DR Sibli PDF

Management of Hypoglicemia in
Primary Health Care
dr. Sibli, Sp.PD

RS Jantung Hasna Medika
DIABETES CARE, VOLUME 32, NUMBER 7,

Learning Objectives
• Identify the causes of hypoglycemia
• Review the signs and symptoms of hypoglycemia
• Identify the risks associated with hypoglycemia
• Outline strategies to prevent hypoglycemia

Hypoglycemia Unawareness
Definition
A reduction in the serum glucose

concentration with reduced or no
autonomic warning symptoms
Signs and Symptoms of
Hypoglycemia in the Adult
Autonomic Neuroglycopenic
Symptoms Signs Symptoms Signs
Hunger Pallor Weakness, fatigue Cortical -blindness
Sweating Tachycardia Dizziness Hypothermia
Anxiety Widened Headache Seizures

pulse-pressure
Paresthesias Confusion Coma
Palpitations Behavioral changes
Tremulousness Cognitive- dysfunction

Blurred vision, diplopia
Classification of Hypoglycemia
in Diabetes
Alert value for hypoglycemia
≤70 mg/dL (≤3.9 mmol/L) plasma concentration
Severe • Requires assistance of another person to actively administer
hypoglycemia carbohydrates, glucagon, or take other corrective actions
• Plasma glucose concentrations may not be available during an
event
• Neurological recovery following plasma glucose levels returning to
normal considered sufficient evidence that event was induced by
low plasma glucose concentration
Documented Typical hypoglycemia symptoms accompanied by measured plasma
symptomatic glucose ≤70 mg/dL (≤3.9 mmol/L)
hypoglycemia
Asymptomatic Not accompanied by typical hypoglycemia symptoms but with measured
hypoglycemia plasma glucose ≤70 mg/dL (≤3.9 mmol/L)
Probable Typical hypoglycemia symptoms not accompanied by plasma glucose
symptomatic determination but likely caused by plasma glucose ≤70 mg/dL (≤3.9
hypoglycemia mmol/L)
Pseudo-hypoglyce Reports of typical hypoglycemia symptoms with measured plasma glucose

mia >70 mg/dL (>3.9 mmol/L) but approaching that threshold
Seaquist ER, Anderson J, Childs B, et al. Diabetes Care 2013;36(5):1384-95

Risk & Causes of Hypoglycemia
• Tight glycemic control • Hypoglycemia unawareness
• Recurrent hypoglycemia • ESRD
• Loss of glucagon response to • Liver disease

hypoglycemia within 5 years of
T1DM diagnosis • Malnutrition
• Attenuation of EPI, NE, growth • Alcohol ingestion without

hormone, cortisol responses appropriate food
• Autonomic neuropathy
EPI = epinephrine
NE = norepinephrine
ESRD = End Stage Renal Disease
Inpatient Setting (1)
Factors Increasing Risk of Hypoglycemia in an

Inpatient Setting:
1. Interruption of any of the following without
associated change in insulin dosing:
– Meals
– TPN
– Enteral feedings
– Continuous renal replacement therapy
2. Lack of coordination between dietary/nursing =
mistiming of insulin dosage with respect to food
TPN = Total parental nutrition
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract 2006;12:458-68 .
Inpatient Setting (2)
Factors Increasing Risk of Hypoglycemia in

an Inpatient Setting:
3. Inadequate glucose monitoring
4. Lack of coordination between nursing/

transportation services
5. Indecipherable orders
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract 2006;12:458-68 .
Hierarchy of Responses
to Decreases in PG Concentrations
90 –
80 – Counter-regulation
70 – Autonomic symptoms
60 –
Neuroglycopenic symptoms
50 –
40 –
Coma
30 –
20 –
10 – Permanent damage
0 – Death
PG = plasma glucose
Gerich JE et al. Endocr Rev 1991;12:356-71.

Recommendations for Treatment
• Glucose (15–20 g) is the preferred treatment for the

conscious individual with hypoglycemia
– If SMBG 15 min after treatment shows continued
hypoglycemia, the treatment should be repeated.
– Once SMBG glucose returns to normal, the individual

should consume a meal or snack to prevent recurrence
of hypoglycemia.
Pattern Management: Hypoglycemia
Each 5 g of glucose increase your blood glucose ∾15 mg/dL.

Your goal blood glucose after treatment of hypoglycemia
is about 120 mg/dL.
If your blood glucose (mg/dL) is: Eat this much glucose:
< 40 30 g
40-50 25 g
51-60 20 g
61-70 15 g
>70 with symptoms 5-10 g
American Diabetes Association. Intensive Diabetes Management : p167

Prevention of Hypoglycemia
• Adjust regimen for exercise or food intake:

– Insulin-treated patient: decrease prandial insulin
1-2 units for meals preceding/following exercise
– Patient with insulin pump: program temporary

25-50% reduction in basal rate during exercise
– Patient treated with sulfonylurea: reduce dose,

exercise in a.m. and take the medication following
exercise, OR snack before exercising
Summary
• Mild hypoglycemia is a common complication of

therapy in patients with diabetes
• Severe hypoglycemia is a potentially preventable

complication of diabetes therapy
– Adjust therapy for glucose levels, meals, exercise
– Educate patients about symptoms
– Encourage patients to always carry a glucose source
– Provide a glucagon kit with instructions

Case 1
Mr. Y., a 64-year-old man, was diagnosed with diabetes during

a medical checkup one week ago. After consulting with a friend
who also has diabetes, he started taking glybenclamide
5 mg TID.
After a long day at work, he did not eat dinner when he got
home. In the morning, his family found him unresponsive and
sweating profusely.
They immediately measured his blood glucose, found it to be

48 mg/dL, and took him – unconscious – to the nearest hospital.
Case 1 Questions
• What is the patient’s status?
• What is the possible cause of his hypoglycemia?
• How is hypoglycemia managed in the

hospital setting?
• What educational materials should you provide

to the patient/patient’s family?
Case 2
Introduction
Mr. P., a 52-year-old obese man, has had diabetes for
11 years. At the outset, he was managed with
metformin 500 mg TID and gliquidon 1x30 mg.
He enjoyed good glycemic control with FBG and PPBG
~ 100-130 and 150-178 mg/dL, A1C 6.8-7.6%. Blood
pressure is within normal range with no need
for pharmacotherapy.
FBG = fasting blood glucose

PPBG = post-prandial blood glucose
Case 2
Mr. P. returns…
Two years ago, he found he no longer had good control.
He came to see you with a complaint about his eyes, and
tests showed that his A1C was 9.7%, FBG 189 mg/dL and
PPBG 356 mg/dL.
Now he is taking metformin 500 mg BID, glimepiride 2 mg

OD and mixed insulin 70/30 : 16 – 0 – 12 unit. His FBG is
70 to 259 mg/dL and PPBG 189-250 mg/dL.
He sometimes notices symptoms of hypoglycemia

between 9-10 am.
Case 2 Questions
• What is Mr. P.’s health status?
• How do you explain the problems he is having?
• What might be the cause of the hypogylcemia?
• What diagnostic tools might you use to further

assess his health?
• What are your treatment plans for him?

Matur Kesuwun

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Management of Hypoglicemia in

Primary Health Care

dr. Sibli, Sp.PD

DIABETES CARE, VOLUME 32, NUMBER 7,

• Identify the causes of hypoglycemia

• Review the signs and symptoms of hypoglycemia

• Identify the risks associated with hypoglycemia

• Outline strategies to prevent hypoglycemia

A reduction in the serum glucose

Hunger Pallor Weakness, fatigue Cortical -blindness

Sweating Tachycardia Dizziness Hypothermia

Anxiety Widened Headache Seizures

Paresthesias Confusion Coma

Palpitations Behavioral changes

Tremulousness Cognitive- dysfunction

Pseudo-hypoglyce Reports of typical hypoglycemia symptoms with measured plasma glucose

Seaquist ER, Anderson J, Childs B, et al. Diabetes Care 2013;36(5):1384-95

• Tight glycemic control • Hypoglycemia unawareness

• Recurrent hypoglycemia • ESRD

• Loss of glucagon response to • Liver disease

• Attenuation of EPI, NE, growth • Alcohol ingestion without

Factors Increasing Risk of Hypoglycemia in an

Factors Increasing Risk of Hypoglycemia in

4. Lack of coordination between nursing/

Gerich JE et al. Endocr Rev 1991;12:356-71.

• Glucose (15–20 g) is the preferred treatment for the

– Once SMBG glucose returns to normal, the individual

Each 5 g of glucose increase your blood glucose ∾15 mg/dL.

If your blood glucose (mg/dL) is: Eat this much glucose:

American Diabetes Association. Intensive Diabetes Management : p167

• Adjust regimen for exercise or food intake:

– Patient with insulin pump: program temporary

– Patient treated with sulfonylurea: reduce dose,

• Mild hypoglycemia is a common complication of

• Severe hypoglycemia is a potentially preventable

– Adjust therapy for glucose levels, meals, exercise

– Educate patients about symptoms

– Encourage patients to always carry a glucose source

– Provide a glucagon kit with instructions

Mr. Y., a 64-year-old man, was diagnosed with diabetes during

They immediately measured his blood glucose, found it to be

• What is the patient’s status?

• What is the possible cause of his hypoglycemia?

• How is hypoglycemia managed in the

• What educational materials should you provide

FBG = fasting blood glucose

Now he is taking metformin 500 mg BID, glimepiride 2 mg

He sometimes notices symptoms of hypoglycemia

• What is Mr. P.’s health status?

• How do you explain the problems he is having?

• What might be the cause of the hypogylcemia?

• What diagnostic tools might you use to further

• What are your treatment plans for him?

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