Hyperglycemia and Hypoglycemia

What is the pathophysiology of hyperglycemia?

Defined as blood glucoses levels that are higher than the expected range. Fasting blood glucose levels >110 mg/dL, or random blood glucose levels > 106 mg/dL are considered hyperglycemia.

What is insulin resistance?

The failure of the insulin receptors located on the membrane of target cells to accept insulin. Insulin is an essential hormone that facilitates the uptake of glucose into the cells.

What does the liver do if the cells are unable to absorb glucose due to lack of insulin?

The liver will release glucagon stores and stimulate hepatic glucose production by two processes, gluconeogenesis and glycogenolysis.

What is gluconeogensis?

The generation of glucose from non-carbohydrate sources (proteins, lipids, pyruvate, and lactate.

What is glycogenolysis?

The production of glucose from the breakdown of glycogen in the liver and muscles.

What is an HHS (hyperglycemia hyperosmolar state)?

It is a metabolic complication that results in severe dehydration, severely elevated blood glucose levels and plasma osmolarity, absence of ketosis, hypotension, and altered mental state.

What are the modifiable risk factors of hyperglycemia?

Taking certain steroid medications, illness or infection, chronic stress, insomnia, non-adherence to diet or exercise plans, expired insulin, and improper insulin administration.

What are the non-modifiable risk factors of hyperglycemia?

Genetic or familial predisposition to metabolic disorders like DM and metabolic syndrome.

What are the secondary causes of hyperglycemia?

TPN use, dextrose infusion, and medications like glucocortcoids, phenytoin, and estrogens.

What are the comorbidities of hyperglycemia?

Autoimmune disorders, hyperlipidemia, HTN, gestational diabetes, PCOS, metabolic syndrome, Cushing’s syndrome, acromegaly, and pheochromocytoma (rare tumor in adrenal gland)

What are the complications of untreated hyperglycemia?

Permanent damage to the blood vessels, nerves, tissues, and organs, leading to coronary artery disease, cerebrovascular disease, peripheral vascular disease, retinopathy, nephropathy, poor healing of wounds, and depression

What are the three P’s?

1. Polyuria- excessive urination resulting to dehydration

2. Polyphagia- excessive hunger resulting in overeating

3. Polydispsia- excessive thirst resulting in excessive consumption of fluids.

What are the manifestations of advanced hyperglycemia?

DKA manifestations, kussmaul respiration, nausea and vomiting, and abdominal pain.

What is DKA (diabetic ketoacidosis) and what are the manifestations?

It is caused by an absolute lack of insulin resulting in the prevention of the body’s metabolic demands being met. It causes altered mental status, fatigue, tachypnea, Kussmaul respirations, hypotension, tachycardia, weight loss, dry mucous membranes, n/v, abdominal pain, polyuria, and fruity-smelling breath.

What are Kussmaul respirations?

A deep, rapid breathing pattern that is an attempt to expel carbon dioxide due to the acidity of the body.

What does chronic, uncontrolled hyperglycemia cause in older adults?

It causes damage and inflammation to the vascular walls and increases atherosclerosis. They have higher chance of peripheral artery disease, carotid artery disease, stroke, heart attack, neuropathy, and retinopathy.

What are the clinical manifestations of hyperglycemia?

Dry mouth, increased thirst, blurred vision, weakness, headache, frequent urination, low BP, tachycardia, alterations in mental status (confusion, lethargic, comatose).

What are the labs/diagnostics performed for hyperglycemia?

Fasting blood glucose level, random blood glucose level, postprandial blood glucose level, HbA1C. In cases of the possibility of a tumor or another disease causing hyperglycemia, CT scans, ultrasounds, and MRIs are used.

What is the range for fasting blood glucose?

76-106 mg/dL

What is the recommended range for hemoglobin A1C?

4-5.9%

What are the ranges for hyperglycemia and critical hyperglycemia?

BG higher than 106 mg/dL and BG higher than 450 mg/dL.

What are the teachings related to hyperglycemia control and safety?

• Safety manage and dispose used lancets appropriate.

• If you have recurrent hyperglycemia, obtain a medical ID bracelet

• Know how to use a glucose monitor and understand what the signs are for hyperglycemia

• Proper store equipment (insulin in fridge and test strips kept out of extreme temps and moisture)

• Know when to check urine for ketones

• Identify possible triggers for hyperglycemia

• Participate in life-style modifications like exercise and diet changes

• Dietary modification include smaller portion sizes along with a decrease in carbohydrate intake.

• Understand when and how to take insulin and oral antidiabetic medications, along with there adverse effects.

What should a patient not do if urine show presence of ketones and why?

Exercise; it can cause BG levels to rise even higher if present.

What are the treatment methods/therapies for hyperglycemia?

Insulin, lifestyle and diet modifications, and the use of oral hypoglycemic medications like sulfonylureas, thiazolidinediones, biguanides, DPP-4 inhibitors, SGLT2 inhibitors.

What are sulfonylureas and their therapeutic effects?

Examples include glyburide, glipizide, and glimepiride. They decrease blood glucose by increasing insulin secretion from beta cells in the pancreas.

What are the adverse effects and teachings for sulfonylureas?

Hypoglycemia, weight gain, nausea, diarrhea, dizziness, and headache. Patients should take the medication 30 minutes before meals or with first meal of the day and monitor for hypoglycemia.

What are thiazolidinediones and their therapeutic effects?

Examples include pioglitazone and rosiglitazone. They decrease resistance to insulin.

What are the adverse effects and teachings for thiazolidinediones?

Liver toxicity, weight gain, and edema. Patient should monitor liver function, report changes in appetite, jaundice, abdominal pain, or dark urine; monitor for hypoglycemia and they are allowed to take with or without food.

What are biguanides and their therapeutic effects?

An example is metformin. It decreases the amount of glucose produced in the liver and decreases the amount of glucose absorbed from food.

What are the adverse effects and teachings for biguanides?

It can cause indigestion, bloating, abdominal pain, constipation, headache, and metallic taste. Patient should take it 30 min before meals or with the first meal of the day, unless NPO. It should be held for any procedures requiring contrast dye and monitor for signs of hypoglycemia.

What are dipeptidyl peptidase-4 (DPP-4 inhibitors) and their therapeutic effects?

An example is sitagliptin. It increases insulin production and lower glucagon secretion.

What are the adverse effects and teachings for dipeptidyl peptidase-4 (DPP-4 inhibitors)?

Upper respiratory infection, runny nose, indigestion, edema, changes in urination, and diarrhea. It can be taken with or without food. They should also monitor kidney function and for hypoglycemia.

What are sodium-glucose transport protein 2 (SGLT2) inhibitors and their therapeutic effects?

Examples include canagliflozin, dapagliflozin, and empagliflozin. It decreases renal glucose reabsorption and increases elimination of glucose by urination.

What are the adverse effects and teachings for sodium-glucose transport protein 2 (SGLT2) inhibitors?

UTI, increased urination, increased thirst, nausea, and constipation. They should monitor renal function and for hypoglycemia. Take this medication before the first meal of the day and hold prior to surgical procedures.

What is the pathophysiology of hypoglycemia?

When blood glucose levels drop below the expected range, there is a disruption in glucose homeostasis. This causes the triggering of the release of hormones like glucagon, epinephrine, and norepinephrine. As a result, neuroglycopenia occurs (neuro dysfunction).

What are the risk factors of hypoglycemia?

Difficulty with managing diabetes medication is the most common factor. Whether the patient takes too little or too much insulin or oral hypoglycemic medications. Other factors are a malfunctioning insulin pump, insufficient food intake, a lack the self-awareness of early manifestations of hypoglycemia, increasing exercise w/o the necessary food consumption, or missing meals.

What are the risk factors for clients who don’t have diabetes?

Trauma, surgery, drug use, sustained alcohol use, pancreatitis, anorexia, malnutrition, or liver/kidney malignancies.

What are the medications that can hypoglycemia?

• Antiarrhythmic medications- quinidine

• Antibiotics- levofloxacin

• Beta-Blockers- atenolol

• NSAIDS- indomethacin

• Insulin

• Metformin used concurrently with sulfonylureas

• SGLT2 inhibitor- canagliflozin taken w/ or w/o sulfonylureas

• Sulfonylureas- glipizide

• Thiazolidinediones- pioglitazone used concurrently w/ sulfonylureas

What are the comorbidities of hypoglycemia?

HTN, renal disease, psychological impacts, cancer, and prior stroke or cardiac disease.

What are the circulatory manifestations of hypoglycemia?

Rapid heartbeat and heart palpitations.

What is the endocrine manifestation of hypoglycemia?

Epinephrine may not be released for early warning signs of hypoglycemia.

What is the GI manifestation of hypoglycemia?

Hunger.

What are the nervous system manifestations of hypoglycemia.

Weakness, lack of coordination, chills, sweating, dizziness, confusion, lightheadedness, headaches, nervousness, anxiety, sleep disturbances, irritability, tingling/numbness, pallor, and blurred vision.

What are the three levels of hypoglycemia?

• Level 1: BG 54-70 mg/dL

• Level 2: BG less than 54 mg/dL

• Level 3: not dependent on BG level, but presenting with altered mental or physical status

What are the lab and diagnostic tests performed for hypoglycemia?

Fasting and random blood glucose testing. The used of CGMs to help monitor blood glucose and help in the situation where clients are unaware of hypoglycemic manifestations.

What can cause the loss of accuracy for CGMs (continuous glucose monitors?

Poor oxygenation, extreme temperatures, and medications like vitamin C, acetaminophen, and levodopa.

What are examples of fast-acting carbohydrates?

• 3 to 4 glucose tablets

• 6 to 8 hard candies or gummies

• 8 oz low fat or skim milk

• 1 tablespoon corn syrup, sugar, or honey

• ½ cup (4 oz) 100% fruit juice or regular soda

• 2 tablespoons of raisins

• 4 to 5 crackers

• 1 tube of glucose gel

What are the environment risk factors related to hypoglycemia?

• Changes in work schedule

• Travel to different time zones

• Exercising more than usual

• Food insecurity

• Unpredictable access to nourishing foods

What is the necessary client education for hypoglycemia?

Teach the signs of hypoglycemia and frequent monitoring of BG. Teach dietary intake and exercise rule (exercising= more food). Keep glucose tablets, hard candies, and other sources of rapid glucose intake on hand. Teach both the patient and the family about injectable glucagon and when and how to use it. Keep a glucagon kit in your home. Follow the 15-15 rule when experiencing hypoglycemia. Avoid high-protein and high-fat foods during a hypoglycemic episode due to a delay in the body’s ability to absorb sugar.

What is the treatment for hypoglycemia?

The administration of glucagon/glucose via injection or PO (if conscious and able to eat). If unconscious or in a hospital, IV dextrose is used

What is the 15-15 rule?

• Identify if the client is awake and able to ingest glucose by mouth.

• Administer food with at least 15 grams of fast acting carbohydrates. 

• Wait 15 minutes and recheck blood glucose

• If the client is still hypoglycemic, administer another 15 grams of carbohydrates.

• Continue to monitor blood glucose levels as indicated.

• When stabilized, have the client eat a meal to prevent recurrence.