2. Hypoglycemia

glucose homeostasis

the balance of insulin and glucagon to maintain blood glucose

hyperglycemia

not enough insulin, too much glucagon

hypoglycemia

too much insulin, not enough glucagon

hypoglycemia risk factors

• increased age → older ppl more susceptible

• skipping meals/erratic eating patterns

• exercise/weight loss

• illness

• chronic kidney disease

• dementia/cognitive impairment

• alcohol ingestion (complicated)

  • pure alcohol decreases glucose BUT beer/wine have carbs which increases glucose

medications that cause hypoglycemia

• (too much) insulin

• sulfonylureas → glyburide has the highest risk

• beta-blockers

• fluoroquinolone antibiotics (ex., ciprofloxacin, levofloxacin)

level 1 hypoglycemia

blood glucose level less than 70 mg/dL

level 2, critical hypoglycemia

blood glucose level less than 54 mg/dL

signs & symptoms of hypoglycemia

• hunger (+ irritability = hangry)

• paleness

• fatigue

• rapid heartbeat (very recognizable sign)

• irritability (+ hunger = hangry)

• sweating/shaking (very recognizable sign)

signs & symptoms of severe hypoglycemia

• loss of consciousness

• seizures

• coma

• death

beta blockers mask hypoglycemia

the use of beta-blockers may mask these symptoms of hypoglycemia:

• rapid heartbeat, tremor

• hunger

• irritability

• confusion

ONLY symptom that is NOT masked is sweating!

beta blockers blunt hypoglycemia response

• beta-blockers inhibit hepatic glucose production

• body’s normal response to hypoglycemia is release of glucagon → can cause glycogenolysis/gluconeogenesis → into bloodstream from liver

• but, they also reduce glycogenolysis

relative hypoglycemia

• when a person with diabetes has symptoms of hypoglycemia despite having blood glucose more than 70 mg/dL (normal levels)

• can occur when someone has chronically elevated blood glucose

  • BG levels are always so high it becomes the new normal, so when they drop to actual normal it feels like a “low” drop and reacts as such/accordingly

• can be distressing and interferes with a pt’s sense of well-being, while also limiting the achievement of optimal glucose control

• episodes pose no direct harm to the pt

• still, treat it like hypoglycemia due to discomfort

hypoglycemia prevention

• patient education

• setting patient specific glycemic targets

• frequent monitoring of glucose levels

• flexible and rational regimens for insulin and other drugs

• ongoing professional guidance and support

treatment of hypoglycemia

• outpatient conscious (@ home, not @ hospital)

• outpatient unconscious

• inpatient conscious → able to take oral

• inpatient unconscious OR unable to take oral, with IV access

treatment of hypoglycemia → outpatient conscious (KNOW!)

Rule of 15

• consume 15 g of fast-acting carbohydrates

  • examples: 4 oz of juice or REGULAR pop (diet doesn’t have carbs so no go!)

  • hard candies (NOT chocolate → fat from chocolate slows down absorption of carbs from gut to bloodstream = slows response to hypoglycemia treatment)

  • 1 tbsp of sugar

  • 3-4 glucose tablets (sold OTC)

  • 1 dose of oral glucose gel (sold OTC)

• check blood sugar after 15 minutes

• if still below 70 mg/dL, repeat steps 1 & 2

• once blood sugar is above 70 mg/dL, make sure to eat a meal or snack containing protein and fiber

treatment of hypoglycemia → outpatient unconscious

glucagon

• vial + powder kit → prepped/done by family member or caregiver

• intranasal 3mg

• prefilled syringe 1mg

• reconstituted powder kit 1mg

• call 911 or drive them to hospital if they fail to regain consciousness within a few minutes

treatment of hypoglycemia → inpatient, unable to take oral (ex., could be intubated or unconscious)

• NO IV access → glucagon

  • vial + powder kit → prepped/done by family member or caregiver

  • intranasal 3mg

  • prefilled syringe 1mg

  • reconstituted powder kit 1mg

  • call 911 or drive them to hospital if they fail to regain consciousness within a few minutes

• YES IV access → 25g of 50% dextrose IV