APPROPRIATE HEALTH CARE
. Outpatient except for complicating emergencies (coma, inapparent cause, long acting oral hypoglycemic)
. Admit the patient if:
. There is any doubt of the cause
. Expectation of prolonged hypoglycemia (eg, caused by a sulfonylurea drug)
. Inability of the patient to drink
. The treatment has not resulted in prompt recovery of sensorium
. Seizures, coma, or altered behavior (eg, ataxia, disorientation, unstable motor coordination, dysphasia)
secondary to documented or suspected hypoglycemia
GENERAL MEASURES
. Glucose is the preferred treatment for hypoglycemia, however, any form of carbohydrate that contains
glucose should be effective
. Education is the mainstay of prevention
. Blood glucose targets should be individualized
. Any sugar-containing food or beverage which can be rapidly absorbed, eg, juice (4-6 ounces), candy (5-6
pieces of hard candy) or non-diet soda
. OTC glucose tablets or gels
. Hypoglycemic unawareness (most commonly found in patients with long-standing type 1 DM) is a major risk
factor for severe hypoglycemic reactions
. Intensive therapy for diabetes should be adjusted to minimize the occurrence of severe hypoglycemia
. Meticulous prevention of hypoglycemia can reverse hypoglycemia unawareness
. Hypoglycemia unawareness can be reversed by avoidance of iatrogenic hypoglycemia
. In younger children and in patients suspected of having hypoglycemic unawareness, blood glucose profiles
should include early morning measurements
DIET
β’ Avoid extra calories without changing the source of the problem - excess insulin or oral hypoglycemic
β’ If alcohol is consumed, it should be with food to reduce the risk of hypoglycemia
β’ Protein does not slow the absorption of carbohydrates
β’ Fats may slow the absorption of carbohydrates
PATIENT EDUCATION
β’ Most important measure is prevention
β’ Educate patients, their relatives and close friends, teachers and supervisors
β’ Teach self-monitoring of blood glucose (SMBG) and self-adjustment for insulin therapy, diet control, and
exercise regimen
β’ Emergency medical assistance may be needed if the person does not recover within a few minutes
β’ Carry an ID tag
β’ Always keep some type of quick-acting carbohydrate close by
DRUG(S) OF CHOICE
. General
. Oral administration of small molecule sugars (saccharose/glucose) - glucose is preferred
. Approximately 60-90 calories (15-20 g of glucose) repeated every 15 minutes until blood sugar is 100
mg/dL (5.55 mmol/L) or more
. It takes about 15 minutes for the carbohydrates to be digested and to enter the blood stream as glucose
. In patients with loss of consciousness at home
. Administer glucagon IM or subcutaneous in the deltoid or anterior thigh:
. If under 5 years old, give 0.25 to 0.50 mg
. Older child (5-10 years old) give 0.50 to 1 mg
. Over 10 years old, give 1 mg
. If emergency medical personnel are present or patient hospitalized
. Give one-half amp 50% dextrose every 5-10 minutes until the patient awakens
. Then feed orally and/or administer 5% dextrose intravenously at a level that will maintain the blood
glucose at a level above 100 mg/dL.
. Patients with hypoglycemia secondary to oral hypoglycemics should be monitored for 24-48 hours since hypoglycemia may recur after apparent clinical recovery
ALTERNATIVE DRUGS Acarbose, a potent alpha-glucosidase inhibitor slows the absorption kinetics of dietary carbohydrates by reversible competitive inhibition of alpha-glucosidase activity, and so reduces the post-prandial blood glucose increment and insulin response
PATIENT MONITORING Self-monitoring of blood glucose
PREVENTION/AVOIDANCE
β’ Educating patients, family, teachers and close friends
β’ Maintaining a routine schedule of diet, medication and exercise
β’ Stabilize daily carbohydrate intake
β’ Self monitoring of blood glucose
β’ Self monitoring of blood glucose is recommended for patients treated with insulin
β’ 3 or more times daily testing if multiple injections
β’ Severe or frequent hypoglycemia indicates a need to modify glycemic goals and treatment regimens
β’ Continuous subcutaneous glucose monitoring
β’ Wearing a medical alert identifi cation bracelet or necklace
β’ Those patients who experience recurrent hypoglycemic episodes should be individually evaluated and when
appropriate, the employment position should be modified
β’ Information should be given to the school or daycare setting so that personnel are aware of the diagnosis of diabetes in a student and the signs, symptoms and treatment of hypoglycemia
β’ Blood glucose testing should be available at school or workplace
POSSIBLE COMPLICATIONS
β’ Coma
β’ Seizure
β’ Prolonged or severe hypoglycemia may cause permanent neurological damage and/or cognitive impairment
β’ Evaluation of neuropsychological functioning of DCCT participants shows no evidence of signifi cant cognitive deterioration associated with repeated episodes of severe hypoglycemia. Repeated episodes of severe hypoglycemia are not necessarily associated with cognitive dysfunction.
β’ Significant differences have been documented between adults and children in the incidence of Hypoglycemia
β’ Myocardial infarction, stroke, especially in the elderly
EXPECTED COURSE/PROGNOSIS
Full recovery is usual depending on the rapidity of diagnosis and treatment