Canadian Diabetes Association Clinical Practice Guidelines - PowerPoint Presentation

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2018 Clinical Practice GuidelinesHypoglycemia

Chapter 14

Jean-François Yale

MD FRCPC

Breay Paty

MD FRCPC

Peter Senior

MD FRCPCSlide2

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Key ChangesReinforcement of the importance of counselling individuals on insulin or insulin secretagogues and their support persons on the risk, prevention, recognition and treatment of hypoglycemia

New information

on strategies to reduce the risk of hypoglycemia

2018

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide4

Hypoglycemia ChecklistRECOGNIZE

hypoglycemia and

CONFIRM

DIFFERENTIATE

mild-moderate vs. severe

TREAT hypoglycemia but AVOID OVERTREAMENTAVOID hypoglycemia in the future

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide5

Development of neurogenic or neuroglycopenic symptoms

Low blood glucose (<4 mmol/L if on insulin or secretagogue)

Response to carbohydrate load

Neurogenic (autonomic)

Neuroglycopenic

Trembling

Difficulty Concentrating

Palpitations

Confusion

Sweating

Weakness

AnxietyDrowsinessHungerVision ChangesNauseaDifficulty SpeakingDizziness

Definition of Hypoglycemia

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide6

Mild

Autonomic symptoms present

Individual is able to self-treat

Moderate

Autonomic and

neuroglycopenic symptomsIndividual is able to self-treat

Severe

Requires the assistance of another person

Unconsciousness may occur

Plasma glucose is typically <2.8

mmol

/LSeverity of Hypoglycemia2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide7

Risk factors for severe hypoglycemia in people treated with sulfonylureas or insulin

Prior episode of severe hypoglycemia

Current low A1C (<6.0%)

Hypoglycemia unawareness

Long duration of insulin therapy

Autonomic neuropathy

Chronic kidney disease

Low economic status, food insecurity

Low health literacy

Preschool-age children unable to detect and/or treat mild hypoglycemia on their own

Adolescence

PregnancyElderlyCognitive impairment2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide8

Can result in significant morbidity and mortalitySerious obstacle to meet glycemic targets

Counsel patients who drive on insulin or secretagogues re: SMBG and taking appropriate precautions

Drug Induced Hypoglycemia

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

SMBG,

self-monitoring of blood glucose Slide9

Recognize autonomic or neuroglycopenic symptoms

Confirm

if possible (blood glucose <4.0 mmol/L)

Treat

with

“fast sugar” (simple carbohydrate) (15 g) to relieve symptomsRetest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if neededEat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus proteinSteps to Address Hypoglycemia

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide10

15 g of glucose in the form of glucose tablets15 mL (3 teaspoons) or 3 packets of sugar dissolved in water150 mL of juice or regular soft drink

6 Lifesavers (1 = 2.5 g of carbohydrate)

15 mL (1 tablespoon) of honey

Examples of 15 g Simple Carbohydrate

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide11

Treatment of SEVERE Hypoglycemia in Unconscious Person with no IV Access

Treat

with

1 mg of glucagon

subcutaneously or intramuscularly

Call 911Discuss with diabetes health-care team

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide12

Treatment of SEVERE Hypoglycemia in Unconscious Person with IV Access

Treat

with

10-25 g (20-50 mL of D50W)

of glucose intravenously over 1-3 minutes

Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat with a further 15 g of carbohydrate if neededOnce conscious, eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide13

Treatment of SEVERE Hypoglycemia in Conscious PersonTreat

with

oral

“

fast sugar”

(simple carbohydrate) (20 g) to relieve symptomsRetest in 15 minutes to ensure the BG> 4.0 mmol/L and retreat with a further 15 g of carbohydrate if neededEat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide14

Recommendations 1-2All people with diabetes currently using or starting therapy with

insulin

or

insulin secretagogues

and their support persons should be

counselled about the risk, prevention, recognition and treatment of hypoglycemia. Risk factors for severe hypoglycemia should be identified and addressed [Grade D, Consensus]The DHC team should review the person with diabetes’ experience with hypoglycemia at each visit including an estimate of cause, frequency, symptoms, recognition, severity and treatment, as well as the risk of driving with hypoglycemia [Grade D, Consensus]

2018

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

DHC,

diabetes health-care teamSlide15

Recommendation 3

3. In people with diabetes at increased risk of hypoglycemia, the following

strategies may be used to reduce the risk

of hypoglycemia:

Avoidance of  pharmacotherapies

associated with increased risk of recurrent or severe hypoglycemia [Grade D, Consensus] (see Glycemic Management  in Adults with Type 1 Diabetes in Adults with Type 1 Diabetes; Pharmacologic Glycemic Management of Type 2 Diabetes in Adults, for further discussion of drug-induced hypoglycemia)A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control [Grade B, Level 2]Increased frequency of SMBG, including periodic assessment during sleeping hours [Grade D, Consensus]Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4]

A

psycho-behavioural intervention program

(blood glucose awareness training)

[Grade C, Level 3]

Structured diabetes education and frequent follow-up

[Grade C, Level 3 for type 1 diabetes; Grade D, Consensus for type 2]20182018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSMBG, self-monitoring of blood glucose Slide16

Recommendation 4In people with diabetes with recurrent

, or

severe hypoglycemia

, or

impaired awareness

of hypoglycemia, the following strategies may be considered to reduce or eliminate the risk of severe hypoglycemia and to attempt to regain hypoglycemia awareness:Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4]CSII or CGM or sensor augmented pump with education and follow-up for type 1 diabetes [Grade B, Level 2]Islet Transplantation for type 1 diabetes [Grade C, Level 3]Pancreas transplantation for

type 1

diabetes

[Grade D, Level 4]

2018

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaCGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infusion Slide17

Recommendation 5Mild to moderate hypoglycemia should be treated by the oral ingestion of

15 g

carbohydrate, preferably as

glucose or sucrose tablets

or solution. These are preferable to orange juice and glucose gels

[Grade B, Level 2]. People with diabetes should retest BG in 15 minutes and re-treat with another 15 g carbohydrate if the BG level remains <4.0 mmol/L [Grade D, Consensus]Note: This does not apply to children. See Type 1 Diabetes in Children and Adolescents; and Type 2 Diabetes in Children and Adolescents, for treatment options in children

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

BG,

blood glucose Slide18

Recommendation 66. Severe hypoglycemia in a

conscious

person with diabetes should be treated by oral ingestion of

20 g carbohydrate

, preferably as

glucose tablets or equivalent. BG should be retested in 15 minutes and then re-treated with another 15 g glucose if the BG level remains <4.0 mmol/L [Grade D, Consensus]

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

BG,

blood glucose Slide19

7. Severe hypoglycemia in an unconscious individual with diabetes

With

no intravenous access

:

1 mg glucagon

should be given subcutaneously or intramuscularly. Caregivers or support persons should call for emergency services and the episode should be discussed with the DHC team as soon as possible [Grade D, Consensus]With intravenous access: 10-25 g (20-50 mL of D50W) of glucose should be given intravenously over 1-3 minutes [Grade D, Consensus]Recommendation 7

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

DHC, diabetes health-care teamSlide20

Recommendations 8-98. Once the hypoglycemia has been reversed, the person should have the usual meal or snack

that is due at that time of the day to prevent repeated hypoglycemia. If a meal is >1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumed

[Grade D, Consensus]

9. For individuals with diabetes at risk of severe hypoglycemia,

support persons

should be taught how to administer glucagon [Grade D, Consensus]

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide21

Key MessagesIt is important to prevent, recognize and treat

hypoglycemic episodes

secondary to the use of insulin or insulin secretagogues

It is safer and more effective to prevent hypoglycemia than to treat it after it occurs, so people with diabetes who are at

high risk for hypoglycemia should be identified and counselled about ways to prevent low blood glucoseIt is important to counsel individuals who are at risk of hypoglycemia and their support persons about the recognition and treatment of hypoglycemia

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide22

Key MessagesThe goals of treatment for hypoglycemia are to detect

and

treat

a low BG level

promptly

by using an intervention that provides the fastest rise in blood glucose to a safe level, to eliminate the risk of injury and to relieve symptoms quickly. Once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia. If a meal is >1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumedIt is important to avoid overtreatment of hypoglycemia, since this can result in rebound hyperglycemia and weight gain

2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

BG,

blood glucose Slide23

Key Messages for People with DiabetesKnow the signs and symptoms of a low blood glucose level. Some of the more common symptoms of low blood glucose are trembling, sweating, anxiety, confusion, difficulty concentrating or nausea. Not all symptoms will be present and some individuals may have other or no symptoms

Carry a source of fast acting carbohydrate with you at all times such as glucose tablets, lifesavers and/or a juice box

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide24

Key Messages for People with DiabetesWear diabetes identification (i.e. a MedicAlert® bracelet)

Talk with your diabetes health-care team about prevention and emergency treatment of a severe low blood glucose associated with confusion, loss of consciousness or seizure

2018 Diabetes Canada CPG – Chapter 14. HypoglycemiaSlide25

Visit guidelines.diabetes.ca Slide26

Or download the AppSlide27

Diabetes Canada Clinical Practice Guidelines

www.guidelines.diabetes.ca

– for health-care providers

1-800-BANTING (226-8464)

www.diabetes.ca – for people with diabetes