Danilo F.

Baldemor, MD, MS, DPCP

Internist - Diabetetologist
Magandang Hapon!
Turn me off!
Level of Blood Sugar
 objectives
 What is hypoglycemia?

How do we diagnose hypoglycemia?

How does hypoglycemia happens?

What are the causes of hypoglycemia?

What are the work-ups for hypoglycemia?

Where to go from here?

HYPOGLYCEMIA
HYPOGLYCEMIA
What is Hypoglycemia?
 Background:
 Hypoglycemia is considered present when serum
glucose level is <50 mg/dL.
 An alternative definition is a decrease in the blood
glucose level or its tissue utilization that results in
demonstrable signs or symptoms.
 These signs or symptoms usually include altered
mental status and/or sympathetic nervous system
stimulation. The glucose level at which an
individual becomes symptomatic is highly variable.
Definitions of Hypoglycemia per Protocol
 Symptomatic
- Patient presents symptoms related to hypoglycemia,
confirmed by BG (PG) < 72 mg/dL
 Severe
- Patient presents symptoms related to hypoglycemia
and requires assistance; associated with PG < 56
mg/dL; prompt recovery after oral carbohydrate, IV
glucose, or glucagon administration
 Nocturnal
- Associated with PG < 72 mg/dL; occurs after bedtime
insulin injection and before morning FBG monitoring,
breakfast, or morning administration of oral
antihyperglycemia agent
Riddle M. Rosenstock J. Poster presented at: 62 nd Scientific Sessions of the ADA;
June 14-18, 2002; San Francisco, Calif. Poster 457
 1) Severe hypoglycemia

 An event requiring assistance of another person

to actively administer carbohydrate, glucagons,
or other resuscitative actions. These episodes
may be associated with sufficient
neuroglycopenia to induce seizure or coma.
 Plasma glucose measurements may not be
available during such an event, but neurological
recovery attributable to the restoration of plasma
glucose to normal is considered sufficient
evidence that the event was induced by a low
plasma glucose concentration.
AMERICAN DIABETES ASSOCIATION
WORKGROUP ON HYPOGLYCEMIA
 2) Documented symptomatic
hypoglycemia
 An event during which typical symptoms of
hypoglycemia are accompanied by a
measured plasma glucose concentration
≤70 mg/dl (3.9 mmol/l).

70
3) Asymptomatic hypoglycemia
 An event not accompanied by typical symptoms of
hypoglycemia but with a measured plasma glucose
concentration ≤70 mg/dl.
 Since the glycemic threshold for activation of
glucagon and epinephrine secretion as glucose
levels decline is normally 65–70 mg/dl and since
antecedent plasma glucose concentrations of ≤70
mg/dl reduce sympathoadrenal responses to
subsequent hypoglycemia, this criterion sets the
lower limit for the variation in plasma glucose in
nondiabetic, nonpregnant individuals as the
conservative lower limit for individuals with diabetes.
 4) Probable symptomatic
hypoglycemia
 An event during which symptoms of hypoglycemia are
not accompanied by a plasma glucose determination
(but that was presumably caused by a plasma glucose
concentration ≤70 mg/dl).
 Since many people with diabetes choose to treat
symptoms with oral carbohydrate without a test of
plasma glucose, it is important to recognize these
events as “probable” hypoglycemia. Such self-reported
episodes that are not confirmed by a contemporaneous
low plasma glucose determination may not be suitable
outcome measures for clinical studies that are aimed at
evaluating therapy, but they should be reported.
 5) Relative hypoglycemia
 An event during which the person with diabetes reports
any of the typical symptoms of hypoglycemia, and
interprets those as indicative of hypoglycemia, but with a
measured plasma glucose concentration ≤70 mg/dl.
 This category reflects the fact that patients with
chronically poor glycemic control can experience
symptoms of hypoglycemia at plasma glucose levels ≤70
mg/dl as plasma glucose concentrations decline toward
that level. Though causing distress and interfering with
the patient’s sense of well-being, and potentially limiting
the achievement of optimal glycemic control, such
episodes probably pose no direct harm and therefore may
not be a suitable outcome measure for clinical studies
that are aimed at evaluating therapy, but they should be
reported.
 HYPOGLYCEMIA
1) Severe
2) Documented symptomatic
3) Asymptomatic
4) Probable symptomatic
5) Relative

AMERICAN DIABETES ASSOCIATION

WORKGROUP ON HYPOGLYCEMIA
Food intake  Drug intake

Hypoglycemia
 Whipple’s Triad

1. Symptoms compatible with hypoglycemia,

2. Low plasma or blood glucose concentration, and
3. Resolution of those symptoms after the glucose
concentration is raised to normal.
 Pathophysiology:
 The organ systems that manifest the signs
and symptoms of hypoglycemia are the
central and autonomic nervous systems.
 Insulin
 Counter regulatory hormones – glucagon &
epinephrine
 Mortality/Morbidity: Delay in treatment can
result in profound sequelae, including death.
 Acute sequelae include coma, cardiac dysrhythmia,
and death.
 The risk of permanent neurologic deficits increases
with prolonged hypoglycemia; such deficits can include
hemiparesis, memory impairment, diminished
language skills, decreased abstract thinking
capabilities, and ataxia.
 Because the consequences of hypoglycemia can be
devastating and an antidote is readily available,
diagnosis and treatment must be rapid in any patient
with suspected hypoglycemia, regardless of the cause.
 Sex: Females are affected more than
males.
 Age: Affects predominantly older adults.
How does Hypoglycemia
happens?
 Normal physiological responses to
hypoglycemia
 The human brain primarily uses glucose as its
source of energy.

 Under normal conditions, the brain is unable to

synthesize or store glucose and is exquisitely
vulnerable to glucose deprivation.

 To protect the integrity of the brain, several

physiological mechanisms have evolved to
respond to and limit the effects of hypoglycemia.
Normal physiological responses to
hypoglycemia
In humans, the initial response to a decline in
blood glucose

suppression of endogenous insulin secretion

release of counterregulatory hormones, of which

glucagon and epinephrine (adrenaline) are the
most potent.
 Normal physiological responses to
hypoglycemia
 When blood glucose falls in a nondiabetic adult, the
secretion of counterregulatory hormones and the onset
of cognitive, physiological, and symptomatic changes
occur at reproducible blood glucose thresholds within a
defined hierarchy. Subjective recognition of the
symptoms of hypoglycemia is fundamental to effective
self-management and to prevent progression in severity.

 Symptoms are generated at arterialized blood glucose

concentrations around 2.8–3.2 mmol/l (50–58 mg/dl) and
in young adults have been classified as
neuroglycopenic, autonomic, and malaise.
Hypoglycemic symptoms are idiosyncratic and age
specific.
 Neurogenic (or autonomic) symptoms

 Neuroglycopenic symptoms
 Neurogenic (or autonomic) symptoms are the result of the
perception of physiological changes caused by the activation
of the ANS triggered by hypoglycemia.

 Although all three efferent components of the ANS—

adrenomedullary, sympathetic neural, and parasympathetic
neural — are activated by hypoglycemia,

 Neurogenic symptoms are thought to be caused by

 sympathoadrenal activation and mediated by norepinephrine
released from sympathetic adrenergic postganglionic neurons,
the adrenal medullae, or both,
 by acetylcholine released from cholinergic sympathetic
postganglionic neurons and
 by epinephrine released from the adrenal medullae.
 Some neurogenic symptoms, such as tremulousness,
palpitations, and anxiety/arousal, are adrenergic
(catecholamine mediated);

 whereas others, such as sweating, hunger, and

paresthesias, are cholinergic.

 Awareness of hypoglycemia is largely the result of the

perception of neurogenic symptoms and the recognition that
they are indicative of hypoglycemia.

 Awareness of hypoglycemia is a function of the knowledge

and the experience of the individual, as well as the
physiological responses to low glucose concentrations.
 Neuroglycopenic symptoms are the result of
brain neuronal glucose deprivation.

 They include sensations of warmth, weakness,

and fatigue as well as difficulty thinking,
confusion, behavioral changes (not infrequently
confused with inebriation by others), and
emotional lability.

 They also include seizures, loss of

consciousness, and, if hypoglycemia is severe
and prolonged, brain damage and even death.
 Hypoglycemia Unawareness
 Some people have no symptoms of
hypoglycemia.  They may lose consciousness
without ever knowing their blood glucose levels
were dropping.  This problem is called
hypoglycemia unawareness.
 Hypoglycemia unawareness tends to happen to
people who have had diabetes for many years. 
Hypoglycemia unawareness does not happen to
everyone.  It is more likely in people who have
neuropathy (nerve damage), people on tight
glucose control, and people who take certain
heart or high blood pressure medicines.
 Hypoglycemia Unawareness
 As the years go by, many people continue to have
symptoms of hypoglycemia, but the symptoms change. 
In this case, someone may not recognize a reaction
because it feels different.
 These changes are good reason to check the blood
glucose often, and to alert the friends and family of the
symptoms of hypoglycemia. 

 Treat low or dropping sugar levels even if the pt. feel

fine.  And tell the team if the blood glucose ever drops
below 50 mg/dl without any symptoms.
    FREQUENCY OF HYPOGLYCEMIA WITH
DIFFERENT TREATMENT MODALITIES
Oral antidiabetic agents
 predominantly associated with the insulin secretagogues.

 not a common side effect of treatment with metformin,

TZD, or AGI, although it has been occasionally reported
in association with metformin when food intake is limited.
The frequency of hypoglycemia is lower in people treated
with SU than in those treated with insulin but is probably
underestimated.
 The risk of hypoglycemia of each sulfonylurea relates to
its pharmacokinetic properties and is highest with long-
acting sulfonylureas such as chlorpropamide, glyburide
(glibenclamide), and long-acting glipizide.
Alternative insulin regimens
 Basal insulins can be used safely in combination with oral
antidiabetic agents in people with type 2 diabetes.
 In a systematic review of randomized controlled trials
comparing insulin monotherapy and combination therapy
with oral agents, 13 of 14 studies did not show any
significant difference in hypoglycemia rates between the
different regimens.
 In one study, 41 people with type 2 diabetes treated with
bedtime NPH (isophane) insulin and oral antidiabetic drugs,
49% had experienced infrequent mild hypoglycemia since
commencing insulin, with an incidence of four episodes per
patient per year and no episodes of severe hypoglycemia.
Alternative insulin regimens
 Insulin analogs appear to limit hypoglycemia. In
some studies, the risk of hypoglycemia has been
reported to be lower with long-acting insulin glargine
and insulin detemir when compared with NPH
insulin. Glargine was also associated with a lower
frequency of hypoglycemia than premixed insulins.

 Rapid-acting insulin analogs, such as lispro and

glulisine, were also associated with a lower
frequency of hypoglycemia in people with type 2
diabetes when compared with short-acting (soluble)
regular insulins.
Alternative insulin regimens
 Studies of alternative formulations of insulin,
which can be administered by inhalation, include
a 6-month randomized trial of 299 participants
with type 2 diabetes in which inhaled insulin was
compared with subcutaneous insulin. Glycemic
control was comparable and inhaled insulin was
associated with a relative risk of all
hypoglycemia of 0.89 (95% CI 0.82–0.97) when
compared with subcutaneous insulin.
How do we diagnose
Hypoglycemia?
 History
 Patients often have a history of diabetes
mellitus.
 A history of insulin usage or ingestion of
an oral hypoglycemic agent may be
known, and possible toxic ingestion should
be considered.
 Inquire if the patient is taking any new
medications.
 History
 Obtaining an accurate medical history may
be difficult if the patient's mental status is
altered.
 The medical history may include diabetes
mellitus, renal insufficiency/failure,
alcoholism, hepatic cirrhosis/failure, other
endocrine diseases, or recent surgery.
 History
 The patient's medication and drug history
should be reviewed carefully for potential
causes of hypoglycemia.
 The social history may include ethanol
intake and nutritional deficiency.
 Review systems for weight reduction,
fatigue, somnolence, nausea and
vomiting, and headache.
 Look for other symptoms suggesting
infection.
 History
• Central nervous system
 Headache
 Confusion
 Personality changes
 Cardiovascular system - Palpitations
 GI symptoms
 Hunger
 Nausea
 Belching
 Adrenergic symptoms
 Sweating
 Anxiety
 Tremulousness
 Nervousness
 Polyuria, polydipsia
 Nocturia
 Physical
 Physical findings are nonspecific in
hypoglycemia and generally are related to the
central and autonomic nervous systems.
 Assess VS for hypothermia, tachypnea,
tachycardia, hypertension, and bradycardia
(neonates).
 The HEENT examination may indicate blurred
vision, pupils normal to fixed and dilated, icterus
(usually cholestatic due to hepatic disease), and
parotid pain (due to endocrine causes).
 Physical
 Cardiovascular disturbances may
include tachycardia (bradycardia
in neonates), hypertension or
hypotension, and dysrhythmias.
 Respiratory disturbances may
include dyspnea, tachypnea, and
acute pulmonary edema.
 GI disturbances may include
nausea and vomiting, dyspepsia,
and abdominal cramping.
 Physical
 Skin may be diaphoretic
and warm or show signs of
dehydration with decrease
in turgor.
 Neurologic conditions
include coma, confusion,
fatigue, loss of
coordination, combative or
agitated disposition, stroke
syndrome, tremors,
convulsions, and diplopia.
 What are the
Manifestations of
Hypoglycemia?
 Symptoms
 hunger
 nervousness and shakiness
 perspiration
 dizziness or light-headedness
 sleepiness
 confusion
 difficulty speaking
 feeling anxious or weak
 Symptoms
Hypoglycemia can also happen while you
are sleeping. You might
 cry out or have nightmares
 find that your pajamas or sheets are
damp from perspiration
 feel tired, irritable, or confused when you
wake up
What are the Causes of
Hypoglycemia?
 Causes of Hypoglycemia
 excessive doses of insulin or some
diabetes medications, including SUs and
meglitinides (AGIs, biguanides, and
TZDs alone should not cause
hypoglycemia but can when used with
other diabetes medicines.)
 increased activity or exercise
 excessive drinking of alcohol
 Causes
 Causes of hypoglycemia are varied, but it is
seen most often in diabetic patients.

 Hypoglycemia may result from medication

changes or overdoses, infection, diet changes,
metabolic changes over time, or activity
changes; however, no acute cause may be
found.
 Causes
 Early in the course of Type 2 diabetes, patients
may experience episodes of hypoglycemia
several hours after meals. The symptoms
generally are brief and respond spontaneously.

 Patients with no prior history of hypoglycemia

require a complete workup to find a potentially
treatable disease.
 Causes
 Drugs that may be related to hypoglycemia include the
following: oral hypoglycemics, sulfonamide, phenylbutazone,
insulin, bishydroxy coumarin, salicylates, p-aminobenzoic acid,
propoxyphene, haloperidol, stanozolol, ethanol, hypoglycin,
carbamate insecticide, disopyramide, isoniazid, methanol,
methotrexate, pentamidine, sulfonamide, tricyclic
antidepressants, cytotoxic agents, organophosphates,
propranolol plus ethanol, didanosine, chlorpromazine, quinine,
sulfa drugs, fluoxetine, sertraline, fenfluramine, trimethoprim, 6-
mercaptopurine, thiazide diuretics, thioglycolate, tremetol,
ritodrine, disodium ethylenediaminetetraacetic acid (EDTA),
clofibrate, angiotensin converting enzyme (ACE) inhibitors, and
lithium.
 Factitious hypoglycemia or self-induced hypoglycemia
can be seen in health care workers or in relatives who care for
diabetic family members at home.
 Causes
 Other causes include the following:
 GI surgery
 Idiopathic
 Hepatic disease
 Islet cell tumor/extrapancreatic tumor
 Exercise (in diabetic patients)
 Pregnancy
 Renal glycosuria
 Ketotic hypoglycemia of childhood
 Adrenal insufficiency
 Hypopituitarism
 Enzyme deficiency
 Large tumors (eg, mesenchymal tumors, epithelial tumors, endothelial
tumors)
 Sepsis
 Starvation
 Artifact
 Differentials
 Alcohol and Substance Abuse Evaluation
 Anorexia Nervosa
 Arthritis, Rheumatoid
 HIV Infection & AIDS
 Hypopituitarism
 Hypothyroidism and Myxedema Coma
 Neoplasms, Brain, Lung, Spinal Cord
 Plant Poisoning, Glycosides – Coumarin
 Plant Poisoning, Hypoglycemics
 Shock, Septic
 Systemic Lupus Erythematosus
 Toxicity, Beta-blocker, Isoniazid, Lithium, Organophosphate
and Carbamate, Salicylate
What are the Work-ups for
Hypoglycemia?
 Laboratories
 Treatment and disposition of hypoglycemia are
guided by the history and the clinical picture.
Serum glucose should be measured frequently
and used to guide treatment, because clinical
appearance alone may not reflect the
seriousness of the situation.

 Hypoglycemia is defined according to the

following serum glucose levels:
 <50 mg/dL in men
 <45 mg/dL in women
 <40 mg/dL in infants and children
 Laboratories
 If the cause of hypoglycemia is other than oral
hypoglycemic agents or insulin in a diabetic
patient, other lab tests may be necessary.
 C-peptide measurement: This measurement is
elevated in insulinoma, normal or low with exogenous
insulin, and elevated with oral sulfonylureas.

 Check liver function tests, serum insulin, and cortisol

and thyroid levels.
 Laboratories
 Search for a source of infection. Studies should
be considered to rule out the possibility of a
concurrent occult infection contributing to the
new hypoglycemic episode.
 Complete physical examination
 Chest radiograph
 Urinalysis
 Blood cultures
 Laboratories
 Imaging Studies:
 Performing an abdominal CT scan or an ultrasound to rule out an
abdominal tumor may be appropriate in the patient with new-onset
hypoglycemia and no clear etiology.
 In diabetic patients presenting with hypoglycemia, perform a chest
radiograph to rule out infection.

 Other Tests:
 Plasma glucose overnight fasting - <60 mg/dL
 Plasma glucose 72-hour fasting
 <45 mg/dL (2.5 mmol/L) for females
 <55 mg/dL (3.05 mmol/L for males
 Oral glucose tolerance - <50 mg/dL
 Insulin radioimmunoassay - Insulin levels elevated if islet cell tumor
present
How do we treat
Hypoglycemia?
 Emergency Department Care
 The initial approach should include the following: ABCs,
intravenous (IV) access, oxygen, monitoring, and
Accucheck. Administration of glucose as part of the initial
evaluation of altered mental status often corrects
hypoglycemia.
 Treatment should not be withheld while waiting for a
laboratory glucose value. Because the brain uses glucose
as its primary energy source, neuronal damage may occur
if treatment of hypoglycemia is delayed.
 A hyperglycemic patient with an altered mental status may receive
a bolus of glucose. This procedure is unlikely to harm the patient
with high glucose; however, the delay in giving glucose to the
hypoglycemic patient may be detrimental.
 If an Accucheck can be performed immediately, awaiting the
results of this test (available within 1 minute) before deciding
whether to administer glucose is reasonable.
Emergency Department Care
 Once the diagnosis of hypoglycemia is made,
search carefully for the cause in the previously
healthy patient.

 In the diabetic patient, search diligently for the

cause (eg, medication changes, dietary
changes, new metabolic changes, recent illness,
occult infection) of the episode.
Paano magamot ang
Hypoglycemia?
Treatment of Hypoglycemia
 For the unconscious patient / those
with sensorial changes:
Intravenous glucagon or glucose (50cc
in 50% dextrose followed by 5-10%
dextrose drip
 Treatment
 If you think the blood glucose is too low, use a
blood glucose meter to check the level. If it is 70
mg/dL or below, have one of these "quick fix"
foods right away to raise the blood glucose:
 2 or 3 glucose tablets
 1/2 cup (4 ounces) of any fruit juice
 1/2 cup (4 ounces) of a regular (not diet) soft drink
 1 cup (8 ounces) of milk
 5 or 6 pieces of hard candy
 1 or 2 teaspoons of sugar or honey
How is hypoglycemia treated?
 The acute management of hypoglycemia involves the
rapid delivery of a source of easily absorbed sugar.
 Regular soda, juice, lifesavers, table sugar, and the
like are good options.
 In general, 10-15 grams of glucose is used, followed
by an assessment of symptoms and a blood glucose
check if possible. If after 10 minutes there is no
improvement, another 10-15 grams should be given.
This can be repeated up to 3 times. At that point, the
patient should be considered as not responding to
the therapy and an ambulance should be called.
 The equivalency of 10-15 grams of glucose (approximate
servings) are:
 Ten lifesavers
 4 teaspoons of sugar
 1/2 can of regular soda or juice
 Many people like the idea of treating hypoglycemia with
cake, cookies, and brownies. However, sugar in the form of
complex carbohydrates or sugar combined with fat and
protein are much too slowly absorbed to be useful in the
acute treatment of hypoglycemia.
 Once the acute episode has been treated, a healthy, long-
acting carbohydrate to maintain blood sugars in the
appropriate range should be consumed. Half a sandwich is
a reasonable option.
 Treatment
 After 15 minutes, check the blood glucose again
to make sure that it is no longer too low. If it is
still too low, have another serving. Repeat these
steps until the blood glucose is at least 70.
Then, if it will be an hour or more before the
next meal, have a snack.
 If patient is taking insulin or a diabetes
medication that can cause hypoglycemia,
always carry one of the quick-fix foods with
them. Wearing a medical identification bracelet
or necklace is also a good idea.
 Exercise can also cause hypoglycemia. Check
blood glucose before the exercise.
 Severe hypoglycemia can cause patient to lose
consciousness. In these extreme cases when
they lose consciousness and cannot eat,
glucagon can be injected to quickly raise the
blood glucose level.
 Ask your health care provider if having a
glucagon kit at home and at work is appropriate
for you. This is particularly important if you have
type 1 diabetes. Your family, friends, and co-
workers will need to be taught how to give you a
glucagon injection in an emergency.
 Dextrose (Glucose-D) -- Monosaccharide absorbed from intestine
and distributed, stored, and used by tissues. Parenterally injected
dextrose is used in patients unable to obtain adequate oral intake.
Direct oral absorption results in rapid increase of blood glucose
Drug Name concentrations. Effective in small doses, and no evidence that it
may cause toxicity. Concentrated dextrose infusions provide
higher amounts of glucose and increased caloric intake with
minimum fluid volume.
Long-term management of hypoglycemia is dictated by cause (eg,
insulinoma).
Acute management: 50 mL of 50% dextrose IV bolus after blood
draw
Adult Dose Long-term management: 10% glucose IV infusion in water by
central venous line; avoid vein sclerosis that may occur with
peripheral infusion
Neonates: 200 mg/kg (2 mL/kg 10% glucose in water) IV bolus
Pediatric Dose
Children: 0.5 g/kg dextrose IV bolus
Diabetic coma if blood sugar levels are extremely high
Do not administer concentrated solution if intraspinal or
intracranial hemorrhage present
Contraindications
Avoid in dehydrated patients, especially if severely dehydrated or
those with delirium tremens, hepatic coma, or glucose-galactose
malabsorption syndrome
 Caution when administering parenteral fluids to patients receiving
Interactions corticosteroids or corticotropin, especially if solution contains
sodium ions

Pregnancy A - Safe in pregnancy

May cause nausea, which also may occur with hypoglycemia; IV

solutions may dilute serum electrolyte concentrations or result in
overhydration in fluid overload; caution in patients suffering from
congested states or pulmonary edema; hypertonic dextrose given
peripherally may cause thrombosis (administer instead through
central venous catheter); caution in subclinical diabetes mellitus or
carbohydrate intolerance; increased risk of inducing significant
Precautions hyperglycemia or hyperosmolar syndrome if solution administered
rapidly, especially in patients with chronic uremia or carbohydrate
intolerance; concentrated solutions should not be administered SC
or IM; rates of dextrose infusion higher than 0.5 g/kg/h may
produce glycosuria—at infusion rates of 0.8 g/kg/h, incidence of
glycosuria is 5%; monitor fluid balance, electrolyte concentrations,
and acid-base balance closely; dextrose administration may
produce vitamin B-complex deficiency
 Drug Category: Glucose-elevating agents -- These agents can act in the
pancreas or the peripheral tissues to increase blood glucose levels.

Glucagon hydrochloride -- Pancreatic alpha cells of islets of

Langerhans produce this polypeptide hormone. Exerts effects
opposite of insulin on blood glucose. Elevates blood glucose levels
by inhibiting glycogen synthesis and enhancing formation of
glucose from noncarbohydrate sources, such as proteins and fats
Drug Name (gluconeogenesis).Increases hydrolysis of glycogen to glucose
(glycogenolysis) in liver. Accelerates hepatic glycogenolysis and
lipolysis in adipose tissue by stimulating cyclic AMP synthesis via
adenylyl cyclase and enhancing phosphorylase kinase activity.
Useful when IV access is problematic. May be administered as part
of EMS protocol in patients with altered mental status and no IV
access.

Adult Dose 1-2 mg IV/IM/SC; dose may be repeated every few h

< 20 kg: 0.5 mg (0.5 U) or dose equivalent to 20-30 mcg/kg

Pediatric Dose
> 20 kg: 1 mg (1 U) IV/IM/SC
 Drug Category: Glucose-elevating agents -- These agents can act in the
pancreas or the peripheral tissues to increase blood glucose levels.

Contraindications Documented hypersensitivity; pheochromocytoma

May enhance effects of anticoagulants (although onset may be
Interactions delayed); monitor PT and for signs of bleeding in patients receiving
anticoagulants—adjust dose accordingly
Pregnancy B - Usually safe but benefits must outweigh the risks.

Monitor blood glucose levels in hypoglycemic patients until they are

asymptomatic; effective in treating hypoglycemia only if sufficient
Precautions liver glycogen present, therefore glucagon has virtually no effects
on patients in states of starvation, adrenal insufficiency, or chronic
hypoglycemia
 Diazoxide (Hyperstat) -- Direct inhibitor of insulin secretion.
Increases hepatic glucose output and decreases cellular glucose
uptake. Has very limited role in treating hypoglycemia, but may be
Drug Name indicated in some cases of insulinoma or overdosage with oral
hypoglycemic agents.
Hyperglycemic effect starts within 1 h, lasting maximum of 8 h if
renal function normal. Patients with refractory hypoglycemia may
require high dosages.
200 mg PO q4h
Adult Dose
Infuse 300 mg IV over 30 min as adjunct to glucose infusion
Pediatric Dose 3-8 mg/kg/d divided bid/tid q8-12h
Documented hypersensitivity; aortic coarctation;
Contraindications
pheochromocytoma; arteriovenous shunts; aortic aneurysm

May decrease serum hydantoins, possibly resulting in decreased

Interactions anticonvulsant effects; thiazide diuretics may potentiate
hyperuricemic and antihypertensive effects
Pregnancy C - Safety for use during pregnancy has not been established.

Patients with diabetes mellitus may require treatment for

hyperglycemia; when given prior to delivery, may produce fetal or
Precautions
neonatal hyperbilirubinemia, thrombocytopenia, altered
carbohydrate metabolism, and other adverse reactions
 Further Inpatient Care
 Patients with no known cause or no previous episodes of
hypoglycemia must be admitted for further evaluation.
 For overdose, accidental ingestion, or therapeutic misadventures
with oral hypoglycemics, little correlation exists between the amount
of oral hypoglycemic agent ingested and the length or depth of
coma. These patients require admission.
 Inadequate data are available to predict the extent or the time
course of hypoglycemia in children.

 Chlorpropamide has demonstrated refractory hypoglycemia

for up to 6 days after ingestion. Asymptomatic patients who
have ingested hypoglycemic agents should be observed for
the development of hypoglycemia, because the onset of
action and the half-life are extremely variable. The length of
observation is based on the ingested agent.
 Further Inpatient Care
 Admission criteria
 No obvious cause
 Oral hypoglycemic agent
 Long-acting insulin
 Persistent neurologic deficits

 Discharge may be considered after a high

carbohydrate meal in the ff. situations:
 Obvious cause is found and treated.
 Episode is reversed rapidly.
 Further Outpatient Care
 For patients on either short-acting insulin or
hypoglycemic agents who have not eaten and
have had their hypoglycemia reversed rapidly, a
high carbohydrate meal prior to discharge is
recommended.

 A competent adult who has been directed to

monitor fingerstick glucose measurements
closely during the remainder of the day should
accompany the patient after discharge.
 Deterrence/Prevention
 Patients must be counseled as to the causes
and the early signs and symptoms of
hypoglycemia.

 General outpatient diabetic education or

inpatient diabetic teaching is indicated.
 Complications
 Prolonged hypoglycemia may cause permanent
neurologic deficit or death.

 Unrecognized infection causing hypoglycemia in

diabetic patients may result in recurrent
hypoglycemic spells or progression of the
infection.
 Prognosis
 The prognosis for this condition is excellent if
detected and treated early.

Patient Education
 Diabetic patients with episodes of hypoglycemia
need education in nutrition, checking glucose
levels at home, and early signs and symptoms of
hypoglycemia.
 Recognition of early symptoms is paramount for
self-treatment
 Preventing recurrence of
hypoglycemia
 Treatment of the precipitating event
which caused the hypoglycemia
 Reduction or adjustment of the
implicated medications
 Replacement of the respective
hormones necessary
 Eating meals at the right time
consistently
 Prevention
 To help prevent hypoglycemia, you should
keep in mind several things:
 Your diabetes medications. Some
medications can cause hypoglycemia. Ask
health care provider if yours can. Also,
always take medications and insulin in the
recommended doses and at the
recommended times.
 What to Ask Your Doctor About
Diabetes Medications
 Could my diabetes medication cause
hypoglycemia?
 When should I take my diabetes
medication?
 How much should I take?
 Should I keep taking my diabetes
medication if I am sick?
 Should I adjust my medication before
exercise?
 Normal and target blood glucose ranges
(mg/dL)
 Normal blood glucose levels in people
who do not have diabetes.
 Upon waking (fasting): 70 to 110
 After meals: 70 to 140

 Target blood glucose levels in people

who have diabetes.
 Before meals: 90 to 130
 1 to 2 hours after the start of a meal:

less than 180

 Hypoglycemia (low blood glucose): 70 or
below
 What should I do each day to stay healthy
with diabetes?
 Follow the healthy eating plan that you and your
doctor or dietitian have worked out.

 Be active a total of 30 minutes most days. Ask

your doctor what activities are best for you.

 Take your diabetes medicines at the same times

each day.
 What should I do each day to stay healthy
with diabetes?
 Check your blood glucose every day.
Each time you check your blood glucose,
write the number in your record book.
 Check your feet every day for cuts,
blisters, sores, swelling, redness, or sore
toenails.
 Brushand floss your teeth and gums
every day.
 Don't smoke.
 Charles Schultz Philosophy

 The following is the philosophy of Charles Schultz, the creator of the "Peanuts" comic strip. You don't have to actually answer the questions.

1. Name the five wealthiest people in the world.

2. Name the last five Heisman trophy winners.
3. Name the last five winners of the Miss America.
4. Name ten people who have won the Nobel or Pulitzer Prize.
5. Name the last half dozen Academy Award winner for best actor and actress.
6. Name the last decade's worth of World Series winners.
 Charles Schultz Philosophy

 How did you do?

 The point is, none of us remember the headliners of yesterday. These are no second-rate
achievers. They are the best in their fields. But the applause dies. Awards tarnish.
Achievements are forgotten. Accolades and certificates are buried with their owners.
 Charles Schultz Philosophy

 Here's another quiz. See how you do on this one:

1. List a few teachers who aided your journey through school.

2. Name three friends who have helped you through a difficult time.
3. Name five people who have taught you something worthwhile.
4. Think of a few people who have made you feel appreciated and special.
5. Think of five people you enjoy spending time with.
 Charles Schultz Philosophy
 Easier?

 The lesson: The people who make a difference in your life are not the
ones with the most credentials, the most money, or the most awards.
They are the ones that care.
 Charles Schultz Philosophy

Pass this on to those people who have made a difference in your life. You are receiving this
because you made a difference in mine.
"Don't worry about the world coming to an end today.
It's already tomorrow in Australia." (Charles Schultz)

  

Any comments?
Thank You!
Lets have a break!