Hyperglycemic Targets & Hypoglycemia Naina Lalani PGY-3 08/05/19 Hyperglycemic Targets & Hypoglycemia

Hyperglycemic Targets There are many bodies/agencies with varied guidelines on diabetes management (AACE, ADA, ACP, NICE, etc) All recommend individualizing HbA1c targets on the basis of patient characteristics comorbid conditions risk for hypoglycemia life expectancy ADA: HbA1c < 7% for the general population AACE: HbA1c ~ 6.5% (if it can be achieved safely) ACP: HbA1c range < 7% - 8% more stringent targets may be appropriate for patients who have a long life expectancy (>15 years), newly diagnosed diabetes without significant co-morbidities

ACP Update ACP released an update to their guidelines on Diabetes Management in 2018, which is essentially more “lenient” Target range HbA1c < 7% - 8% Consider de-intensifying therapeutic regimen if A1c <6.5% If patient is has a life expectancty <10 years due to advanced age, chronic conditions, or lives in a nursing home, treat sx of hyperglycemia rather than target an A1c Based on ACCORD, ADVANCE, VADT trials showing increased adverse events with intensive therapy without consistent improvement in clinical microvascular events, macrovascular events, or death.

ADA Guidelines Diabetes Control and Complications Trial (DCCT) and long term follow-up in the United Kingdom Prospective Diabetes Study (UKPDS) show improved microvascular and macrovascular outcomes, respectively, with more stringent glycemic targets

Hypoglycemia

Clinically significant hypoglycemia: glucose < 54 mg/dL  Insulin secretion ceases when the glucose level falls <80mg/dL

Symptoms of Level 1-2 Hypoglycemia Palpitations Sweating Tremors Hunger Anxiety

Counterregulatory hormones (in order of escalating degree of hypoglycemia): Glucagon Norepinephrine Cortisol Growth Hormone

Level 3 Hypoglycemia If the counterregulatory measures fail or the hypoglycemia is not corrected: Decline in cognitive function Loss of consciousness Seizures Death

Relative Hypoglycemia Patient with symptoms of hypoglycemia but the plasma glucose level is > 70 mg/dL Rapid decreases/correction in glucose in patient with a history of prolonged hyperglycemia (plasma glucose >200 mg/dL) Less likely to occur if treatment to goal glucose level is achieved over a longer period of time in patients with a history of prolonged uncontrolled diabetes

Risk Factors for Hypoglycemia Exercise 15-30g of carbohydrates before exercise Reduce the dose of prandial insulin before exercise Skipped meals or smaller meals Reduced kidney function (esp in elderly patients) Alcohol consumption

Treatment of Hypoglycemia Two-fold treatment: immediate correction & prevention Immediate Correction: Consume 15-20g of carbohydrates, glucose tablets, or glucose gel Recheck BS in 15 min with goal BS >70 if BS >70, repeat above steps Once corrected, consume a meal/snack to avoid continued hypoglycemia If patient is not conscious, use IM glucagon Prevention: Identify risk factors for hypoglycemia Reduce doses of therapeutic agents

MKSAP Question A 40-year-old man with type 1 diabetes mellitus presents to the office. He seeks advice on his diabetes management as he intensifies his exercise routine in preparation for participation in a 10-K race. He reports prolonged hypoglycemia during intense exercise, despite eating a meal prior to the activity. His insulin regimen is insulin glargine and insulin glulisine. His most recent hemoglobin A1c level was 7.0%.

Which of the following is the most appropriate management of this patient's hypoglycemia on the days that he exercises? A Decrease meal-time insulin glulisine dose prior to exercise, continue insulin glargine dose B Discontinue insulin glargine, continue insulin glulisine dose C Increase meal-time protein prior to exercise, continue current insulin doses D Switch insulin glulisine to a sliding-scale regimen, continue insulin glargine dose

Which of the following is the most appropriate management of this patient's hypoglycemia on the days that he exercises? A Decrease meal-time insulin glulisine dose prior to exercise, continue insulin glargine dose B Discontinue insulin glargine, continue insulin glulisine dose C Increase meal-time protein prior to exercise, continue current insulin doses D Switch insulin glulisine to a sliding-scale regimen, continue insulin glargine dose