TITLE : HYPOGLYCEMIA

INTRODUCTION :

Hypoglycemia is a condition that blood sugar (glucose) level is lower

than normal. Glucose is body's main energy source. Hypoglycemia is often
related to diabetes treatment but other drugs and a variety of conditions which
is rare can cause low blood sugar in people who don't have diabetes.
Hypoglycemia needs immediate treatment when blood sugar levels are low.
For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL)
or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for
hypoglycemia. But numbers might be different every person.
Patients with or without diabetes may experience hypoglycemia in the
hospital due to co-morbidities such as heart failure, renal or liver disease,
malignancy, infection, sepsis or in association with an altered nutritional state.
Additional triggering events include sudden reduction of corticosteroid dose,
altered ability of the patient to report symptoms, reduced oral intake, emesis,
new "nothing by mouth" (NPO) status, inappropriate timing of short-acting or
rapid-acting insulin in relation to meals and unexpected interruption of enteral
feedings or parenteral nutrition.
Patients with diabetes are at a higher risk of hypoglycemia than other
patients due to the added risk of medication errors involving insulin.
Hypoglycemia is associated with increased length of stay and inpatient
mortality. In patients with type 2 diabetes and established cardiovascular
disease (or very high risk for cardiovascular disease), symptomatic
hypoglycemia (<2.8 mmol/L) is associated with increased mortality.
Symptoms of hypoglycemia are including sweating, shakiness,
tachycardia, anxiety, hunger, weakness, fatigue, dizziness, difficulty
concentrating, confusion and blurred vision. In extreme cases, hypoglycemia
may lead to coma and death.
Among people with diabetes, prevention is by matching the foods
eaten with the amount of exercise and the medications used. When people
feel their blood sugar is low, testing with a glucose monitor is recommended.
Some people have few initial symptoms of low blood sugar and frequent
routine testing in this group is recommended. Treatment of hypoglycemia is
by eating foods high in simple sugars or taking dextrose. If a person is not
able to take food by mouth, glucagon by injection or in the nose may help.
The treatment of hypoglycemia unrelated to diabetes includes treating the
underlying problem and a healthy diet. The term "hypoglycemia" is sometimes
incorrectly used to refer to idiopathic postprandial syndrome, a controversial
condition with similar symptoms that occurs following eating but with normal
blood sugar levels.
PROBLEM STATEMENT :

A 58 years old women patient with diabetes mellitus medical history

come to the Emergency Department complaint that she was feel dizziness
and profuse sweating onset because of hypoglycemia.
Patient woke up from sleep and went to toilet. She noted feel dizziness
and profuse sweating. She was checked her blood blood sugar with
glucometer and the result was 2.8 mmol/L. After that, she immediately drink
milo water.
Her last insulin injection at 1845 H and have taking dinner as usual.
After she drank the milo water, she still feel dizziness and profuse sweating.
So she go the hospital for the futher treatment. Doctor ordered for patient
admitted to the ward for maintance her blood sugar.

Patient profile :
NAME : Rashidah Binti Abdullah
AGE : 58 years old
NATION : Melayu
R/N : 16230-21

Examination :
1. Glucometer : 2.7 mmol/L
2. Blood pressure : 169/81 mmHg
3. Pulse rate : 70/min
4. SPO2 : 99% under room air
LITERATURE VIEW :

Hypoglycemia causes recurrent physical and recurrent or even

persistent psychosocial morbidity, and some mortality, in patients with
insulindependent diabetes mellitus (IDDM), and in some patients with non-
insulin-dependent diabetes mellitus (NIDDM). There is now compelling
evidence, from the Diabetes Control and Complications Trial (DCCT), that
metabolic control delays the development and progression of retinopathy,
nephropathy and neuropathy in IDDM, albeit at the expense of an increased
frequency of treatment-induced hypoglycemia. (Philip E. Cryer, 1994)

Hypoglycemia is a common, potentially avoidable consequence of

diabetes treatment and is a major barrier to initiating or intensifying
antihyperglycemic therapy in efforts to achieve better glycemic control.
Therapy regimen and a history of hypoglycemia are the most important
predictors of future events. Other risk factors include renal insufficiency, older
age, and history of hypoglycemia-associated autonomic failure. (Javier
Morales, 2014)

In patients with diabetes treated with insulin or insulin secretagogues,

severe hypoglycemia is more common when glucose control is intensified.
Although most episodes of severe hypoglycemia resolve without apparent
permanent injury, there are anecdotal reports of acute coronary syndromes
coinciding with hypoglycemia in people with type 2 diabetes. (Sophia
Zoungas, 2010)

Hypoglycemia always constitutes an emergency because it signals an

inability of the central nervous system (CNS) to meet its energy needs.
Resultant mental status impairment places the patient and others at risk for
accidents and traumatic injury. Left untreated, hypoglycemia can result in
permanent neurologic damage and death. To make the diagnosis of
hypoglycemia, documentation of plasma glucose below the normal range is
necessary. (Jean-Marc Guettier, 2006)

Hypoglycemia is an important complication of glucose-lowering therapy

in patients with diabetes mellitus. The short- and long-term complications of
diabetes related hypoglycemia include precipitation of acute cerebrovascular
disease, myocardial infarction, neurocognitive dysfunction, retinal cell death
and loss of vision in addition to health-related quality of life issues pertaining
to sleep, driving, employment, recreational activities involving exercise and
travel. (Sanjay Kalra, 2013)
 Hypoglycemia is a clinical and biological syndrome, caused by an
abnormal decrease in plasma glucose levels to below 0.55 g/l (3.0 mmol/l).
Hypoglycemia is responsible for non-specific signs and symptoms which
should be noted in a particular pathological context and for secretion of
counterregulatory hormones (mainly glucagon and catecholamines). Drug-
related hypoglycemia is the most frequent observed cause (mainly in insulin-
treated diabetic patients, but many drugs may be involved), followed par
toxicity (alcohol mainly). (Virally M.L ,1999)
Symptoms caused by a sudden drop in blood glucose [ 3 , 4 ] are
associated with increased autonomic nervous system outflow (adrenergic and
cholinergic symptoms) and include anxiety, tremulousness, palpitation,
sweating, nausea, and hunger. Hypoglycemia is also commonly associated
with symptoms of compromised CNS function because of brain glucose
deprivation (neuroglycopenic symptoms). (Phillip Gorden, 2006)
Recognition of hypoglycemia risk factors, blood glucose monitoring,
selection of appropriate regimens and educational programs for healthcare
professionals and patients with diabetes are the major issues to maintain
good glycemic control, minimize the risk of hypoglycemia, and prevent long-
term complications. (Gita Shafiee, 2012)
For diabetes health-care providers treating most people with diabetes
who are at risk for or are suffering from iatrogenic hypoglycemia, these
principles include selecting appropriate individualized glycemic goals and
providing structured patient education to reduce the incidence of
hypoglycemia. (Philip E. Cryer, 2015)
The risk of hypoglycemia with anti-hyperglycemic agents is an
important limiting factor in the management of type 1 (T1DM) and type 2
(T2DM) diabetes mellitus. While hypoglycemia is more common in T1DM, the
incidence is high in T2DM patients who use insulin or secretagogues,
particularly patients with longer duration of diabetes. The underlying cause of
hypoglycemia in diabetes is a complex interaction between hyperinsulinemia
and compromised physiologic and behavioral responses to falling glucose
levels. (David S. Oyer, 2013)
DISCUSSION :

ETIOLOGY:
A. Drugs
Most cases of hypoglycemia occur in people with diabetes and are caused
by insulin or other drugs especially sulfonylureas that take to lower the levels
of glucose in blood. Hypoglycemia is more common when intense efforts are
made to keep the glucose levels in the blood as close to normal as possible,
or when people who take insulin do not check blood glucose levels frequently
enough. People with diabetes who reduce food intake or who develop chronic
kidney disease are more likely to have hypoglycemia. Older people are more
susceptible than younger people to hypoglycemia resulting from sulfonylurea
drugs.
If after taking a dose of a drug for diabetes, a person eats less than usual
or is more physically active than normal, the drug may lower the level of
glucose in the blood too much. People who have had diabetes for a long time
are particularly prone to hypoglycemia in these situations because they may
not produce enough glucagon or epinephrine to counteract a low level of
glucose in the blood.
Certain drugs other than those for diabetes, most notably pentamidine
which used to treat a form of pneumonia that occurs most often as part of
AIDS and quinine which used to treat muscle cramps occasionally cause
hypoglycemia.

B. Fasting hypoglycemia
In otherwise healthy people, prolonged fasting (even up to several days)
and prolonged strenuous exercise (even after a period of fasting) are unlikely
to cause hypoglycemia.
However, there are several diseases or conditions in which the body fails
to maintain adequate levels of glucose in the blood after a period without food
(fasting hypoglycemia). In people who drink heavily without eating, alcohol
can block the formation of glucose in the liver. In people with advanced liver
disease such as viral hepatitis, cirrhosis or cancer, the liver may not be able to
store and produce sufficient glucose. Infants and children who have an
abnormality of the enzyme systems that control glucose use such as a
glycogen storage disease also may have fasting hypoglycemia.
A rare cause of fasting hypoglycemia is an insulinoma, which is an insulin-
producing tumor in the pancreas. Disorders that lower hormone production by
the pituitary and adrenal glands which is most notably Addison disease can
cause hypoglycemia. Other diseases, such as chronic kidney disease, heart
failure, cancer and sepsis, may also cause hypoglycemia especially in
critically ill people.

C. Reaction to eating
Hypoglycemia can occur after a person eats a meal containing a large
amount of carbohydrates (reactive hypoglycemia) if the body produces more
insulin than is needed. However, this type of reaction is rare. In some cases,
people with normal blood glucose levels experience symptoms that can be
confused with hypoglycemia.
After certain types of bariatric surgery such as gastric bypass surgery,
sugars are absorbed very quickly, stimulating excess insulin production which
then may cause hypoglycemia.
Problems with digestion of some sugars (fructose and galactose) and
amino acids (leucine) may also cause hypoglycemia if an affected person eats
foods containing those substances.
TYPE OF HYPOGLYCEMIA

Hypoglycemia can be categorized into several types . Among the types

of hypoglycemia are :

A. Hypoglycemia Unawareness
Some people with diabetes do not have early warning signs of low blood
glucose, a condition called hypoglycemia unawareness. This condition occurs
most often in people with type 1 diabetes, but it can also occur in people with
type 2 diabetes. People with hypoglycemia unawareness may need to check
their blood glucose level more often so they know when hypoglycemia is
about to occur. They also may need a change in their medications, meal plan,
or physical activity routine.

B. Reactive Hypoglycemia
The causes of most cases of reactive hypoglycemia are still open to
debate. Some researchers suggest that certain people may be more sensitive
to the body’s normal release of the hormone epinephrine, which causes many
of the symptoms of hypoglycemia. Others believe deficiencies in glucagon
secretion might lead to reactive hypoglycemia.

C. Fasting Hypoglycemia
Fasting hypoglycemia is diagnosed from a blood sample that shows a blood
glucose level below 50 mg/dL after an overnight fast, between meals, or after
physical activity. uses of fasting hypoglycemia include certain medications,
alcoholic beverages, critical illnesses, hormonal deficiencies, some kinds of
tumors, and certain conditions occurring in infancy and childhood.
SYMPTOM :

Hypoglycemia symptoms rarely develop until the level of glucose in the

blood falls below 60 mg/dL (3.3 mmol/L). Some people develop symptoms at
slightly higher levels, especially when blood glucose levels fall quickly and
some do not develop symptoms until the glucose levels in their blood are
much lower.
The body first responds to a fall in the level of glucose in the blood by
releasing epinephrine from the adrenal glands. Epinephrine is a hormone that
stimulates the release of glucose from body stores but also causes symptoms
similar to those of an anxiety attack such as sweating, nervousness, shaking,
faintness, palpitations and hunger.
More severe hypoglycemia reduces the glucose supply to the brain,
causing dizziness, fatigue, weakness, headaches, inability to concentrate,
confusion, inappropriate behavior that can be mistaken for drunkenness,
slurred speech, blurred vision, seizures and coma. Severe and prolonged
hypoglycemia may permanently damage the brain.
Symptoms can begin slowly or suddenly, progressing from mild
discomfort to severe confusion or panic within minutes. Sometimes, people
who have had diabetes for many years especially if they have had frequent
episodes of hypoglycemia are no longer able to sense the early symptoms of
hypoglycemia and faintness or even coma may develop without any other
warning.
In a person with an insulinoma, symptoms are likely to occur early in
the morning after an overnight fast especially if the glucose stores in the blood
are further depleted by exercise before breakfast. At first, people with a tumor
usually have only occasional episodes of hypoglycemia, but over months or
years, episodes may become more frequent and severe.
TREATMENT:

A. Immediate treatment of hypoglycemia

The symptoms of hypoglycemia are relieved within minutes of consuming
sugar in any form such as candy, glucose tablets or a sweet drink, such as a
glass of fruit juice. People with recurring episodes of hypoglycemia especially
those with diabetes often prefer to carry glucose tablets because the tablets
take effect quickly and provide a consistent amount of sugar. These people
may benefit from consuming sugar followed by a food that provides longer-
lasting carbohydrates such as bread or crackers. When hypoglycemia is
severe or prolonged and taking sugar by mouth is not possible, doctors will
quickly give glucose intravenously to prevent brain damage.
People who are known to be at risk of episodes of severe hypoglycemia
may keep glucagon on hand for emergencies. Glucagon administration
stimulates the liver to release large amounts of glucose. It is given by injection
or by a new nasal inhaler and generally restores blood glucose to an
adequate level within 5 to 15 minutes. Glucagon kits are easy to use and
family members can be trained to administer the glucagon.

B. Treatment of the cause of hypoglycemia

If a drug is causing hypoglycemia, the dose is adjusted or the drug is
changed. Insulinomas should be removed surgically. However, because
these tumors are small and difficult to locate, a specialist should do the
surgery. Before surgery, the person may be given a drug such as octreotide
or diazoxide to control symptoms. Sometimes more than one tumor is present
and if the surgeon does not find them all a second operation may be
necessary.
People who do not have diabetes but are prone to hypoglycemia often can
avoid episodes by eating frequent small meals rather than the usual three
meals a day. Limiting intake of carbohydrates, especially simple sugars is
sometimes advocated to prevent hypoglycemia that occurs after a meal who
called reactive hypoglycemia. Alpha-glucosidase inhibitors such as acarbose,
which slow the absorption of carbohydrates, have also been used
successfully in people with reactive hypoglycemia and post-bariatric surgery
hypoglycemia.
CONCLUSION :

Hypoglycaemia literally means low blood glucose concentration. Many

apparently healthy subjects may have low blood glucose concentrations
during a prolonged fast or 3–5 h after ingestion of glucose. Pathological
hypoglycaemia should be defined as a clinical syndrome in which symptoms
or signs of hypoglycaemia occur in the presence of low plasma glucose
concentration and that the symptoms or signs are relieved after the plasma
glucose concentration is raised (Whipple’s triad). Although it is frequently
suspected as a cause of symptoms, hypoglycaemia is rare other than in
diabetic patients who are being treated with insulin or oral hypoglycaemic
drugs.
Hypoglycemia has many associated complications adversely affecting
patients' longevity and is an economic burden both for individuals and for
society as a whole. It is important for clinicians to pay close attention to
hypoglycemia when managing patients with diabetes. Implementing
appropriate glycemic targets sets the precedence for which tools will allow
patients to achieve those goals. Selecting or modifying therapy to reduce
hypoglycemia can take one of the variables of diabetes management and turn
it into somewhat more of a constant, minimizing hypoglycemia risk.
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