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Ueda2016 workshop - hypoglycemia1 -lobna el toony
- 2. Hypoglycemia The DELTA Project TM, © 2 Hypoglycemia In Diabetes Lobna F El toony Professor of Internal Medicine Head of Internal Medicine Department Head of Diabetes &Endocrinology Unit Assuit University
- 3. Hypoglycemia The DELTA Project TM, © 3 Hypoglycemia “The Greatest Limiting Factor In Diabetes Management”
- 5. Hypoglycemia The DELTA Project TM, © Hypoglycemia … is common Common ; up to 30- 60% in DM patients Type 1 > Type 2 …But ! Intensive DM control (lower HbA1c…?) Elderly Duration of disease Asymptomatic in 50% + …Unawareness ! Nocturnal …very common !
- 6. The DELTA Project TM, © What is hypoglycemia?
- 9. Hypoglycemia The DELTA Project TM, © 9 Hypoglycemia Definition (Cont.) In addition, a BG that falls > 100 mg/dL in one hour may be accompanied by symptoms of hypoglycemia. For example, a BG level of 120 mg/dL may elicit signs and symptoms of hypoglycemia if the BG has fallen from 220 mg/dL an hour earlier.
- 11. Hypoglycemia The DELTA Project TM, © 1. Development of neurogenic or neuroglycopenic symptoms 2. Low blood glucose (<70mg/dl ) if on insulin or secretagogue) 3. Response to carbohydrate load Neurogenic (autonomic) Neuroglycopenic Trembling Difficulty Concentrating Palpitations Confusion Sweating Weakness Anxiety Drowsiness Hunger Vision Changes Nausea Difficulty Speaking Dizziness Definition of Hypoglycemia
- 13. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Symptoms of Hypoglycemia 13 Classification Blood Glucose Level (mg/dL) Typical Signs and Symptoms Mild hypoglycemia ~60-70 • Neurogenic: palpitations, tremor, hunger, sweating, anxiety, paresthesia Moderate hypoglycemia ~50-60 • Neuroglycopenic: behavioral changes, emotional lability, difficulty thinking, confusion Severe hypoglycemia <50* • Severe confusion, unconsciousness, seizure, coma, death • Requires help from another individual *Severe hypoglycemia symptoms should be treated regardless of blood glucose level. Q6. How should hypoglycemia be managed?
- 14. The DELTA Project TM, © Why Hypoglycemia Prevention And Treatment Are Important?
- 17. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. Consequences of Hypoglycemia CV events Cardiac autonomic neuropathy Cardiac ischemia Angina Fatal arrhythmia Cognitive, psychological changes (eg, confusion, irritability) Accidents Falls Recurrent hypoglycemia and hypoglycemia unawareness Refractory diabetes Dementia (elderly) 17 Q6. How should hypoglycemia be managed?
- 18. Copyright © 2015 AACE. May not be reprinted in any form without express written permission from AACE. 18
- 19. Hypoglycemia The DELTA Project TM, © 19 Physical Morbidity Of Hypoglycemia Decreased performance Errors in judgment
- 20. Hypoglycemia The DELTA Project TM, © 20 Physical Morbidity Of Hypoglycemia Accident Risk
- 22. The DELTA Project TM, © How The Body Protect Itself From Hypoglycemia?
- 24. Hypoglycemia The DELTA Project TM, © 24 What Happen In Diabetes?
- 25. Hypoglycemia The DELTA Project TM, © 25 Hypoglycemic Symptoms Autonomic symptoms : After few years of diabetes duration (2-5 years). Glucagon secretion is impaired in type 1 (irreversible). Epinephrine secretion becomes the primary mechanism for raising low blood glucose levels. Over the course of type 1 diabetes (10-12 Ys)-, epinephrine response to hypoglycemia becomes diminished or delayed resulting in: ↓Hypoglycemic symptom awareness (Hypoglycemia Unawareness) ↑↑Severe hypoglycemic episodes
- 26. Hypoglycemia The DELTA Project TM, © 26 Vicious circle where recurrent hypoglycemia during intensive treatment of type 1 diabetes causes hypoglycemia unawareness and impaired counterregulation, ultimately increasing the risk for severe hypoglycemia.
- 27. Hypoglycemia The DELTA Project TM, © Recognize Risk Factors for Severe Hypoglycemia Risk factors in Type 1 DM patients Risk factors in Type 2 DM patients Adolescence Elderly Children unable to detect and/or treat mild hypoglycemia Poor health literacy, Food insecurity A1C <6.0% Increased A1C Long duration of diabetes Duration of insulin therapy Prior episode of severe hypoglycemia Severe cognitive impairment Hypoglycemia unawareness Renal impairment Autonomic neuropathy Neuropathy
- 29. Hypoglycemia The DELTA Project TM, © 29 Hypoglycemia In Type 2 Diabetes
- 30. Hypoglycemia The DELTA Project TM, © 30 Factors That Risk of Hypoglycemia in Type 2 DM Advanced age. Poor nutrition. Hepatic disease. Renal Disease. Hypothyroidism and/or adrenal insufficiency. Postpartum bleeding can lead to pituitary damage.
- 32. Hypoglycemia The DELTA Project TM, © Setting for hypoglycemia Identification of the precipitating factors is important to prevent future events Mismatch Between Insulin , Food & Exercise
- 33. Hypoglycemia The DELTA Project TM, © Hypoglycemia Medications Common with Diabetics who are treated with Insulin releasing pills (sulfonylureas, Meglitinides, or Nateglinide) Insulin Very unlikely with Lifestyle changes (TLC) only Using alone medications like : ( ex: Metformin ,DPP4I, GLP-1 + ,SGLT2 -)
- 35. High risk of hypoglycemia is obtained from commonly used combination SU/Met CI=confidence interval; Glyb=glyburide; Met=metformin; repag=repaglinide; SU=sulfonylurea; TZD=thiazolidinediones. Bolen S, et al. Ann Intern Med. 2007;147:386–399 Met vs Met + TZD Weighted absolute risk difference 0.20.150.150.50 3 (1557) 5 (1495) 6 (2238) 8 (2026) 3 (1028) 5 (1921) 8 (1948) 9 (1987) Studies (participated) 0.00 (-0.01 to 0.01) 0.02 (-0.02 to 0.05) 0.03 (0.00 to 0.05) 0.04 (0.0 to 0.09) 0.08 (0.00 to 0.16) 0.09 (0.03 to 0.15) 0.11 (0.07 to 0.14) 0.14 (0.07 to 0.21) Pooled effect (95% CI) SU vs repag Glyb vs other SU SU vs Met SU + TZD vs SU SU vs TZD SU + Met vs SU SU + Met vs Met Drug 1 more harmfulDrug 1 less harmful
- 37. Hypoglycemia The DELTA Project TM, © DRUGS CAUSING HYPOGLYCEMIA ESTABLISHED DRUGS: DISORDE R DRUG DM Insulin, SU, other secretogogues, metformin, alcohol Infection Pentamidine, Quinine, Sulphonamides Arrhythmias Quinidine, dispyramide, cibenzoline Pain Acetylsalicylic acid
- 40. Hypoglycemia The DELTA Project TM, © 40 Hypoglycemia . Insulin Program Setup (Meal/Bolus) Blood Sugar Rise After Eating Carbs Analog (Humalog or Novolog taken with meal) Regular (taken 30 min. pre-meal) NPH / Lente (taken 4 hours prior) Only rapid analogs work when needed – right after eating!
- 41. Hypoglycemia The DELTA Project TM, © 41 Premixed Insulin 2 Peaks 8 am 12 4 pm 8pm 12 4am 8am 12 . . . . . .. . Coincide with hypoglycemic events
- 42. Hypoglycemia The DELTA Project TM, © 42 Conventional Therapy: traditional regimens 50-70% don’t attain target A1c Erratic blood glucose values Requires fixed life style Danner T et al Diabetes Care (2001) 8 12 16 20 24 4 8 Hypergl . Hypogl. Hypergl . Hypogl. Premixed Premixed
- 43. Hypoglycemia The DELTA Project TM, © 43 Compared to biphasic human insulins More patient convenience regarding administration Better pharmacokinetics and pharmacodynamics Lower incidence of hypoglcemia 8 am 12 4 pm 8pm 12 4am 8am 12 . . . . . .. . Biphasic insulin analogues Biphasic Aspart: Aspart + NPAspart (30/70 Novomix) Biphasic Lispro: Lispro + NPLispro (25/75 humalogue mix)
- 45. Hypoglycemia The DELTA Project TM, © 45 Nocturnal Hypoglycemia Causes: 1. Exercise during the previous day. 2. Failure to eat a bedtime snack. 3. Predinner injections of intermediate-acting insulin (NPH, Lente) may peak in action during the night and cause relative hyperinsulinemia overnight. 4. Insulin requirements decrease between midnight and 3 AM. 5. Significant increases in physical activity, combined with failure to increase carbohydrate consumption and/or reduce the insulin dose. 6. Concomitant use of sulfa antibiotics (TMP, Septrin, Bactrim) with a sulfonylurea cause profound and refractory hypoglycemia.
- 46. Hypoglycemia The DELTA Project TM, © 46 Intermediate acting insulins: NPH and Lente Day time Peak Nocturnal Peak Dawn pheno 8 am 12 4 pm 8pm 12 4am 8am B D . . . . . Morning Hyperglycemia High Insulin Sensitivity Hyperglycemia . 2 Peaks Nocturnal Hypoglycemia
- 47. Hypoglycemia The DELTA Project TM, © 47 Prevention of Nocturnal Hypoglycemia Do not skip presleep snacks. Measure presleep blood glucose levels regularly. Increase the carbohydrate content of the snack. If daytime physical activity was increased. Eat additional slowly absorbed carbohydrate snack before bed time. Move the Predinner NPH or Lente to presleep rather than decreasing the predinner dose. Reduction in evening regular insulin dose.
- 48. Hypoglycemia The DELTA Project TM, © 48 4:00 25 50 75 16:00 20:00 24:00 4:00 Breakfast Lunch Dinner PlasmaInsulinµU/ml) 12:008:00 Time NPH/ Lente REGREG REGNPH/ Lente Basal + Meal-related Insulin NPH/lente + Regular
- 49. Hypoglycemia The DELTA Project TM, © 49 4:00 16:00 20:00 24:00 4:00 Breakfast Lunch Dinner 12:008:00 Time Glargine PlasmaInsulin Aspart Aspart Aspart or or or Lispro Lispro Lispro Basal-bolus Treatment Program Rapid-acting & Long-acting Analogs Lower Incidence of hypoglycemia
- 51. Hypoglycemia The DELTA Project TM, © 51 The use of Subcutaneous glucose sensors for continuous glucose monitoring with sophisticated software may make it possible to trigger an alarm when hypoglycemia risk is detected.. Hypoglycemia Prevention (cont.)
- 52. Hypoglycemia The DELTA Project TM, © Setting for hypoglycemia Food intake Skipped or delayed meals Vomiting after meal & meds intake Mismatch: Wrong dose or too high a dose of medications for the amount of food; Too little carbohydrate
- 53. Hypoglycemia The DELTA Project TM, © 53 Snack Or not To snack? اإلفطارخفيفة وجبة الغذاء خفيفة وجبة العشاء خفيفة وجبة 10-15%30–35%25-30% 10%10% 10%
- 54. Hypoglycemia The DELTA Project TM, © 54 Snack Or Not To Snack ? With Twice daily mixture of NPH +R Use snack at time of inappropriate hyperinsulinemia (10-11 am & at bedtime). With Multiple Daily Injections (MDI) or Insulin Pumps No need for snacks. They may increase the BG before the next meal. In adults no need for snacks.
- 55. Hypoglycemia The DELTA Project TM, © 55 Physical activity
- 56. Hypoglycemia The DELTA Project TM, © Setting for hypoglycemia Unplanned / Excess exercise without snack / Rx adjustment Excessive insulin / OHA doses Organ Failure Medications Alcohol use Identification of the precipitating factors is important to prevent future events
- 57. Hypoglycemia The DELTA Project TM, © 57 When adequate insulin level is present, muscular activity lowers BG during, immediately after and /or several hrs after exercise This has been attributed to increased insulin levels originating from subcutaneous depots and increased insulin sensitivity by enhancing receptor site binding. Particularly if the patient takes a hot shower after exercising.
- 58. Hypoglycemia The DELTA Project TM, © 58 Hypoglycemia Prevention Strategies
- 59. Hypoglycemia The DELTA Project TM, © Hypoglycemia Management Prevention = Education Education …Education …Education
- 60. Hypoglycemia The DELTA Project TM, © Hypoglycemia-Prevention Patient education and empowerment Frequent self-monitoring of blood glucose (SMBG) Flexible and rational insulin (and other drug) regimens Individualized glycemic goals Professional guidance and support.
- 62. Hypoglycemia The DELTA Project TM, © Hypoglycemia-Prevention Self-monitoring of blood glucose (SMBG) Keeping some sugar or sweet handy Teach patient/care-giver Medical alert identification Glucagon Emergency kit.
- 63. Hypoglycemia The DELTA Project TM, © 63 Hypoglycemia Prevention Strategies Continuous Glucose Monitoring Alarms to alert user/family of pending lows
- 65. Hypoglycemia The DELTA Project TM, © 65 Hypoglycemia Prevention Strategies . Meal/Snack Timing Vs Insulin Major issue w/a.m. NPH/Lente Minor issue w/Lantus or Levemir Not usually an issue with pump use
- 66. Hypoglycemia The DELTA Project TM, © 66 Treatment Of Hypoglycemia
- 68. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 1 1. Mild to moderate hypoglycemia should be treated by oral ingestion of 15 g carbohydrate; glucose or sucrose tablets/solutions are preferable to orange juice and glucose gels [Grade B, Level 2] Patients should retest blood sugar in 15 minutes and retreat with another 15 g of carbohydrates if BG remains <4.0 mmol/L [Grade D, Consensus]
- 69. Hypoglycemia The DELTA Project TM, © 15 g of glucose in the form of glucose tablets 15 mL (3 teaspoons) or 3 packets of sugar dissolved in water 175 mL (3/4 cup) of juice or regular soft drink 15 mL (1 tablespoon) of honey Examples of 15 g Simple Carbohydrate
- 70. Hypoglycemia The DELTA Project TM, © Role of 15 minutes
- 71. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2. Severe hypoglycemia in a conscious person should be treated by oral ingestion of 20 g of carbohydrate, preferable as glucose tablets or equivalent. Blood sugar should be retested in 15 minutes, and then retreated with a further 15 g of glucose if BG remains <4.0 mmol/L [Grade D, Consensus]
- 72. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 3. Severe hypoglycemia in an unconscious individual: – No IV access: 1 mg of glucagon should be administered subcutaneously or intramuscularly. Caregivers or support persons should call for emergency services and the episode should be discussed with the diabetes healthcare team as soon as possible [Grade D, Consensus] – With IV access: 10-25 g (20-50 cc of D50W) of glucose should be given intravenously over 1-3 minutes [Grade D, Consensus] Recommendation 3
- 73. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5. Once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia [Grade D, Consensus]. If a meal is > 1 hour away, a snack (including 15 g of carbohydrate and protein source) should be consumed [Grade D, Consensus]
- 74. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 6 6. Patients receiving antihyperglycemic agents that may cause hypoglycemia should be counseled about strategies for prevention, recognition and treatment of hypoglycemia related to driving and be made aware of provincial driving regulations [Grade D, consensus] 2013
- 76. ADA 2015 - HYPOGLYCEMIA Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger reevaluation of the treatment regimen. E Action: Raise their glycemic targets to avoid further hypoglycemia for at least several weeks Aiming to partially reverse hypoglycemia unawareness and reduce risk of future episodes. A
- 77. The DELTA Project TM, © Take-Home Messages
- 78. Hypoglycemia The DELTA Project TM, © 78 Take home messages The Patient with chronic disease like diabetes has a very good chance of living a long life, especially if he has good glycemic control. Hypoglycemia can occur with very little warning. The patient should be aware of these. With good education , matching insulin , food and physical activity , most patients will survive these problems after exclusion of co- morbid conditions.
- 79. Hypoglycemia The DELTA Project TM, © Take home messages Know the risk factors /setting Beware of nocturnal , exercise-induced and unawareness forms Treat and try to prevent recurrence Educate your self , your patients and their families