and the CNS
o Pancreas is going to sense the glucose and decrease insulin secretion and increase glucagon
o CNS is going to release acetylcholine and epinephrine
o Adrenal medulla is going to increase epinephrine
o All working together to increase glucose

Question 4

Neurogenic Symptoms

Answer 4

Through the autonomic nervous system
Patient tends to recognize
Catecholamine and cholinergic symptoms

Question 5

Catecholamine Symptoms

Answer 5

AKA sympathetic
Shakiness/tremor
Palpitations
Anxiety/arousal

Question 6

Cholinergic Symptoms

Answer 6

AKA parasympathetic
Sweating
Hunger
Parasthesia

Question 7

Neuroglycopenic Symptoms

Answer 7

Via brain glucose deprivation
Family tends to recognized
•	Warmth
•	Weakness/fatigue
•	Difficulty thinking/confusion
•	Behavioral changes
•	Mood swings
•	Seizures/loss of consciousness
•	Coma
•	Brain damage and death with severe prolonged hypoglycemia

Question 8

Causes of Hypoglycemia

Answer 8

o Too much insulin
o Exogenous glucose decrease (meal size, missed meal, overnight fasting)
o Endogenous glucose decrease (alcohol)
o Increased use of glucose (exercise)
o Increased insulin sensitivity (weight loss, exercise)
o Decreased insulin clearance (renal disease)

Question 9

Define Relative Hypoglycemia

Answer 9

Patient’s weight higher A1c may perceive hypoglycemia at higher plasma glucose levels
- Takes 2-4 weeks to readjust

Question 10

Define Hypoglycemia Unawareness

Answer 10

Reduce sympathoadrenal response caused by recent hypoglycemia or diet and exercise

Question 11

Hypoglycemia Unawareness Occurs more frequently in those who:

Answer 11

Have hypoglycemia often
Have long-term diabetes
Tightly controlled diabetes

Question 12

Strategies for Preventing Hypoglycemia

Answer 12

Patient education (signs/symptoms, proper administration, appropriate SMBG)
Dietary Interventions
Medication adjustments
Exercise Management
Patient instructions regarding administration times

Question 13

Exercise Management

Answer 13

 Test before and after
 If BG less than 100 → pre-treat with 1 carb serving
 Avoid exercise if BG > 250 + ketones
 Use caution if BG > 300 without ketones

Question 14

Questions to Ask

Answer 14

 Do they recognize the symptoms of hypoglycemia
 Frequency, timing and treatment
 What level prompts low symptoms
 Physical activity
 Meal timing (how often and how long between meals)
 Medication timing
 Recent Illness

Question 15

Insulin Counseling Point

Answer 15

o Take medications at the appropriate time
o Always eat when taking bolus insulin
o Take before eating!
o Avoid alcohol on an empty stomach
o Always inform your health care provider of any new medications
o Always inform your health care provider before starting a new exercise regimen
o Anytime a BG level is low or symptoms occur, record BG level, timing/quantity of food, activity changes, symptoms

Question 16

Rule of 15

Answer 16

• Consume 15-20 grams of glucose or simple carbohydrates
• Recheck your blood glucose after 15 minutes
• If hypoglycemia continues, repeat
• Once blood glucose returns to normal, eat a small snack if your next planned meals or snack is more than an hour or two away

Question 17

Good Options for 15 grams of Carbs

Answer 17

3-4 glucose tablets
Glucose gel tube
1/2 cub of juice or regular soda
8 ounces of nonfat or 1% milk
1 tablespoon sugar, honey or corn syrup
4-5 hard candies
2 tablespoons of raisins

Question 18

Things NOT to use for Carbs

Answer 18

Diabetic or sugar-free bars/drinks
High fat food (candy bars, cookies, cake)
Alcohol (causes hypoglycemia or mask symptoms)

Question 19

What do you do after the Rule of 15?

Answer 19

•	Patient should have a snack after hypoglycemia is resolved consisting of carbohydrate + protein
o	½ peanut butter sandwich
o	4 peanut butter crackers
o	4 crackers with cheese or
o	8 ounces of milk

Question 20

How do you treat SEVERE hypoglycemia?

Answer 20

• Use glucagon when the patient is unconscious or in a state of stupor
• 1 mg given IM via an emergency kit
• Inject into the patient’s buttock, arm, or thigh
• When the patient regains consciousness (5-15minutes), they may experience N/V
• If patient does not respond within 15 minutes, call 911
• DO NOT GIVE ORAL GLUCOSE TO AN UNCONCIOUS PATIETN DUE TO RISK OF ASPIRATION!!

Question 21

Hypoglycemia Counseling Points

Answer 21

 Always carry a source of sugar
 Treat all glucose levels less than 70 mg/dL regardless of presence of symptoms
 If more than 1-2 episodes occur within a week, patients should contact their provider
 In the long-term symptoms can change
 Patients should always be aware of all types of symptoms

Question 22

Microvascular Complications

Answer 22

Retinopathy
Neuropathy
Nephropathy

Question 23

Diabetic Retinopathy

Answer 23

Most common
Initially asymptomatic
Causes blindness

Question 24

Diabetic Retinopathy Screening

Answer 24

• Dilated and comprehensive eye exam should occur: within 5 years after onset of T1 and shortly after diagnosis of T2
• If normal, repeat in 2 years
• If abnormal, re-examine in 1 year

Question 25

Diabetic Nephropathy

Answer 25

Causes Renal failure
Marker of CVD
Defined as persistent albuminuria > 30mg/24 hours

Question 26

Diabetic Nephropathy Screening

Answer 26

Annually via a 24-hour urine collection or a spot measurement
Confirm: 2 out of 3 abnormal results within 3-6 months

Question 27

Diabetic Nephropathy Treatment

Answer 27

• ACEi decrease the risk of microalbuminuria and delay the progress of micro → macroalbuminuria
• Dyslipidemia and smoking cessation

Question 28

Peripheral Neuropathy leads to

Answer 28

Pain
Foot ulcer
Amputation

Question 29

Autonomic Neuropathy leads to

Answer 29

Hypoglycemia unawareness
Urinary incontinence
Erectile dysfunction
Orthostatic hypotension

Question 30

Chronic Hyperglycemia Leads to

Answer 30

Loss of myelinated and unmyelinated fibers, degeneration and blunted nerve-fiber reproduction

Question 31

Chronic Sensorimotor Distal Symmetric Polyneuropathy Shows As:

Answer 31

Burning, tingling, numbness, electrical pain

May worsen at night

Question 32

Diabetic Neuropathy Screening

Answer 32

Diabetic Neuropathy Physical Exam to reveal sensory loss to light touch, vibration and temperature
ANNUALLY

Question 33

Diabetic Neuropathy Prevention

Answer 33

• Tight glycemic control
• Smoking cessation
• Regular foot care by patient and providers
• Adequate cleaning
• Inspection for abnormalities
• Proper nail trimming and callus debridement
• Wearing socks/shoes at all times
• Appropriately fitted shoes

Question 34

Diabetic Neuropathy Treatment

Answer 34

Control Symptoms and Prevent Worsening
• FDA approved: duloxetine, pregabalin, tapendatol
• Non-FDA approved: gabapentin, TCA, venlafaxine, valproate, opioids, etc

Question 35

What drugs requires renal adjustment?

Answer 35

Gabapentin and Pregabalin