Hypoglycemia occurs when blood glucose levels fall below normal levels. When this happens, the body activates mechanisms to raise blood glucose like increasing glucagon release and reducing glucose uptake. Prolonged insulin therapy can impair these mechanisms. Symptoms of hypoglycemia range from sweating to confusion. Treatment involves consuming carbohydrates to raise glucose levels. Patients at risk require education to prevent hypoglycemia and its complications like hypoglycemia unawareness.

1. Hypoglycemia
Notes

2. Introduction
● Glucose <3.9mmol/L
● Presence of autonomic / neuroglycopenic symptoms
● Reverse by carbohydrate intake

3. What happen when blood glucose falls?
● Endogenous insulin release from pancreatic Beta cells is suppressed
● Release of glucagon from pancreatic Alpha is increased
● The autonomic nervous system is activated, with release of catecholamines both
systematically and within the tissues
● Stress hormones (cortisol, growth hormone) are increased in blood
These actions reduced whole body glucose uptake, increase hepatic glucose production,
maintaining a glucose supply to the brain.
* Within 5 years of diagnosis, most patient have lost their ability to release glucagon specifically
during hypoglycemia

4. Symptoms of Hypoglycemia

5. Symptoms of hypoglycemia
Sweating
Trembling
Pounding heart
Hunger
Anxiety
Delirium
Drowsiness
Speech difficulty
Inability to concentrate
Incoordination
Irritable, anger
Nausea
Tiredness
Headache

6. Classification

7. Risk factors
› advancing age
› severe cognitive impairment
› poor health knowledge
› uncontrolled T2DM with glucose variability
› hypoglycemia unawareness
› long duration of insulin therapy
› renal and hepatic impairment
› peripheral and autonomic neuropathy

8. Common causes and risk factors
Medical issues
● Strict glycemic control
● Previous severe hypoglycemia
● Long duration type 1 diabetes
● Duration of insulin therapy in type
2 diabetes
● Lipohypertrophy at injection sites
● Severe hepatic dysfunction
● Impaired renal function
● Inadequate treatment of previous
hypoglycemia
● Terminal illness
● Bariatric surgery involving bowel
resection
● Endocrine disorder

9. Common causes and risk factors
Reduced carbohydrate intake
● Gastroparesis due to autonomic neuropathy causing variable carbohydrate
absorption
● Malabsorption (coelic disease)
● Eating disorder
Lifestyle issues
● Exercise
● Breast feeding

10. Prevention
● identifying patients at risk
● education on recognising symptoms of hypoglycaemia,
● structured educational and psycho-behavioural programs (e.g. Blood glucose
awareness training) that may help to improve detection of hypoglycaemia and
reduce the frequency of severe episodes

11. Caution
Patients at risk of hypoglycaemia should be discouraged from driving motor
vehicles, cycling, swimming or operating heavy machinery, as these activities may
endanger oneself and the public.

12. Treatment
The aims of treatment are to:
● detect and treat a low plasma glucose level promptly,
● eliminate the risk of injury to oneself and to relieve symptoms quickly;
● avoid over-correction of hypoglycemia especially in repeated cases as this
will lead to poor glycaemic control and weight gain.

13. Level 1 and level 2
● 15 g of simple CHO e.g.
○ 1 tablespoon of honey
○ 150-200 ml of fruit juice such as orange juice or regular soft drink; or
○ 3 teaspoons of table sugar dissolved in water.
● Measure plasma glucose after 15 minutes.
○ If the level at 15 minutes is still <3.9 mmol/L, another 15 g of CHO should be
taken.
● People taking AGIs (acarbose) must use glucose (dextrose) tablets
or, if unavailable, milk or honey to treat the hypoglycaemia

14. Level 3
● where the individual is still conscious, administer 20 g of CHO and the
above steps are repeated.
● where the individual is unconscious, administer:
○ 20-50 ml of Dextrose (D) 50% intravenously (IV) over 1-3 minutes, or
○ 75-100 ml of D20% over 15 minutes, or
○ 1 mg glucagon subcutaneously (SC) or intramuscularly (IM).Outside the hospital
setting, a tablespoon of honey (or equivalent e.g.maple syrup) should be
administered into the oral cavity

15. Treatment (cont…)
● Once hypoglycemia has been reversed, the patient should have the usual
meal or snack that is due at that time of the day to prevent recurrent
hypoglycemia.
● Evaluate cause of the hypoglycaemia and educate patient on how to prevent
future episodes.
● Diabetes treatment (OGLDs and insulin) regime may need to be reviewed
and adjusted.

16. Acute
Management
of
Hypoglycemia

17. Hypoglycemic Unawareness
● Hypoglycemia unawareness occurs when the ability to perceive the autonomic
warning symptoms is either diminished or lost such that the first sign of
hypoglycaemia is confusion or loss of consciousness.
● Recent or recurrent hypoglycemia can decrease normal responses to
hypoglycemia and lead to defective glucose counterregulation and hypoglycemia
unawareness.
● Hypoglycemia unawareness increases the incidence of severe hypoglycaemia
and therefore should trigger re-evaluation of the treatment regimen.
● Both hypoglycemia unawareness and defective glucose counter-regulation are
potentially reversible.
● Patients should be advised to temporarily relax their targets.
● Strict avoidance of hypoglycaemia for up to 3 months has been associated with
improvement in the recognition of severe hypoglycaemia, the counterregulatory
hormone responses or both

18. Nocturnal Hypoglycemia
• Risk of nocturnal hypoglycemia is higher especially in the elderly
• The clinical manifestations may include:
› poor sleep quality,
› vivid dreams or nightmares,
› waking up with chills or sweating,
› morning headache,
› chronic fatigue,
› mood changes,
› nocturnal convulsions.
• Nocturnal hypoglycaemia may contribute to morning hyperglycaemia

19. ● Undetected nocturnal hypoglycaemia can promote:
› hypoglycaemia unawareness,
› blunt counterregulatory responses,
› anxiety, reduce quality of life and increase treatment
› negative outcomes such as falls, accidents and arrhythmias.
● To reduce the risk of asymptomatic nocturnal hypoglycaemia, individuals on
basal insulin therapy should periodically monitor early morning (2-5 am,
corresponding with the peak action time of the basal insulin) plasma glucose
levels.40 (Level III)
› Consider switching from human basal insulin to basal insulin analogues
● Patients on SU should readjust dose/consider switching to an OGLD without
hypoglycaemia risk.

20. Complication of hypoglycemia
● Hypoglycaemia can cause acute harm to the person with T2DM or others,
especially if it causes falls, motor vehicle accidents, or other accidents.
● A large cohort study suggested that among older adults with T2DM, a history
of severe hypoglycaemia was associated with greater risk of dementia.
● Severe hypoglycaemia was associated with excess mortality in participants in
both the standard and the intensive glycaemia arms of the ACCORD, VADT
and ADVANCE trials

21. ● In people with T2DM and established or very high risk for CVD, there is a
clear association between severe hypoglycaemia and increased mortality.
● Acute hypoglycaemia is proinflammatory, increases platelet activation and
decreases fibrinolysis, leading to a prothrombotic state
● Hypoglycaemia is associated with increased heart rate, SBP, myocardial
contractility, stroke volume and cardiac output, and can induce ST- and T-
wave changes with a lengthening of the QT interval (slower repolarization),
which may increase the risk of arrhythmias and sudden cardiac death

22. CPG recommendation
1. Patients at risk of hypoglycaemia or with high CV risk should be educated to
recognise and prevent hypoglycaemia.
2. Patients on insulin/insulin secretagogues therapy should periodically monitor
early morning glucose to detect nocturnal hypoglycaemia.
3. Patients with hypoglycaemia unawareness and those with concomitant CVD
should relax their glycaemic targets.
4. Hypoglycaemia unawareness should trigger reevaluation of the treatment
regimen.
5. Patients with hypoglycaemia unawareness should avoid hypoglycaemia for up
to 3 months to regain early hypoglycaemia warning symptoms.

23. Treatment
Severe hypoglycemia need glucose, glucagon