HYPOGLYCEMIA

By Ns. Retno Setyawati, M.Kep, SpKMB

 Introduction
• Hypoglycaemia is the commonest side effect of insulin
and sulphonylureas in the treatment of diabetes and
presents a major barrier to satisfactory long term
glycaemic control.

• Metformin, thiazolidinediones, DPP-4 inhibitors and

GLP-1 analogues prescribed without insulin or
sulphonylurea therapy are unlikely to result in
hypoglycaemia.

• Hypoglycaemia results from an imbalance between

glucose supply, glucose utilisation and current insulin
levels.
• The American Diabetes Association (ADA)
Workgroup on Hypoglycemia (2005) defined
hypoglycemia in diabetes as “all episodes
of abnormally low plasma glucose
concentration that expose the individual to
potential harm.”

• The modern definition of hypoglycemia is plasma

glucose < 70 mg/dl (ADA, 2010)

Definition
 Table 1. Risk Factors for Hypoglycaemia
Medical issues Lifestyle issues
• Tight glycaemic control • Increased exercise (relative to
• Previous history of severe usual)
hypoglycaemia • Irregular lifestyle
• Undetected nocturnal hypoglycaemia • Increasing age
• Long duration of diabetes • Alcohol
• Poor injection technique • Early pregnancy
• Impaired awareness of hypoglycaemia • Breast feeding
• Preceding hypoglycaemia (less than • Injection into areas of
3.5mmol/L) lipohypertrophy (lumpy sites)
• Severe hepatic dysfunction • Inadequate blood glucose
• Renal dialysis therapy monitoring
• Impaired renal function Reduced carbohydrate intake
• Inadequate treatment of previous • Food malabsorption
hypoglycaemia e.g.gastroenteritis, coeliac
• Terminal illness disease
Adrenergic Symptoms Neuroglycopenic
Symptom
Pallor Confusion
Diaphoresis Slurred Speech
Shakiness Irrational behavior
Hunger Disorientation
Anxiety Loss of consciousness
Irritability Seizures
Headache Pupillary Sluggishness
Dizziness Decreased response to
noxious stimuli

Hypoglycemia Symptoms
+
Table 2. ADA classification of hypoglycemia in diabetes

An event requiring assistance of another

person to actively administer carbohydrate,
glucagon or other resuscitation actions.
Plasma glucose measurements may not be
available during such an event, but
Severe hypoglycemia neurological recovery attributable to the
restoration of plasma glucose to normal is
considered sufficient evidence that the event
was induced by a low plasma glucose
concentration.

An event during which symptoms typical of

hypoglycemia are not accompanied by a
Probable
plasma glucose determination but that was
symptomatic
presumably caused by a plasma glucose
hypoglycemia
concentration ≤ 70 mg/dL (≤ 3.9 mmol/L).
+ An event during which typical symptoms
Documented of hypoglycemia are accompanied by a
severe measured plasma glucose
hypoglycemia concentration ≤ 70 mg/dL (≤ 3.9 mmol/L).

An event not accompanied by typical

symptoms of hypoglycemia but with a
Asymptomatic
measured plasma glucose concentration
hypoglycemia
≤ 70 mg/dL (≤ 3.9 mmol/L).

an event during which the person with

diabetes reports any of the typical
Pseudo- symptoms of hypoglycemia with a
hypoglycemia measured plasma glucose concentration
> 70 mg/dL (> 3.9mmol/L) but approaching
that level
+
Mechanisms of Hypoglycemic
Mortality

Prolonged, profound hypoglycemia

can cause brain death, but most fatal
episodes are probably the result of
ventricular arrhythmias. The
mechanisms of the latter include
reduced baroreflex sensitivity
+

Nobody dies of HYPERGLYCEMIA

They do from HYPOGLYCEMIA !!!
+

Figure 3. Treatment of hypoglycemia.BG, blood glucose, IM, intramuscular; SC, subcutaneous.

+
Adults who are unconscious and/or having
seizures and/or are very aggressive
1) Check: Airway (and give oxygen)
Breathing
Circulation
Disability (including GCS and
blood glucose)
Exposure (including
temperature)
+
2) The following three options are all appropriate;
local agreement should be sought:
a) Glucagon 1mg IM (may be less effective in
patients prescribed sulphonylurea therapy).
Glucagon, which may take up to 15 minutes
to take effect,
b) If IV access available, give 75-80 ml of 20%
glucose (over 10-15 minutes). Repeat
capillary blood glucose measurement 10
minutes later. If it is still less than 4.0mmol/L,
repeat
+
c) If IV access available, give 150-160ml of
10% glucose (over 10-15 minutes). Repeat
capillary blood glucose measurement 10
minutes later. If it is still less than
4.0mmol/L, repeat
3) Once the blood glucose is greater than
4.0mmol/L (70 mg/dL) and the patient has
recovered give a long acting carbohydrate of
the patient’s choice where possible, taking
into consideration any specific dietary
requirements.
+

4) Document event in patient’s notes. Ensure

regular capillary blood glucose monitoring
is continued for 24 to 48 hours. Ask the
patient to continue this at home if they are
to be discharged.
+
Adults who are conscious, orientated and able
to swallow
1) Give 15-20g quick acting carbohydrate of the
patient’s choice where possible. Some
examples are:
 150-200 ml pure fruit juice e.g. orange
 90-120ml of original Lucozade® (preferable
in renal patients)
 5-7 Dextrosol® tablets (or 4-5 Glucotabs®)
 3-4 heaped teaspoons of sugar dissolved in
water
+
2) Repeat capillary blood glucose
measurement 10-15 minutes later. If it is
still less than 4.0mmol/L, repeat step 1 up
to 3 times
3) If blood glucose remains less than 4.0
mmol/L after 45 minutes or 3 cycles,
contact a doctor. Consider 1mg of
glucagon IM (may be less effective in
patients prescribed sulphonylurea therapy)
or IV 10% glucose infusion at 100ml/hr.
+
4) Once blood glucose is above 4.0 mmol/L
and the patient has recovered, give a long
acting carbohydrate of the patient’s choice
where possible, taking into consideration
any specific dietary requirements. Some
examples are:
 Two biscuits
 One slice of bread/toast
 200-300ml glass of milk (not soya)
 Normal meal if due (must contain
carbohydrate)
+
5) Document event in patient’s notes.
Ensure regular capillary blood
glucose monitoring is continued for 24
to 48 hours.
 DO NOT omit insulin injection if due
(However, dose review may be required)

N.B. Patients given glucagon require a larger

portion of long acting carbohydrate to replenish
glycogen stores (double the suggested amount
above) If the patient was on IV insulin, continue
to check blood glucose every 30 minutes until
above 3.5mmol/L, then re-start IV insulin after
review of dose regimen
The prevention of hypoglycemia requires some principles
consideration. These principles include:
1) diabetes self management (supported by education
and empowerment);
2) self- monitoring of blood glucose or continuous
glucose sensing;
3) flexible and appropriate insulin or other drug
regimens;
4) individualized glycemic goals;
5) consideration of known risk factors of hypoglycemia;
6) professional support and guidance

Prevention of hypoglycemia