Hypoglycaemia

Introduction

• Blood glucose < 5 mmol/L (63 mg/ dL)) in diabetes
• In most circumstances from insulin therapy,
• Less frequently from use of oral insulin secretagogues such as sulphonylurea drugs,
• Rarely with other anti-diabetic drugs.
• This is the most common complication of insulin therapy
• Severe hypoglycaemia can have serious morbidity
• It has a mortality of up to 4% in insulin-treated patients. 

Clinical features

Symptoms 

Develop when the blood glucose level falls below 3 mmol/L

Typically develop over a few minutes,

Presentations :  due to adrenergic drive.

• Sweating,
• Tremor
• Palpitation
• Hunger
• Drowsiness
• Confusion
• Speech difficulty 

Signs

• Pallor
• Altered behaviour
• Altered consciousness
• Convulsions (Occasionally)
• (Even) hemiparesis can occur (that resolves when glucose is administered.)P 

Nocturnal hypoglycaemia 

This is a particular problem as hypoglycaemia does not usually waken a person from sleep

Patients may describe

• poor quality of sleep,
• morning headaches and
• vivid dreams or nightmares,

Or a partner may observe

• profuse sweating,
• restlessness,
• twitching or even seizures 

The problem may be helped by the following:

1. Taking a bedtime snack regularly
2. Patients taking twice-daily mixed insulin can separate their evening dose and take the intermediate insulin at
3. bedtime rather than before dinner
4. Reducing the dose of soluble insulin before dinner
5. since the effects of this persist well into the night
6. Changing to a rapid-acting insulin analogue, with a
7. long-lasting insulin analogue at night. 

Common causes and risk factors of Hypoglycaemia in diabetes 

1. Missed, delayed or inadequate meal
2. Unexpected or unusual exercise
3. Poorly designed insulin regimen, particularly if predisposing to nocturnal hyperinsulinaemia
4. Lipohypertrophy at injection sites causing variable insulin Absorption
5. Gastroparesis due to autonomic neuropathy causing variable carbohydrate absorption
6. Strict glycaemic control
7. Impaired awareness of hypoglycaemia
8. Age (very young and elderly)
9. Long duration of diabetes
10. Renal impairment

Management

Treatment of Acute hypoglycaemia 

Mild (self-treated)

• Oral fast-acting carbohydrate (10–15 g) is taken as glucose drink or tablets or confectionery
• This should be followed with a snack containing complex carbohydrate

Severe (external help required)

• If patient is semiconscious or unconscious, parenteral treatment is required:

IV 75 mL 20% dextrose (= 15 g; give 0.2 g/kg in children)*

Or

IM glucagon (1 mg; 0.5 mg in children)

• If patient is conscious and able to swallow:

Give oral refined glucose as drink or sweets (= 25 g)

Or

Apply glucose gel or jam or honey to buccal mucosa 

• Full recovery may not occur immediately and reversal of cognitive impairment may not be complete until 60 minutes after normoglycaemia is restored. 

• When hypoglycaemia has occurred in a patient treated with a long- or intermediate-acting insulin or a long-acting sulphonylurea, such as glibenclamide –
1. Infusion of 10% dextrose (titrated to the patient’s blood glucose) , may be necessary.
2. If the patient fails to regain consciousness after blood glucose is restored to normal- then cerebral oedema and other causes of impaired consciousness – such as cerebral haemorrhage should be considered. 
• Following recovery-
• It is important to try to identify a cause and make appropriate adjustments to the patient’s therapy.

Unless the reason for a hypoglycaemic episode is clear- 

• the patient should reduce the next dose of insulin by 10–20%. 

Prevention of hypoglycaemia

• Patient education is fundamental.
• Relatives and friends also need to be familiar with the
• symptoms and signs of hypoglycaemia and should
• be instructed in how to help (including how to inject glucagon).
• Risk factors for, and treatment of hypoglycaemia should be discussed.
• The importance of regular blood glucose monitoring and the need to have glucose (and glucagon) readily available should be stressed.
• Glycaemic goal should be reassessed more flexible if-
• Co-morbidities- Cancer, Advanced Cardiac or Renal disease
• Very Old patient
• Good Monitoring is not possible