This document discusses hypoglycemia in diabetes, including its definition, symptoms, causes, treatment, and the role of technology in prevention. Hypoglycemia is defined as a low blood glucose level below 70 mg/dL that causes symptoms. The most common cause is insulin treatment, and symptoms include neurogenic and neuroglycopenic effects. Treatment involves consuming 15-20g of fast-acting carbohydrates. Glucagon injections are recommended for severe hypoglycemia. Continuous glucose monitors can help detect and prevent hypoglycemic episodes through real-time glucose monitoring and alerts.

1. HYPOGLYCAEMIA IN
DIABETES
A presentation by Dr.Abubakkar Siddique
Al-Oyoun PHC KUWAIT

2. How is hypoglycemia defined?

3. • Hypoglycemia in medicine is a clinical syndrome
with diverse causes in which low plasma glucose concentrations
lead to symptoms and signs, and there is resolution of the
symptoms/signs when the plasma glucose concentration is raised
• In patients with Diabetes, hypoglycemia is defined as
All episodes of an abnormally low plasma glucose concentration
(with or without symptoms) that expose the individual to harm

4. The diagnosis of hypoglycaemia is not based on an absolute
blood glucose level; it requires fulfilment of the Whipple triad:
1. Signs and symptoms consistent with hypoglycaemia
2. Associated low glucose level commonly below 3.9 mmol/L
3. Relief of symptoms with supplemental glucose/carbohydrates

5. • Diabetics usually receive alarm as a possibility of Hypoglycaemia at a
self-monitored blood glucose(SMBG) at level ≤70 mg/dL (3.9
mmol/L)
• This cut-off value has been debated, with some favoring a value of
<63 mg/dL (3.5 mmol/L)
• While this value is higher than the value used to diagnose
hypoglycemia in people without diabetes ≤55 mg/dL (3 mmol/L)
• The primary task in a patient without diabetes is to make an
accurate diagnosis, whereas the primary task in a patient with
diabetes is to alter or adjust therapy in an attempt to minimize or
eliminate hypoglycemia

6. The workgroup of the ADA proposed Hypoglycaemia for clinical
trials as follows:

7. The workgroup of the ADA proposed Hypoglycaemia for clinical
trials as follows:

8. The workgroup of the ADA proposed Hypoglycaemia for clinical
trials as follows:

9. The workgroup of the ADA proposed Hypoglycaemia for clinical
trials as follows:

10. What are the symptoms of
hypoglycemia?

11. 1- Neurogenic symptoms catecholamine mediated and
cholinergic mediated
Catecholamine-mediated symptoms are
rapid heart rate, anxiety, and shakiness
Cholinergic-mediated symptoms include
hunger, sweating, and paraesthesia
2- Neuroglycopenic symptoms
During level 2 hypoglycaemia, neuroglycopenic symptoms occur
and can include changes in mental status, confusion, irritability,
behavioural changes, seizures, loss of consciousness and coma

24. What are the health implications
of Hypoglycaemia?

25. • Hypoglycemia is potentially fatal
• Contributor to up to 6% of deaths in people with diabetes
younger than 40 years of age
• An increased risk for cardiovascular and all-cause mortality in
insulin-treated individuals with T1D and T2D who experience
hypoglycemia
• An association of severe hypoglycemia and mortality was found
in the landmark ADVANCE trial, which assessed outcomes of
intensive glucose management to an A1c of <6.5%

26. • Cognitive changes from hypoglycemia are linked to higher
rates of motor vehicle accidents in people with diabetes
• Children experiencing recurrent episodes of hypoglycemia may
develop permanent neurologic deficiencies and learning
differences
• Even level 1 hypoglycemia can cause fatigue and other
symptoms that impair the ability to concentrate up to hours
after the event

27. • Hypoglycemia commonly leads to rebound hyperglycemia from
overtreatment
• Avoidance of hypoglycemia makes it more difficult to achieve
glycemic targets, which can contribute to hyperglycemia and
indirectly contribute to microvascular and macrovascular
complications of diabetes
• Hypoglycemia is associated with reduced quality of life and
reduced health satisfaction
• Correlated to reduced school and work performance, reduced
productivity, and disability

29. What causes hypoglycemia?

30. • The most common cause of hypoglycemia is treatment with insulin
• Most often related to issues with mealtime insulin dosing, such as
taking the wrong dose, taking the insulin and not eating, or taking the
wrong insulin
• Insulin secretagogues— sulfonylureas and meglitinides—cause the
pancreas to release insulin and are also contributors to hypoglycemia.
• Other diabetes medication classes have a very low risk of
hypoglycemia and are not expected to cause hypoglycemia based on
their mechanism of action
• However, when combined with insulin or a secretagogue, they can
increase the incidence of hypoglycemia, especially if the insulin or
secretagogue dose is not adjusted prior to combining

31. What are the physiologic
mechanisms that occurs during
hypoglycemia?

32. • Glucose is an obligate metabolic fuel for the brain under
physiologic conditions
• The brain cannot synthesize glucose or store more than a
few minutes’ supply as glycogen and therefore requires a
continuous supply of glucose from the arterial circulation
• As the arterial plasma glucose concentration falls below the
physiologic range, blood- to-brain glucose transport
becomes insufficient to support brain energy metabolism
and function

33. • When a person's plasma glucose level is less than 70 mg/dL
(3.9 mmol/L), signals are sent from the brain to the
pancreas, liver, and adrenal glands that collectively raise the
plasma glucose level by counterregulatory mechanisms
• The hormones involved are insulin, glucagon, epinephrine,
norepinephrine, Cortisol, and growth hormone

34. • In non diabetics the body decreases its own insulin production
when glucose drops to try to prevent hypoglycemia
• Counterregulatory hormones, including glucagon and
epinephrine, are released when glucose is 65 to 70 mg/dL
• Glucagon stimulates gluconeogenesis in the liver
• Epinephrine stimulates both hepatic glycogenolysis &
gluconeogenesis
• In T1DM Diabetics glucagon secretion & epinephrine response is
partially or fully lost
• With T2DM, these counterregulatory hormone mechanisms are
usually initially intact but can decrease over time

41. How common is hypoglycemia?

42. • Hypoglycemia is common in T1DM, patients receiving
intensive therapy, the risk of severe hypoglycemia is increased
more than 3 fold
• They suffer an average of 02 episodes of symptomatic
hypoglycemia per week
• Thousands of such episodes over a lifetime of diabetes, and 01
episode of severe, at least temporarily disabling hypoglycemia
per year
• Hypoglycemia was reported in 38% of patients with T2DM who
added a sulfonylurea or meglitinide to metformin therapy

43. Can we eliminate Hypoglycaemia?

44. • It is challenging to perfectly pair carbohydrate intake with
insulin doses
• In fact, it is so common that an international consensus report
advises that up to 4% of time spent in hypoglycemia is
acceptable to achieve glycemic targets
• This equates to nearly 1 hour per day
• The guideline does state that for those with more advanced age
or complications, less than 1% of the time should be spent in
hypoglycemia
• This is still around 15 minutes per day

45. • The main limiting factor to tight glycemic management is
hypoglycemia
• For this reason, the American Diabetes Association (ADA)
recommends higher HbA1c targets, of up to <8.5%, for older
adults and those with more comorbidities at the greatest risk of
hypoglycemia
• Current insulin options do not perfectly mimic true physiologic
insulin. For example, compared with physiologic insulin
secretion after a meal, current bolus insulin options take longer
to start working and stay in the body past the point when they
are needed

46. What is impaired awareness of
hypoglycemia?

47. • Hypoglycemic unawareness is when a person may not feel any
symptoms despite a glucose level that is below 70 mg/dL
• Many people with diabetes have impaired counterregulatory
responses to hypoglycemia or experience hypoglycemia
unawareness
• Some people with diabetes may lose all ability to sense
hypoglycemia and must rely on other people to notice signs or
symptoms or on technology (e.g., continuous glucose monitor
[CGM]) to alert them

48. How is hypoglycemia treated?

49. • For individuals who are able to eat, 15 to 20 g of glucose is the
preferred treatment
• Examples include 4-6 oz of juice, 3-4 glucose tablets, or 3-5
hard candies (not chocolate)
• If glucose remains below 70 mg/dL (3.9 mmol) after 15
minutes, then an additional 15 to 20 g should be ingested
• This can be repeated up to 03 times as needed
• Once the glucose reading or glucose pattern is trending up, the
individual should consume a meal or snack to prevent the
recurrence of hypoglycemia

50. Why shouldn’t chocolate be used to treat hypoglycemia?
• Chocolate contains fat, which can delay the absorption of the
carbohydrate, and it will take longer for glucose to rise and to
have a resolution of symptoms

51. What is the role of glucagon?

52. • Glucagon is a counter regulatory hormone that is secreted by
the pancreatic alpha cells
• It stimulate gluconeogenesis, which is the breakdown and
release of glycogen in the liver
• This leads to increased glucose concentrations that’s why
• Glucagon is the preferred treatment option for severe
hypoglycemia and should be prescribed for all people with
diabetes who are at increased risk of level 2 hypoglycemia
• This should generally include all people with T1D and many
insulin-treated people with T2D

60. • Nasal and liquid stable glucagon are easier to administer
compared with the traditional glucagon kit that requires
reconstitution
• Although cost is lower with the traditional kit
• All glucagon formulations are contraindicated in
pheochromocytoma, insulinoma, and glucagon hypersensitivity
• There is a warning about a lack of efficacy in patients with
decreased hepatic glycogen, which can occur in states of
starvation, adrenal insufficiency, and chronic hypoglycemia

61. What is the preferred treatment
for hypoglycemia in the inpatient
setting?

62. • Similar to the outpatient setting, 15 to 20 g of glucose is the
preferred treatment
• However, if level 3 hypoglycemia occurs, then IV dextrose is
used to quickly raise glucose
• Concentrated IV dextrose 50% (D50W) is most appropriate for
severe hypoglycemia

63. What is the role of technology in
preventing hypoglycemia?

64. • CGMs offer the ability to set alarms when hypoglycemia occurs
by predictive alerts
• These alerts can be customized, and there are additional features,
including fall rate, which provides an alert to let a person know
that glucose is dropping rapidly
• There are additional alerts to remind a person to recheck glucose
after it was low.
• Sensor-augmented insulin pumps. These insulin pumps can sus-
pend insulin when glucose is predicted to go low to reduce the
incidence of hypoglycemia
• Hybrid closed-loop insulin pumps that can automatically adjust
insulin rates to help reduce hypoglycemia

65. What is the role of diabetes self-
management in hypoglycemia?

66. •According to the ADA standards of medical care, all
individuals with diabetes should be educated on the signs
and symptoms of hypoglycemia, along with prevention and
treatment strategies
•Those with T1D or insulin-treated T2D should be
counseled on the frequency of self-monitoring of blood
glucose concentrations in response to a hypoglycemic
episode
•People with diabetes should learn their glucose targets and
learn how to problem-solve possible causes of and
solutions to hypoglycemia

67. Key Points
• 1. Hypoglycemia is a common occurrence in diabetes management
and often a barrier to achieving more intensive glycemic targets
• 2. Hypoglycemia can be classified into three levels. Level 3 is the
most severe and requires assistance from another person
• 3. Consuming fast-acting carbohydrates is the treatment of choice if
a person is able to eat or drink. When a person can’t eat or drink,
glucagon can be administered by another person, or IV dextrose can
be given by the healthcare team
• 4. New technologies can help reduce hypoglycemia through glucose
alerts and automated insulin delivery based on glucose levels.

68. References

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70. Thanks to tolerate so much
HYPO….You really need Dinner now