​Kembara Xtra - Medicine - Diabetic Hypoglycemia

​Kembara Xtra - Medicine - Diabetic Hypoglycemia 
Insulin response, the term for an abnormally low concentration of glucose in a patient's blood who has diabetes mellitus (DM).
Hypoglycemia Classification (1):
Level 1 hypoglycemia alert value: 70 mg/dL (3.9 mmol/L); symptoms may or may not be present; level 2 clinically severe hypoglycemia: 54 mg/dL (3.0 mmol/L); symptoms may or may not be present.
severe hypoglycemia at Level 3. No fixed glucose threshold exists: hypoglycemia is linked to serious cognitive impairment that requires outside help to recover from.
Hypoglycemia is the primary limiting factor in the glycemic control of type 1 DM (T1DM) and type 2 DM (T2DM). Pseudohypoglycemia is characterized by usual symptoms but a glucose level of less than 70 mg/dL (3.9 mmol/L). Treatment plans must be modified for severe or frequent hypoglycemia, including setting higher treatment objectives.

Children under the age of 7 and patients with long-standing T1DM are most likely to have hypoglycemia, according to epidemiology incidence data from the ACCORD research.
- 3.14 percent in the group receiving intensive care - 1.0 percent in the control group
From the RECAP-DM study: Hypoglycemia was reported in 35.8% of patients with T2DM who added a sulfonylurea or thiazolidinedione to metformin therapy over the previous year. - Increased risk among women, African Americans, those with less than a high school education, older participants, and those who used insulin at trial entry.

Pathophysiology and Etiology 

Impaired insulin, glucagon, and epinephrine secretion Loss of the hormonal counterregulatory system in glucose metabolism

Risk Elements 
Nearly 3/4 of severe hypoglycemia episodes take place while people are asleep.
In individuals under 65, severe hypoglycemia is linked to concomitant diseases.
Intensive insulin therapy is linked to a higher rate of hypoglycemia (further reducing HbA1c from 7% to 6%).
Renal/liver disease, congestive heart failure (CHF), hypothyroidism, hypoadrenalism, gastroenteritis, gastroparesis (unpredictable CHO delivery), autonomic neuropathy, pregnancy, anxiety, sadness, disordered eating behavior, illness/stress, and unforeseen life events are examples of comorbidities.
Type 1 diabetes patients who are already smoking and have a diagnosis of diabetes that has lasted more than five years, young children with the disease, advanced age, reduced cognitive function, dementia, prolonged fasting, weight loss, or food instability
Alcoholism: Drinking alcohol might raise the risk of delayed hypoglycemia, especially if you take insulin or other insulin-like substances. Alcohol use in the evening is linked to a higher incidence of nocturnal and fasting hypoglycemia, particularly in T1DM patients.
Insulin secretagogues: Glinide derivatives (repaglinide, nateglinide) and sulfonylureas (glyburide, glimepiride, glipizide, etc.) promote insulin secretion.

In diabetics who are not receiving insulin or insulin secretagogues, hypoglycemia is uncommon.
Other diabetic drugs include sodium-glucose cotransporter-2 (SGLT-2) agents, dipeptidyl peptidase 4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) agonists offer a lower but present risk of hypoglycemia, which may rise when mixing medications from other groups.

Aspects of Geriatrics

The American Geriatric Society Beers Criteria advise against using glyburide and chlorpropamide because they increase the risk of extended hypoglycemia episodes in older persons. Drug dosages should take into account renal function and age.
To lower the risk of hypoglycemia in older persons, prevent overtreatment, and, if at all possible, simplify complex regimens while preserving the HbA1c target, individualize pharmacologic therapy.

Child Safety Considerations
Children may not recognize hypoglycemia when it occurs, necessitating more supervision during periods of increased activity. For this reason, glycemic goals may be greater for children. Glucagon (2) usage instructions should be given to caregivers[A].
pregnant women's issues
Due to stricter glycemic objectives and greater risk in early pregnancy, hypoglycemia management and avoidance education should be reemphasized, and blood glucose monitoring should be intensified.

Prevention 
Keep to a regular diet (constant CHO intake), medicine, and exercise program.

Regular blood glucose self-monitoring (SMBG) or continuous glucose monitoring (CGM) is especially beneficial for hypoglycemia without symptoms.
Utilize if you are on insulin or a secretagogue.
- Use three times daily testing when using insulin pump therapy, numerous insulin injections, or while pregnant and diabetes; frequency and timing should be determined by needs and treatment objectives.
Diabetes treatment and education programs (DTTPs), particularly for type 1 patients at high risk, which instruct flexible insulin therapy to allow nutritional freedom
The use of insulin analogs, continuous SC insulin infusion (CSII) pumps, and CGM devices may reduce hypoglycemia.


Cardiomyopathies and Neuropathies are Related Conditions


Discuss the occurrence of episodes, awareness of them, their frequency, and their causes.

The symptoms vary greatly from person to person.
Hunger, pallor, trembling, sweating, shaking, racing heart, anxiety, and incontinence are examples of adrenaline-related symptoms.
Neurologic symptoms: lightheadedness, weakness, disorientation, drowsiness, blurred vision, double vision, unsteadiness, dizziness, and impaired coordination.
– Language processing is hampered during mild hypoglycemia, as seen by the considerable decline in reading span and subject-verb agreement caused by hypoglycemia.

 Behavioral signs: aggression, irritability, drowsiness, disorientation, and tearfulness
Consider hypoglycemia if there are changes in cognition.

clinical assessment 
Neurologic symptoms include trembling, weakness, paresthesia, stupor, seizure, or coma. General symptoms include confusion and tiredness. HEENT symptoms include diplopia.
Skin: pale, diaphoresis; mental status: agitation; anxiety; inability to focus; short-term memory loss; End-organ damage: microvascular; macrovascular; ophthalmologic; neurologic; renal

Multiple Diagnoses 

Chronic alcoholics and binge drinkers, GI dysfunction causing postprandial hypoglycemia or alimentary reactive hypoglycemia, hormonal deficiency states (hormonal reactive hypoglycemia), sepsis-related hypoglycemia, islet cell tumors, and factitious hypoglycemia from covert insulin injection are just a few examples of people who may experience hypoglycemia that is not related to diabetes.

Laboratory Results 
Whole-blood, plasma, or serum glucose
SMBG and CGM are very helpful for hypoglycemia without symptoms.

Unless a specialized device is permitted otherwise, a hypoglycemia reading from a CGM sensor should be confirmed by SMBG fingerstick glucose testing before treatment.

Chronic hypoglycemia may be the cause of low HbA1c levels.
Disorders that could change lab results include hemolysis, blood loss, hemoglobin variations, and conditions that impact erythrocyte turnover.


Management 

Any kind of CHO that contains glucose should be effective (see the "Medication" section below). Glucose: Pure glucose is recommended.

Patients at risk for clinically serious hypoglycemia should be proactive in receiving glucagon prescriptions. The proper use of an emergency glucagon pack should be explained to those who come into touch with these people often.

Glycemic goals should be elevated in insulin-treated individuals who have hypoglycemia awareness or have experienced a clinically severe episode of hypoglycemia in order to completely avoid hypoglycemia.

Acarbose, a -glucosidase inhibitor, prevents the digestion of complex CHOs, hence monosaccharides like glucose tablets are required for the treatment of hypoglycemia.
● Insulin analogs should be used by T1DM patients to lower the risk of hypoglycemia.

Discuss drugs that may cause hypoglycemia, such as insulin, sulfonylureas, GLP-1 agonists, and thiazolidinediones.
CGM-augmented CSII with automatic insulin suspension when blood glucose levels drop below a threshold value lowers the combined rate of moderate and severe hypoglycemia in T1DM and lowers nocturnal hypoglycemia in patients older than 16 without raising HbA1c levels.


Medication Aware individuals (1)[A]: Although any kind of CHO may be utilized, glucose (15 to 20 g) is recommended.
 Any quickly absorbed sugar-containing food or drink, such as juice or non-diet soda (4 to 5 oz), candy (5 to 6 pieces of hard candy), or over-the-counter glucose tablets (4 tablets = 16 g CHO).
It takes around 15 minutes for CHOs to be digested and for glucose to enter the bloodstream.
The "Rule of 15" states that 15 to 20 g of CHO (60 to 80 calories of simple CHO) should be consumed every 15 minutes until blood sugar is 70 mg/dL.

(4) Home loss of consciousness[A]: Give the glucagon.
- IM or SC in the deltoid or anterior thigh Age under 6 years and/or weight between 20 and 25 kg: 0.50 mg Age over 6 years and/or weight between 20 and 25 kg: 1 mg
 If necessary, take a repeat dose in 15 minutes.
Give 25 g IV 50% dextrose every 5 to 10 minutes until the patient awakens if they are unconscious, have emergency medical staff nearby, or are hospitalized.
- Next, feed orally and/or provide 5% dextrose intravenously at a dose that will keep blood glucose levels over 100 mg/dL.
- Patients with hypoglycemia brought on by oral hypoglycemics need to be watched for 24 to 48 hours because even after a clinical recovery seems to have occurred.
Nasal glucagon is available as a ready-to-use device and is now in the development stage.


Admission Each hospital or hospital system should adopt and put into practice a protocol for the prevention and management of hypoglycemia.
Initial stabilization and admission requirements
- Any uncertainty regarding the cause
- Anticipation of extended hypoglycemia, maybe brought on by sulfonylurea medication.
- Lack of ability to consume alcohol - Slow sensory recovery despite treatment.
- Seizures, coma, or changed behavior as a result of known or suspected hypoglycemia, such as ataxia, disorientation, shaky motor coordination, or dysphasia.
Normoglycemia and the risk of severe hypoglycemia are insignificant, according to the discharge criteria.

Diet

Alcohol drinking may raise the risk of delayed hypoglycemia in diabetic individuals.

The treatment or prevention of hypoglycemia should not involve the use of CHO sources high in protein.

Fats have the potential to decrease CHO absorption and lengthen the acute glycemic response.

Due to insufficient or irregular carbohydrate ingestion after the administration of sulfonylureas or insulin, food insecurity increases the risk of hypoglycemia.


Patient Education Always have access to quick-acting CHO If pre-exercise blood sugar is below 100 mg/dL, consider taking extra CHO or reducing your insulin dosage.
Inform patients, their loved ones, close friends, teachers, and employers on the diagnosis and treatment of diabetes mellitus (DM), as well as the warning signs and symptoms of hypoglycemia.
Wear a medical alert identification bracelet or necklace; teach SMBG and self-adjustment for insulin therapy, nutrition management, and fitness program.

Coma, seizures, myocardial infarction, and stroke (particularly in the elderly) are complications.
Long-term or severe hypoglycemia may result in cognitive impairment or permanent brain damage.
Children with T1DM are more susceptible to the neurologic effects of hypoglycemia.