Sulphonylurea- treated type 2 diabetes Insulin- treated type 2 diabetes Standard insulin therapy in type 1 diabetes Intensively Treated in type 1 diabetes (DCCT) Excessive dosage Error by patient, doctor or pharmacist Increased insulin bioavailability Accelerated absorbtion (exercise, injection into abdomen, change to human insulin) Insulin antibodies, Renal failure, Honeymoon periode Increased insulin sensitivity Counter-regulatory hormon deficiencies (Addison, Hypopituitarism) Weight loss, physical exercise, postpartum, menstrual cycle variation Inadequate carbohydrate response Missed, small or delayed meals Anorexia nervosa, Vomiting (gastroparesis), breast feeding, failure to cover exercise Other factors Exercise, alcohol, drugs Heller SR. Textbook of Diabetes 1, 2003, p.33.1 Autonomic Neuroglycopenic Malaise Sweating Pounding heart Tremor Hunger
Confusion Drawsiness Speech difficulty Incoordination Atypical behaviour Visual disturbance Circumoral paraesthesia Nausea Headache Heller SR. Textbook of Diabetes 1, 2003, p.33.1 Glycaemic thresholds for release of epinephrine and activation of autonomic symptoms and for neuroglycopenic effects in diabetic subject who are aware or unaware of hypoglycaemia Blood glucose (mmol/L) Hypoglycaemia unaware 4 3 2 1 Epinephrine release Sweating, tremor Start of brain dysfunction Confusion/loss of concentration Coma/seizure Permanent brain damage Blood glucose (mmol/L) Hypoglycaemia aware 4 3 2 1 Epinephrine release Sweating, tremor Start of brain dysfunction Confusion/loss of concentration Coma/seizure Permanent brain damage Principal metabolic effects of counter-regulation in response to acute hypoglycaemia + + + Glucagon Vasopressin Growth hormone Cortisol ACTH Hypoglycaemia Relationships between the duration of diabetes 0-9 10-19 20-29 30-39 > 40 100 50 0 Duration of diabetes (years) (c) Severe hypoglycaemia without warning 100 50 0 (b) P a t i e n t s
a f f e c t e d
( % )
Sweating and/or tremor Altered symtoms of hypoglycaemia 100 50 0 (a) Established diagnosis Capillary blood sample Oral glucose (liquid) 120 cc Intramuscular glucagon 0.5 1 mg Repeat after 10 Intravenous glucose 20 30 ml 50% dextrose Evaluation Maintainance 180 200 mg% 10% Dextrose Dextamethasone Komplikasi Kronik Makroangiopati Pembuluh darah jantung Pembuluh darah otak Mikroangiopati Retinopati diabetik Nefropati diabetik Neuropati (perifer)
Komplikasi kronik DM IDF AACE ADA HbA1C (%) < 6.5 6.5 < 7.0 Fasting/preprandial glucose (mmol/L / mg/dL) < 6.0 / < 110 < 6.0 / < 110 3.9-7.2/ 70-130 2-h postprandial glucose (mmol/L / mg/dL) < 7.8 / < 140 < 7.8 / < 140 < 10.0 / < 180* *ADA recommends that postprandial glucose measurements should be made 1-2h after the beginning of the meal IDF : International Diabetes Federation AACE : American Association of Clinical Endocrinologist GLYCEMIC GOALS IN ADULT Principal metabolic effects of counter-regulation in response to acute hypoglycaemia