Hypoglycemia & Glucose Assessment and Monitoring

What is glucose homeostasis?

Balance of insulin and glucagon to maintain blood glucose

What causes hyperglycemia?

Not enough insulin; too much glucagon

What causes hypoglycemia?

Too much insulin; not enough glucagon

Risk factors for hypoglycemia?

Increased age; skipping meals; erratic eating; exercise; weight loss

Additional risk factors for hypoglycemia?

Illness; alcohol ingestion; chronic kidney disease; dementia; cognitive impairment

Medications that cause hypoglycemia?

Insulin; sulfonylureas (glyburide highest risk); beta-blockers; fluoroquinolones

Which fluoroquinolones cause hypoglycemia?

Ciprofloxacin; levofloxacin

Level 1 hypoglycemia definition?

Blood glucose <70 mg/dL

Level 2 hypoglycemia definition?

Blood glucose <54 mg/dL

Signs and symptoms of hypoglycemia?

Hunger; paleness; fatigue; rapid heartbeat; irritability; sweating; shaking

Severe hypoglycemia symptoms?

Loss of consciousness; seizures; coma; death

What do beta-blockers do to hypoglycemia symptoms?

Mask symptoms

Which symptom is NOT masked by beta-blockers?

Sweating

What symptoms are masked by beta-blockers?

Rapid heartbeat; tremor; hunger; irritability; confusion

How do beta-blockers affect hypoglycemia response?

Blunt response

What do beta-blockers inhibit in hypoglycemia?

Hepatic glucose production

What process do beta-blockers reduce?

Glycogenolysis

What is relative hypoglycemia?

Symptoms of hypoglycemia with glucose >70 mg/dL

When does relative hypoglycemia occur?

Chronic hyperglycemia

Does relative hypoglycemia cause harm?

No direct harm

How should relative hypoglycemia be treated?

Treat like hypoglycemia due to discomfort

Prevention of hypoglycemia?

Patient education; glycemic targets; frequent monitoring; flexible regimens; professional support

What are treatment settings for hypoglycemia?

Outpatient conscious; outpatient unconscious; inpatient conscious; inpatient unconscious

What is the rule of 15?

15 g carbs; check in 15 min; repeat if <70; eat meal/snack after

Examples of 15 g fast-acting carbs?

4 oz juice or regular soda; hard candies; 1 tbsp sugar; 3–4 glucose tablets; glucose gel

What should be avoided in hypoglycemia treatment?

Chocolate

Treatment for outpatient unconscious hypoglycemia?

Glucagon

Doses of glucagon?

Intranasal 3 mg; prefilled syringe 1 mg; reconstituted kit 1 mg

What to do if patient does not regain consciousness?

Call 911 or go to hospital

Inpatient hypoglycemia without IV access?

Glucagon

Inpatient hypoglycemia with IV access?

25 g of 50% dextrose IV

What is fasting blood glucose?

No food for 8 hours or more

What is post-prandial glucose?

1–2 hours after a meal

What is pre-prandial glucose?

Right before a meal regardless of last food intake

Goal fasting glucose?

<130 mg/dL

Goal post-prandial glucose?

<180 mg/dL

Goal pre-prandial glucose?

No defined goal

What is continuous glucose monitoring (CGM)?

Device with filament under skin that monitors glucose at intervals

What does CGM send data to?

Reader or smartphone

How often is CGM sensor changed?

Every 10–15 days

Examples of CGM devices?

DexCom G6/G7; Freestyle Libre

Difference between DexCom and Libre?

DexCom sends continuous readings; Libre requires scanning

What is Time in Range (TIR) goal?

≥70%

What is Time Below Range (TBR) goal for <70 mg/dL?

<4%

What is Time Below Range (TBR) goal for <54 mg/dL?

<1%

Who should use CGM?

Patients on intensive insulin; prone to hypoglycemia; some children ≥2 years; insurance dependent

How often monitor glucose (non-insulin therapy)?

3x/week up to 2x daily

How often monitor glucose (insulin therapy)?

Once daily to 4x daily

How often monitor glucose (MDI insulin)?

4–6x daily

What glucose levels should be checked?

Fasting; post-prandial; pre-prandial

What does HgbA1C measure?

% of hemoglobin that is glycosylated

What does A1C represent?

Average glucose over ~3 months

What does A1C reflect?

Big picture, not a single moment

A1C goal for most patients?

<7%

How often check A1C if at goal?

Every 6 months

How often check A1C if not at goal?

Every 3 months

Limitations of A1C?

Does not reflect recent changes; affected by RBC turnover; does not show glucose variability

Conditions affecting A1C?

Anemia; blood loss; hemolysis; uremia; pregnancy; ESRD

Who may need different glycemic goals?

Limited life expectancy; cognitive impairment; very young; pregnant; frequent hypoglycemia

Alternative A1C goal example?

<8% in some patients

Alternative CGM goals?

TIR >50%; TBR <1%