Diabetic hypoglycemia from prevention to management. Presented by : Dr Ahmed Elawaa Pediatric Endocrine Consultant Hamad General Hospital 15/11/2015
What are the acute complication of Diabetes? DKA Hypoglycemia Hyperosmolar coma Which one is the commonest complication ?
Which one is the commonest complication ? What are the acute complication of Diabetes? DKA Hypoglycemia Hyperosmolar coma Which one is the commonest complication ?
Should I be worried if the patient have hypoglycemia? Why? Acute sequelae : Seizure , brain damage and death (prolonged severe hypoglycemia is responsible for 5 to 10 %of deaths in patients with T1DM) Chronic sequelae :
Should I be worried if the patient have hypoglycemia? Why? Acute sequelae : Seizure , brain damage and death (prolonged severe hypoglycemia is responsible for 5 to 10 %of deaths in patients with T1DM) Chronic sequelae : Effects the brain development and learning abilities in young children if sever and persistence .
Case 1: Is this considered as hypoglycemia ? Ali is a 3 years old boy known to have type 1 DM for 5 years His RBS pre-lunch is of 50 mg/dl (3mmol/l) Is this considered as hypoglycemia ?
What is the definition of hypoglycemia in diabetes ?? <70 mg/dl (<3.9mmol/L) 25 mg/dl <45 mg/dl <55 mg/dl <70 mg/dl <80 mg/dl <90 mg/dl <100 mg/dl
Pathophysiology of hypoglycemia
Symptoms of hypoglycemia Adrenergic symptoms : Tremor, pallor, rapid heart rate, palpitations, and diaphoresis. Neuroglycopenic symptoms :Fatigue, lethargy, headaches, behavior changes, drowsiness, unconsciousness, seizures, or coma. Behavioral symptoms : Behavioral symptoms include irritability, agitation, erratic behavior, quietness or tantrums, and are most common in younger children.
Ali rbs was 50 mg/dl but he was clinically very well is he considered to be hypoglycemic or not? ! Yes ,but I can Observe until the patient is symptomatic Yes and I should treat immediately No not hypoglycemia but need to be observe the child No not hypoglycemia and no needs to be observe the child
Hypoglycemia unawareness Ali rbs was 50 mg/dl but he was clinically very well is he considered to be hypoglycemic or not? ! Yes ,but can wait until the patient is symptomatic Yes and I should treat immediately No not hypoglycemia but needs to be observe the child No not hypoglycemia and no needs to be observe the child Hypoglycemia unawareness
How to treat Ali’s hypoglycemia? Is the Level of consciousness impaired ? Yes / No
How to treat Ali’s hypoglycemia? Is the Level of consciousness impaired ? Yes / No 1-2 glucose spoon Remember: Use simple sugar only . Than 70 mg/dl
How to treat Ali’s hypoglycemia? Is the Level of consciousness impaired ? Yes / No Give glucagon injection •≤20 kg: 0.5 mg (or 0.02 to 0.03 mg/kg) •>20 kg: 1 mg
How to treat Ali’s hypoglycemia? Is the Level of consciousness normal ? Yes / No Give glucagon injection •≤20 kg: 0.5 mg (or 0.02 to 0.03 mg/kg) •>20 kg: 1 mg Glucose gel IV D102.5ml/kg Rule of 15
Now Ali rbs reached 90 mg/dl should I do something else ? Check RBS after 1 hr Check RBS after 2 hr Eat small snacke Avoid sleeping immediately
Now the rbs reached 90 mg/dl should I do something else ? Check RBS after 1 hr Check RBS after 2 hr Eat small snacke ( complex carb) Avoid sleeping immediately
Did we finish the treatment of hypoglycemia ? Yes No
Did we finish the treatment of hypoglycemia ? Yes No Look for the possible causes
Look for the possible causes 1- Skipping meal 2- Delaying meal 3- Not eating enough CHO 4- Extra insulin dose (wrong dose) 5- Excessive exercise 6- Lipohypertrophy 7- Illness Illness decrease the TDD temporary
We ruled out all the pervious causes but Ali is still complaining from unexplained recurrent hypoglycemia ? WE have to rule out : Iatrogenic Addison GHD Celiac disease
Remember the predictors for the higher possibility of sever hypoglycemia in DM Non-modifiable predictors : • Age (infancy and adolescence) . • Increased duration of diabetes . Modifiable predictors : • Lower hemoglobinA1c (HbA1c) . • Higher insulin dose.
Case 2: Ahmed is 10 years old boy Known to have type 1 DM joined the foot ball team this month He wants to play his first game for one hour , his RBS pre game is 90 mg/dl Can he play ?
Can Ahmed play foot ball ? Yes he can play immediately as his RBS is normal. Yes he can play immediately but he must to check RBS after 10 mins from the game . Yes he can, but he should eat 50grams of simple sugars first . NO he shouldn’t play as long he has normal blood sugar.
Can Ahmed play foot ball ? Yes he can play immediately as his RBS is normal. Yes he can play immediately but he must to check RBS after 10 mins from the game . Yes he can, but he should eat 50grams of simple sugars first . NO he shouldn’t play as long he has normal blood sugar.
ISPAD 2014 stated : BG levels < 6.7– 8.3 mmol/L (120–150 mg/dL), prior to sustained aerobic exercise is associated with a high probability of hypoglycemia within 60–75 mins During prolonged exercise, 15 g of carbohydrate (CHO) will raise the BG by 1 mmol/L , therefore, 30–45 g of oral CHO required to prevent hypoglycemia for a 30 kg child and 50-75 grams for 50 kg child.
Exercise and hypoglycemia in diabetes
Other factors affecting glucose response to exercise Duration and intensity of exercise Type of activity. Metabolic control Blood glucose level Type and timing of insulin injections Type and timing of food
Avoiding hypoglycemia during physical activity
Avoiding hypoglycemia during physical activity
Ahmed rbs was 55mg/dl , 8hrs after the game could it be related to his exercise? NO as hypoglycemia may occur up to 2hrs after NO as hypoglycemia may occur up to 4hrs after NO as hypoglycemia may occur up to 6hrs after Yes as hypoglycemia may occur up to 10 hrs after Yes as hypoglycemia may occur up to 16 hrs after
Ahmed rbs was 55mg/dl , 8hrs after the game could it be related to his exercise? Due to the late effect of increased insulin sensitivity and delay in replenishing liver and muscle glycogen stores and increase glucose transport into skeletal muscle tissue for at least 16 hours postexercise in diabetic patients NO as hypoglycemia may occur up to 2hrs after NO as hypoglycemia may occur up to 4hrs after NO as hypoglycemia may occur up to 6hrs after Yes as hypoglycemia may occur up to 10 hrs after Yes as hypoglycemia may occur up to 16 hrs after
Remember to advocate for exercise in diabetes Exercise is the third essential component in blood glucose regulation for children with type 1 diabetes, after insulin and dietary management. The benefits of exercise go far wider from weight control, to lowering HbA1c ,reducing cardiovascular risk, and an improved sense of wellbeing
Did we finish the treatment of hypoglycemia ? Yes No
Did we finish the treatment of hypoglycemia ? Yes No
Summary Definition of hypoglycemia in DM Should I treat it immediately ? Can it be a symptomatic ? How to treat it in cases of normal LOC? How to treat it in the case of impaired LOC ?
Thank you Remember the rule of 15