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Divisi Endokrin-Metabolik Departemen Ilmu Penyakit Dalam FK USU/ RSUP H Adam Malik Medan.
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What is Hypoglycemia?
Hypoglycemia is an abnormally low plasma glucose level that leads to symptoms of sympathetic NS stimulation or of CNS dysfunction.
3. Neurogenic and neuroglycopenic symptoms, and cognitive impairments in range (5055 mg/dl (2.8 3.0 mmol/l).
Missed or delayed meal Eating less food at a meal than planned Vigorous exercise without carbohydrate compensation Taking too much diabetes medicine (e.g., insulin, insulin secretagogues, and meglitinides) Drinking alcohol
Causes
Fasting hypoglycemia
Result of a serious medical condition Insulinomas (most are benign)* Pancreatic tumors-secrete insulin Other tumors (breast, cervix, adrenal glands)* Secrete insulin-like growth factors (IGF) Glucose production by liver inhibited; increased uptake in peripheral tissues
Causes
Postprandial (reactive)
2-5 hrs after eating Early insulin release with excess secretion in response to the hyperglycemia
Alimentary
In patients w/GI procedures (gastrectomy, pyloroplasty, gastrojejunostomy)
Idiopathic alimentary
RARE; over-diagnosed Healthy young-adults 2-4 hrs after meal or after a missed meal
Various Causes
Alcoholic hypoglycemia
Ingestion of alcohol after a long fast
Factitious hypoglycemia
Insulin & sulfonylureas Primarily in health care worker and relatives of diabetics Distribution of incorrect drugs to patients*
*Robinson, Irving, et. Al.
Practice, 38, 1. (1994) Closet Hypoglycemia. Journal of Family
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Glucagon (glycogenolysis and gluconeogenesis). Epinephrine (glycogenolysis and gluconeogenesis and limits glucose utilization) growth hormone (reduce glucose utilization and support its production). Cortisol (reduce glucose utilization and support its production) play less important roles in the control of glucose flux during normal physiologic circumstances, except in critically ill
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Symptoms
BG level at which symptoms develop varies from person to person
Adrenergic Sweating, trembling, anxiety, nausea, pallor, faintness, palpitations, hunger Neuroglycopenic (CNS manifestations) Confusion, fatigue, difficulty speaking, headache, dizziness, inability to concentrate, inappropriate behavior, stupor, coma
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SYMPTOMS OF HYPOGLYCEMIA
Neurogenic (autonomic) trembling palpitations sweating anxiety hunger nausea tingling Neuroglycopenic difficulty concentrating confusion weakness drowsiness vision changes difficulty speaking headache dizziness tiredness
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Management of Hypoglycemia
Lifestyle:
5-6 small meals/day (CHO, PRO, FAT) Spread out intake of CHO evenly (2-4/meal) Avoid foods w/large amounts of CHO Restrict/avoid coffee & alcohol Decrease fat intake (moderate intake <30% of total kcal) Moderate (upper range) PRO intake
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Treatment
Two components:
Relief of symptoms by restoring blood glucose levels within normal ranges Correcting the underlying cause
Immediate:
Eat foods/beverages containing CHO IV glucose may be required
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TREATMENT
GOALS: To detect and treat a low blood glucose level and provides a rapid rise is blood glucose to a safe level eliminating the risk of injury, and relieving symptoms quickly. 15 g of glucose will usually increase blood glucose by 2.1 mmol/L within 20 minutes with adequate symptom relief for most people. 20 g will usually increase blood glucose by 3.6 mmol/L within 45 minutes.
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TREATMENT
Mild to moderate hypoglycemia 15 g of oral carbohydrate (CHO), preferably as glucose or sucrose tablets or solution. Retest blood glucose in 15 minutes; repeat treatment if BG still < 4.0 mmol/L Severe hypoglycemia, conscious 20 g of oral CHO (glucose tablets or equivalent); retest in 15 minutes, repeat treatment if BG still < 4.0 mmol/L Severe hypoglycemia, unconscious adult 1 mg glucagon subcutaneously or intramuscularly or 10 to 25 g of glucose intravenously (20 50 cc of D50W)
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Preventing Hypoglycemia
If blood glucose is < 70 mg/dl, give 1520 g of quick-acting carbohydrate (12 teaspoons of sugar or honey, 1/2 cup of regular soda, 56 pieces of hard candy, glucose gel or tablets as directed, or 1 cup of milk). Test blood glucose 15 minutes after treatment. If it is still < 70 mg/dl, re-treat with 15 g of additional carbohydrate. If blood glucose is not < 70 mg/dl but it is > 1 hour until the next meal, have a snack with starch and protein (crackers and peanut butter, crackers and cheese, half of a sandwich, or crackers and a cup of milk).
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HYPOGLYCEMIA - RECOMMENDATIONS
In hospitalized patients, efforts must be made to ensure that patients using insulin have ready access to an appropriate form of glucose at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus]. In adults, mild to moderate hypoglycemia should be treated by the oral ingestion of 15 g of carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels [Grade B, Level 2]. To wait 15 minutes, retest BG and retreat with another 15 g of carbohydrate if BG level remains < 4.0 mmol/L. In smaller children (< 5 years of age or < 20 kg), 10 g of carbohydrate may be used initially [Grade D, Consensus].
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HYPOGLYCEMIA - RECOMMENDATIONS
Severe hypoglycemia in a conscious adult, should be treated by the oral ingestion of 20 g of carbohydrate, preferably as glucose tablets or equivalent. Patients should be encourage to wait 15 minutes, retest BG and retreat with another 15 g of glucose if the BG level remains < 4.0 mmol/L [Grade D, Consensus]. Severe hypoglycemia in an unconscious individual 5 years of age, in the home situation, should be treated with 1 mg of glucagon subcutaneously or intramuscularly. In children < 5 years of age, a dose of 0.5 mg of glucagon should be given. Caregivers or support persons should call for emergency services and the episode should be discussed with the diabetes healthcare team as soon as possible [Grade D, Consensus].
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HYPOGLYCEMIA - RECOMMENDATIONS
In the home situation, support persons should be taught how to administer glucagon by injection [Grade D, Consensus]. For severe hypoglycemia with unconsciousness in adults, when intravenous (IV) access is available, glucose 10 to 25 g (20 to 50 cc of D50W) should be given over 1 to 3 minutes. The pediatric dose of glucose for IV treatment is 0.5 to 1 g/kg [Grade D, Consensus].
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HYPOGLYCEMIA - RECOMMENDATIONS
In hospitalized patients, a PRN order for glucagon should be considered for any patient at risk for severe hypoglycemia (i.e. requiring insulin and hospitalized for concurrent illness) when IV access is not readily available [Grade D, Consensus]. To prevent repeated hypoglycemia, once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of day. If a meal is > 1 hour away, a snack (including 15 g of carbohydrate and a protein source) is recommended in the absence of complicating factors [Grade D, Consensus].
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Conclusions
Hypoglycemia is rareshould not automatically suspect it on basis of reported symptoms Due to past over-diagnosis, Whipples Triad most important determinant of hypoglycemia In those with diagnosed hypoglycemia, serious underlying medical conditions must be considered Testing for medications in blood important in ruling out insulinomas
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HYPOGLYCEMIA IN DIABETES
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1. doses Insulin (or insulin secretagogue or sensitizer) 2. Exogenous glucose delivery. 3. Endogenous glucose production 4. Glucose utilization 5. Sensitivity to insulin 6. Insulin clearance
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Gliclazide
Repaglinide Glipizide Glimepiride Glibenclamide
1 - 2(2)
1-2 2(1) 3 - 4(3) 5(1)
1) Ferner 1988 (2) Teisse, Diab Med,1994 (3) Dills, Horm Metab Res,1996
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Hypoglycemic risk
Glibenclamide has greatest risk for hypoglycemia (less so when given 2-3 times a day in smaller portions) Repaglinide (3 times a day) seems to have smallest risk, but needs more confirmation on its efficacy in severe DM. Although different receptor-binding explains this difference, the small doses used is crucial.
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(2) hypoglycemia unawareness. a loss of the warning symptoms the first manifestation of hypoglycemia
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Interventions
Mild carbohydrate 10-15 gram Moderate 20-30 gram of carbs Glucagon, 1 mg SC or IM Severe 50% dextrose 25 g IV Glucagon 1 mg IM or IV
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Somogyi Effect
Rebound hyperglycemia
Counterregulatory hormones activate gluconeogenesis and glycogenolysis Hormones supress insulin 12-48 hours Also influenced by excessive carb intake
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Somogyi Effect
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