Hypoglycemia, Diabetic - Diabetic Hypoglycemia Prevention

Hypoglycemia, Diabetic

Description

Abnormally low concentration of glucose in circulating blood of diabetic. Often referred to as an insulin reaction.
Classification includes (1)[A]:
Severe hypoglycemia: An event requiring assistance of another person to actively administer treatment
Documented symptomatic hypoglycemia: An event during which typical symptoms are accompanied by a measured plasma glucose of ≤70 mg/dL (3.9 mmol/L)
Asymptomatic hypoglycemia: An event not accompanied by symptoms, but a measured glucose of ≤70 mg/dL (3.9 mmol/L)
Probable symptomatic hypoglycemia: Event with symptoms, but glucose not tested
Relative hypoglycemia: An event with typical symptoms, but glucose >70 mg/dL (3.9 mmol/L)
Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes (2)[B].
System(s) affected: Endocrine/Metabolic

ALERT

Hypoglycemic unawareness:
Major risk factor for severe hypoglycemic reactions
Most commonly found in patients with long-standing type 1 diabetes and children <7 years of age
Can be reversed by:
Meticulous prevention of hypoglycemia
Avoidance of iatrogenic hypoglycemia

General Prevention

Improved self-management skills
Maintaining a routine schedule of diet, medication, and exercise
Stabilizing daily carbohydrate intake
Regular blood glucose testing:
≥3 times daily testing if multiple injections of insulin
Intensive therapy for diabetes should be adjusted to minimize occurrence of severe hypoglycemia; the tighter the diabetic control, the greater the importance of home glucose monitoring.
Diabetes treatment and teaching programs (DTTPs), especially for high-risk type 1 patients, teach flexible insulin therapy to enable dietary freedom.
Hypoglycemia rates are reduced by up to 70% using continuous subcutaneous insulin-infusion pumps compared with multiple daily injections (3)[B].
Patients who experience recurrent hypoglycemic episodes should be individually evaluated and, when appropriate, the employment position should be modified if contributing to frequent insulin reactions.
Severe or frequent hypoglycemia indicates a need to modify glycemic goals and treatment.

Prevalence
Most common in type 1 diabetics:
Most experience hypoglycemia.
If tightly controlled: Often experience hypoglycemia frequently, weekly (4)[A]
Type 2 diabetics:
Uncommon if treated with diet, exercise alone
Common if treated with insulin and/or insulin secretagogues

Risk Factors

Nearly 3/4 of severe hypoglycemic episodes occur during sleep.
Autonomic neuropathy
Illness, stress, and unplanned life events
Duration of diabetes >5 years
Advanced age
Renal, liver disease
CHF
Hypothyroidism
Hypoadrenalism
Gastroenteritis
Starvation or prolonged fasting
Alcoholism: Evening consumption of alcohol is associated with an increased risk of nocturnal and fasting hypoglycemia, especially in type 1 patients.
Current smokers with type 1 diabetes have higher odds of severe hypoglycemia episodes.
Oral hypoglycemics with long duration and high potency have greater hypoglycemic risks.
แ-Glucosidase inhibitors, biguanides, and thiazolidinediones when used in combination with insulin and/or sulfonylureas or meglitinides
Severe hypoglycemia is more likely to occur with insulin (inhaled or subcutaneous) than with oral agents. (5)[A]
No or little difference in hypoglycemic risk between inhaled and subcutaneous insulin (5)[A].

Etiology

Loss of hormonal counter-regulatory mechanism in glucose metabolism
Diet:
Too little food (skipping meal)
Decreased carbohydrate intake
Medication: Too much insulin or oral hypoglycemic agent (improper dose or timing)
Erratic absorption of insulin or oral hypoglycemics
Adverse reaction from other medications
Exercise: Unplanned or excessive
Alcohol consumption
Vomiting or diarrhea
Gastroparesis