Hypoglycaemia in Diabetes

Introduction

In patients with diabetes, hypoglycaemia is defined as any episode of abnormally low blood glucose that exposes an individual to potential harm.

It is more common in type 1 diabetes than in type 2 diabetes and is usually caused by glucose-lowering medications, often in the context of reduced oral intake, conditions of decreased treatment requirements (such as exercise or renal insufficiency), or mis-dosing.



Symptoms

In patients with diabetes, the onset of symptoms of hypoglycaemia may occur at glucose levels less than 65 mg/dL (3.6 mmol/L), although the specific value varies between and within individuals over time.

Hypoglycaemia causes neurogenic (autonomic) and neuroglycopenic symptoms.

Neurogenic symptoms

  • Tremor
  • Palpitations
  • Anxiety/arousal
  • Sweating
  • Hunger
  • Paraesthesias

Neuroglycopenic symptoms

  • Dizziness
  • Weakness
  • Drowsiness
  • Delirium
  • Confusion
  • Seizure and coma (at lower plasma glucose concentrations)

Any patient experiencing repeated hypoglycaemia, but especially those with type 1 diabetes or advanced type 2 diabetes, may develop hypoglycaemia unawareness (i.e. reduction or absence of the autonomic symptoms).



Acute Treatment for Symptomatic Hypoglycaemia

If the patient is conscious, give glucose 15-20 g orally.

  • Glucose-containing carbohydrates are acceptable alternative to pure glucose. Avoid carbohydrate sources high in protein or fat to treat hypoglycaemia.
  • Check the blood glucose after 15 minutes and repeat the treatment if hypoglycaemia persists.
  • A meal or snack should be consumed once the blood glucose normalizes to prevent recurrent symptoms.
Quick Sources of Sugar to Treat Low Blood Sugar

NOTE: In patients taking insulin or an insulin secretagogue in combination with an alpha-glucosidase inhibitor (e.g. acarbose), only pure glucose (e.g., glucose tablets) should be used to treat symptomatic hypoglycaemia. Other forms of carbohydrates, such as table sugar (sucrose), will be less effective in raising blood sugar as alpha-glucosidase inhibitors slow digestion of disaccharides.

If the patient is unable or unwilling to take glucose orally, give parenteral glucose or glucagon.

  • Glucagon therapy must be followed by administration of carbohydrates.



Prevention of Recurrent Hypoglycaemia

Re-evaluate treatment regimen and individualized glycaemic goals after an episode of severe hypoglycaemia, or if hypoglycaemia unawareness is suspected.



Pseudohypoglycaemia

Pseudohypoglycaemia is an event during which the person with diabetes reports typical symptoms of hypoglycaemia but has a measured glucose level >70 mg/dL (3.9 mmol/L). This category reflects the fact that patients with chronically poorly controlled diabetes can experience symptoms of hypoglycaemia as glucose levels fall into the physiologic range.



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