CME INDIA Presentation.

Based on deliberation by Professor Brian M Frier.

Modified by Dr NK Singh

(1) Do you agree – Insulin Saved life; Insulin took life?

(2) Is it a Common Story Everywhere?

125 visits for symptomic hypoglycemia in one 12-month period

• 65 with obtundation, stupor or coma
• 38 with confusion or bizarre behavior
• 9 with seizures
• 3 with hemiparesis (2.4%)

This Scenario, what you think?

11-year-old Rani, type 1 diabetes for last 6 years.

Currently controlled on insulin glargine 10 units once daily and insulin aspart 5 units before meals and 3 units at bedtime.

Rani ‘s most recent A1C (measured last month: 6.8) – when symptoms occur.

She is currently experiencing 1–2 episodes of hypoglycemia per week, typically after gymnastics class. Her plasma glucose level is 65-70 mg/dL.

She self-treats herself as soon as symptoms develop with three to four glucose tablets and then she feels fine.

Today came for regular check up.

She demonstrates the use of her glucose meter.

……..

Result reveals a plasma glucose level of 58 mg/dL.

The patient is surprised the level is so low, since she was not aware or feeling any symptoms that she has had in the past.

How would you classify Rani’s most recent hypoglycemic event in your progress notes?

1. Severe Hypoglycemia
2. Documented symptomatic hypoglycemia
3. Asymtomatic hypoglycemia
4. Pseudo-hypoglycemia

Hypoglycemia

Plasma glucose levels < 54 mg/dL———–Does this definition serve the purpose?

• Pseudo-hypoglycemia is defined as a patient having hypoglycemic symptoms with a blood glucose reading above 70 mg/dL
•  Probable symptomatic hypoglycemia is when patients report definite symptoms typical of hypoglycemia are not accompanied by a plasma glucose reading, while not measured, are assumed to be ≤70 mg/dL
• Documented symptomatic hypoglycemia is an event during which typical symptoms of hypoglycemia are accompanied by a measured plasma glucose concentration ≤70 mg/dL 
• Severe hypoglycemia is an event requiring assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions.
• Asymptomatic hypoglycemia is an event not accompanied by typical symptoms of hypoglycemia but with a measured plasma glucose concentration of ≤ 70 mg/dL.

With a plasma glucose level of 55 mg/dL, one would expect Rani to be experiencing at least symptoms of a sympatho-adrenal response, which would alert her to ingest carbohydrates to raise her plasma glucose levels. But Rani is unaware of her hypoglycemia based upon her lack of symptoms

(3) Are symptoms of hypoglycemia age-specific?

(4) What are modifying factors of Hypoglycemia?

(5) Are you Alert for These Facts?

(6) How dreaded are complications of Hypoglycemia?

 सो क्या समझे  पीड़ पराई

(7) Does Hypo cause Dementia?

(8) Does Hypo affect Renal Function

(9) What is correct

Severe hypertension occurs during Hypoglycemia

1. More in T1 DM
2. More in T2DM

(10) Do symptoms of hypoglycemia change with time?

(11) Can dangerous Hypoglycemia occur without symptoms?

(12) How many times Inappropriate Awareness of Hypoglycemia (IAH) get enhanced?

(13) Is it possible to assess Awareness of hypoglycemia?

(14) Is antecedent Hypoglycemia diminishes symptoms during subsequent Hypoglycemia?

(15) Does nocturnal Hypoglycemia induce IAH?

(16) How to manage IAH?

(17) How many days pathophysiological consequences persists after Hypoglycemia:

1. up to 24 hr
2. up to 36 hr
3. up to 48 hr
4. up to 7 days

Does Hypoglycemia aggravate Microvascular function?

(18) Does worsening of Retinopathy occurs with rapid improvement of glycaemic control?

(19) Can Hypoglycemia lead to Athero-thrombosis?

(20) How to tackle Hypoglycemia?

खून का बदला खून /ग्लूकोज़ का बदला ग्लूकोज़

RULE of 15:

1. Have patient eat or drink fast acting carbohydrates (15g).  May be fewer grams for young, small students.
2. Check blood glucose 10-15 minutes after treatment
3. Repeat treatment of 15 grams if blood glucose level remains low and recheck at another 15 minutes
4. If symptoms continue or blood glucose levels do not increase, call parent/guardian.
5. Oral glucose (dextrose), whose absorption is not inhibited by voglibose, should be used instead of sucrose (cane sugar) in the treatment of mild to moderate hypoglycemia. Sucrose, whose hydrolysis to glucose and fructose is inhibited by voglibose, is unsuitable for the rapid correction of hypoglycemia.
6. Severe hypoglycemia in an unconscious individual:
   1. With no IV access: 1 mg glucagon SC or IM. Caregivers or support persons should call for emergency services [Grade D, Consensus].
   2. With IV access: 10–25 g (20–50 cc of D50W) of glucose should be given intravenously over 1–3 minutes [Grade D, Consensus].

Is routine use of D₅₀W for the majority of patients unnecessary, costly and wasteful?

• D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia.
  • Hyperosmolar load to patients that might already be in hyperosmolar coma.
  • Hypertonic dextrose can cause hypo or hyperkalemia.
  • Hypertonic dextrose may damage ischemic CNS tissue.
  • Some studies suggest that higher concentrations of dextrose-containing fluids do not expedite reversal of Hypoglycemia as compared to lower concentrations, and that lower concentration formulations are more likely to achieve normal glycaemic targets.
• Hang a 250mL bag of 10% dextrose, and administer a bolus of 100-200 mL.
• Repeat boluses as needed until the patient becomes alert and oriented, and/or until normoglycemia is achieved.
• More recently, EMS system revised their current protocol adopting the use of a 100mL bolus of 10% dextrose for treatment of Hypoglycemia.

CME INDIA Learning Points:

• जैसे हुस्न के हजार रंग वैसे ही हाइपोग्लाइसीमिया के हजार रंग
• Definition of Hypoglycemia – Imminent change in near future
• Also, a severe problem in Type 2
• Complications are dreaded
• Symptoms are age specific and change with duration of diabetes
• Hypoglycemia and Cognition defect still a grey zone
• Neuronal death in Hypoglycemia does not require COMA
• Hypoglycemia affects subsequent renal function
• Severe hypertension seen more in type 2 related Hypoglycemia
• IAH (Impaired awareness of Hypoglycemia) a serious issue
• Try to access for IAH and have vision to treat it.
• Technology useful but EDUCATION is the magic bullet to prevent
• Rule of 15 to be displaced in all clinics. Routine use of D50 is wasteful

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