4.1 Hypoglycemia

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It is defined biochemically with blood glucose level below 3.9 mmol/L (70 mg/dL) with clinical features of autonomic over activity and neuroglycopenia.

Some people with DM, especially those with persistent high blood glucose, may develop clinical features (particularly autonomic) of hypoglycemia at a higher blood glucose level. Hypoglycemia is more common in T1DM than in T2DM.

4.1.1 Levels of hypoglycemia1

Level 1: blood glucose <3.9-3.0 mmol/L
Level 2: blood glucose <3.0 mmol/L
Level 3: a severe event characterized by altered mental and/or physical status requiring assistance.

4.1.2 Causes of hypoglycemia

  • Taking excess dose of insulin
  • Excess intake of antidiabetic medications, specially insulin secretagogues
  • Delay, omission or undue reduction of a meal
  • Unusual exercise
  • Severe renal or hepatic impairment
  • Over intake of alcohol

4.1.3 Consequences of hypoglycemia2

Recurrent hypoglycemia may cause behavioral change and cognitive impairment. Increased incidence of life-threatening cardiovascular events due to severe hypoglycemia.

4.1.4 Hypoglycemia unawareness and nocturnal hypoglycemia

Occurs in individuals with long standing T1DM, autonomic neuropathy, medications (like nonselective beta-blockers), or very tight glycemic control. Frequent blood glucose should be monitored to prevent hypoglycemia.

Nocturnal hypoglycemia occurs any time during night, usually between 2 and 4 am.

Table 4.1 Clinical features of hypoglycemia1

Table 4.1 Clinical features of hypoglycemia

4.1.5 Treatment of hypoglycemia1,2

Level 1 and 2 hypoglycemia:

  • Treated by the person him/herself or by a family member.
  • It is usually relieved by 15 gm glucose or equivalent food, e.g. a glass of soft drink or fruit juice or snacks or meal (if it is due). These measures are usually adequate to raise blood glucose to reasonably safe limit (5.5 mmol/L).
  • The food/drink is repeated every 15 minutes, and blood glucose should be checked every 15 minutes until the person is stable.
  • Modification in ongoing treatment should be considered. Not to omit insulin/OAD altogether; dose may be reduced according to the condition.
  • Glucagon 1 mg intramuscularly or subcutaneously can be given in those at increased risk of level 2 hypoglycemia if it is available.

Level 3 hypoglycemia

  • 100 ml of 25% dextrose is given intravenously under medical supervision.
  • If hypoglycemia is due to longer acting antidiabetic medications then 10% dextrose infusion should be started and may need to be continued for some time to prevent recurrent hypoglycemia.
  • Ongoing activity of the antidiabetic medication may lead to recurrence of hypoglycemia. Hence, food ingestion is to be ensured after initial recovery.
  • If recovery does not occur, addressing additional causes, modification in treatment and keeping the person under supervision in hospital may be required.
  • Glucagon 1 mg intramuscularly or subcutaneously can be given if it is available.

Hospitalization criteria

  • Level 3 hypoglycemia
  • Recurrent hypoglycemia
  • Hypoglycemia in people on long acting antidiabetic agents

Nocturnal hypoglycemia

  • Reduction of evening dose of insulin
  • Changing time of evening insulin dose with dinner time
  • Taking bed time snacks may be considered
  • These adjustments are made in conjunction with blood glucose monitoring

4.1.6 Prevention of ‘hypo’

  • Frequent monitoring of blood glucose
  • Proper meal timing and amount
  • Avoid unaccustomed exercise
  • Setting higher target for some people, e.g. older people, children, hypoglycemia unawareness