January 10th, 2018
Education Plan for Managing Hypoglycemia in Diabetes Mellitus – Content of the session
Hypoglycemia is a condition that frequently occurs in individuals taking insulin as a therapy for T1DM and advanced T2DM. Early stages of T2DM do not result into large numbers of hypoglycemic episodes probably out of a largely intact glucose feedback-control system (Cryer 2002). Deficiency in this blood-sugar-levels correcting system in T1DM and advanced T2DM patients results in increased cases of hypoglycemia in these subjects (Cryer, 2001; Cryer 2002; Jackson et al., 2004; Israelian et al, 2006). Hypoglycemia becomes of concern to such patients since its risks heighten as one attempts to achieve more aggressive glycemic goals (Cryer, 2002; Cryer et al., 2003 Fisher & Kapustin, 2007), but could also occur with poor glycemic control (Boyle & Zrebiec, 2007a). Outcomes of hypoglycemia are not only restricted to physical morbidity (e.g. accidents), but also psychosocial morbidity (e.g. anxiety, fear, seclusion) and at times fatalities (Cryer et al., 2003; Boyle & Zrebiec, 2007a). With these adverse outcomes, the need for increased patient knowledge on managing the condition arises.
Prevention of hypoglycemia in diabetics involves effective surveillance of the predisposing factors. Hypoglycemia risk for instance becomes pronounced by factors such as hypoglycemia unawareness, excessive alcohol intake, reduced food intake or missing meals, and strenuous or unplanned physical activity (Boyle & Zrebiec, 2007a; 2007b; Renda, 2006). Other factors that predispose diabetics to a higher hypoglycemic risk are stress, age related factors, sleep (for nocturnal hypoglycemia), co-occurring diseases and prior history of hypoglycemia episodes (Boyle & Zrebiec, 2007a; Renda, 2006). Of these predisposing risk factors, hypoglycemic unawareness could be vital since it precludes behavioral defenses (e.g. food intake) against hypoglycemia progression (Cryer et al., 2003). Such unawareness occurs both in T1DM and advanced T2DM (Cryer et al., 2003; Murata, Duckworth, Shah, Wendel, Hoffman, 2004). In T2DM patients, impaired hypoglycemia perception could be enhanced by the patients’ relative old age compared to T1DM patients and reduced attention to symptoms due to depression, dementia, stroke history or occurrence of other chronic illnesses (Murata et al., 2004; Renda 2006). Aggravated levels of hypoglycemia also arise from lack of knowledge on the symptoms of the condition and on behavioral approaches (e.g. taking food) to avert progression of the condition to severe levels (Murata et al., 2004; Boyle & Zrebiec, 2007a). Preventative approaches thus do not only involve lifestyle changes (e.g. in level of physical activity, planning meals) but also training to inform on the condition and management approaches (Boyle & Zrebiec, 2007a).
Since effectively recognizing and addressing hypoglycemia symptoms is one of the preventative aspects (Cryer et al., 2003; Murata, et al, 2006), its signs and symptoms are presented here. Hypoglycemia manifests itself through physical, neuroglycopenic and behavioral (mood) signs and symptoms. Physical symptoms include tremors, shiver, increased blood pressure and heart rate, and blurred vision (Boyle & Zrebiec, 2007a). Others include pale skin color, profuse sweating, and skin numbness (Boyle & Zrebiec, 2007a). Once plasma glucose concentrations fall below 45 mg/dl, hypoglycemia leads to neuroglycopenic symptoms (Cryer et al., 2003; Boyle & Zrebiec, 2007a). These include concentration difficulties, hunger, warmth, fatigue, clumsiness and slurred speech (Boyle & Zrebiec, 2007a). Others are motor impairment, seizures, loss of consciousness, brain damage and coma (Boyle & Zrebiec, 2007a). Hypoglycemia could also manifest itself in mood/ behavioral changes such as tenseness, anger, giddiness, anxiety, arousal, frustration intolerance, tearfulness and other unhappy moods (Boyle & Zrebiec, 2007a). Diabetic patients who experience such symptoms should thus check their plasma glucose levels regularly to confirm hypoglycemia conditions (<70mg/dl), in order to institute corrective behavioral approaches before blood glucose levels decline further (Renda, 2006; Boyle & Zrebiec, 2007a; Fischer, 2007; Nadkami, Kucukarslan, Bagozzi, Yates & Erickson, 2010).
When symptoms of hypoglycemia are recognized early enough, most episodes could be self-treated by appropriate behavioral approaches. Family members trained to recognize and respond to severe hypoglycemia cases could also help alleviate a patient’s further regression. Treatment of for mild or moderate cases involves ingestion of fast-acting carbohydrates (Boyle & Zrebiec, 2007a). An increase of 15mg/dl plasma glucose concentration could result from ingestion of 5 grams of carbohydrates but typically, 25 grams are used to correct mild to moderate episodes (Boyle & Zrebiec, 2007a). Such carbohydrates include glucose tablets, high sugar drinks and fruit juices (Boyle & Zrebiec, 2007a). Failure of plasma levels to rise to 70mg/dl or above levels after 15 minutes of such carbohydrate ingestion, requires the patient to eat a second helping of carbohydrate rich diet (Boyle & Zrebiec, 2007a). Hypoglycemia levels that result into neuroglycopenic symptoms may limit carbohydrate consumption, and in such cases intravenous administration of glucose (25g) could be necessitated. Such infused glucose achieve temporal effects hence repeated infusions or feeding may be required after 1 to 2 hours for complete correction of the condition (Boyle & Zrebiec, 2007a). Medical personnel could perform such infusion or where such a personnel is not available, a trained individual could do so using glucagon emergency kits (Boyle & Zrebiec, 2007a). The glucagon emergency kits have a syringe prefilled with sterile diluting agent, recombinant glucagon in a vial, and directions for mixing and administration (Boyle & Zrebiec, 2007a). Since some types of hypoglycemia (e.g. nocturnal ones) may be hard to detect (see Renda, 2006 for case studies), regular self monitoring is core to effective surveillance and management of hypoglycemia in diabetics (Boyle & Zrebiec, 2007a). Patients should thus effectively monitor their blood glucose levels and self-medicate through carbohydrate ingestion to correct hypoglycemia or seek help from trained family members when self-treatment is precluded by advanced neuroglycopenic symptoms (American Diabetes Association, 2010; LeRoith & Smith, 2005; Strowing & Raskin, 1998). Go to part 5 here.