Slide 1

Lecture:
Diabetes Acute Complications – Hypoglycemia and DKA

30 minutes
 Slide 2

Management of Hypoglycemia
Lecture

Main Learning Points

• Understand the hypoglycemia

mechanism, diagnosis and how
hypoglycemia should be treated
• Understand how to adjust OAD - or
insulin dosage after hypoglycemic
events
• Understand what causes a DKA event,
how DKA is treated and what to do if
you experience a patient with DKA
 Slide 3

What is hypoglycemia?

neurogenic symptoms due to low plasma glucose

A state of neuroglycopenic and/or neurogenic
levels
symptoms due to low plasma glucose levels

• Low plasma glucose levels defined as:

• ≤70 mg/dL (ADA)1
• <60 mg/dl (PERKENI)2
• <72 mg/dL (CDA)3
• Symptoms respond to the administration of
carbohydrate3

ADA, American Diabetes Association; CDA, Canadian Diabetes Association;

1. ADA. Diabetes Care 2005;28:1245–9; 2. PERKENI Konsensus 2011. 3. Yale et al. Canadian J
Diabetes 26:22–35
 Slide 4

Why address hypoglycemia in diabetes training

• Reducing HbA1c levels associated with prevention or

delay in complications and death
• Hypoglycaemia is a limiting factor in achieving
glycaemic targets
• Hypoglycaemia is associated with morbidity and rarely
even be fatal
• Optimising glycaemic control is of obvious importance:
• $465 billion USD spent to treat diabetes and its
complications in 2011; hypoglycaemia is cost-intensive
• 6.8% of global all-cause mortality attributed to diabetes
in 2010 (4 million deaths)

Cryer et al 2003. Diabetes Care; 26,6: 1902-1912. IDF Diabetes Atlas tth ed., 2009. Roglic and Unwin
2010. Diabetes Research and Clinical Practice; 87: 15-19
 Slide 5

Most common symptoms of Hypoglycemia

Sweating
Blurred vision
Weakness
Tremor
Slurred speech
Palpitations
Hunger
Circumoral paraesthesia
Vertigo
Headache
Cold feeling
Anxiety
Euphoria
Nausea
Difficulties in concentration

0 20 40 60 80 100
Patients (%)

Pramming 1991
 Slide 6

Sequel of hypoglycaemia

• Mild symptomatic hypoglycaemia

• No direct serious clinical effects
• May impair subsequent hypoglycaemia awareness

• Severe hypoglycaemia associated with

• Stroke and transient ischaemic attacks
• Memory loss/cognitive impairment
• Myocardial infarction
• Injury (direct/indirect)
• Death

Turner et al. (UKPDS 33), 1998. The Lancet; 352: 837-853

 Slide 7

Risk Factors of Hypoglycemia

• General risk factors for hypoglycaemia:1,2

• delayed or missed meal
• consuming a smaller meal than planned
• exercise
• use of diabetes medications
• drug/alcohol consumption
• increased insulin sensitivity or decreased insulin clearance
• Risk factors for major hypoglycaemia:3,4
• age/duration of diabetes treatment
• intensive glycaemic control
• hypoglycaemia unawareness
• sleep
• antecedent hypoglycaemia
• history of major hypoglycaemia

1.Briscoe & Davis. Clin Diabetes 2006;24:115–21; 2. ADA Workgroup on Hypoglycemia. Diabetes
Care 2005;28:1245–9. 3. Frier. Diabetes Metab Res Rev 2008;24:87–92; 4. Cryer. Diabetes
2008;57:3169–76
 Slide 8

Hypoglycaemic events occur more often in Type 1

diabetes patients and are less frequent and less severe
in Type 2 diabetes patients both on conventional and
intensive therapy

Conventional Therapy Intensive Therapy

100 100
Events per 100 Patient Years

Events per 100 Patient Years

90 DCCT (T1 DM) 90 DCCT (T1 DM)
80 ACCORD (T2 DM) 80 ACCORD (T2 DM)
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
6.0 6.5 7.0 7.5 8.0 8.5 9.0 6.0 6.5 7.0 7.5 8.0 8.5 9.0
HbA1c (%) HbA1c (%)

Adapted from DCCT Research Group. Diabetes 1997. Adapted from Bonds D., data presented at
ADA 2009
 Slide 9

Prevention of Hypoglycemic Events

• Education
• Symptoms
• Self management
• Proper food intake in therapy
• For elderly patients, caregiver should also be educated
• Repetitive education in patients with decreased cognitive
function
• Self monitoring blood glucose (SMBG)
• Exercise planning
• Measuring blood glucose before exercise
• Consuming carbohydrate
• Adjust insulin dose based on the blood glucose level
• Right type and dose for therapy
 Slide 10

Treatment of mild Hypoglycemia

Treating early signs

First: 10–20 g fast-acting carbohydrate, e.g.:
• 3–6 glucose tablets*
• 90–180 ml fizzy drink or squash (not diet)**
• Two teaspoons of sugar added to a cup of cold drink
• 50–100 ml energy drink (e.g. Lucozade®)*

Then:
• If next meal is due, add extra carbohydrate
• If next meal is not due, eat longer-acting
carbohydrate, such as biscuits or a sandwich

*not widely available in Indonesia

** Indonesia  processed drinks (tea, etc)

RCN 2004
 Slide 11

Treatment of moderate-to-major Hypoglycemia

Treating late signs

Patient requires assistance with treatment
If conscious:
• Carer should help the patient to consume
10–20 g fast-acting carbohydrate
• Dextrose gel* may be useful
If unconscious:
• Don’t put anything in patient’s mouth
• IM or SC glucagon* or IV glucose should be
administered
• Emergency services should be called

IM: intramuscular, SC: subcutaneous, IV: intravenous

RCN 2004; Cryer 2010

 Slide 12

Adjusting Dosage after a Hypoglycemic Event

OAD: Depending on drug

If hypoglycemic events are

repeated, OAD and / or Insulin
dosages should be reduced
Insulin: Initially decrease
with 2 units / day
 Slide 13

Diabetes Ketoacidosis
 Slide 14

What is Diabetes Ketoacidosis

 Acute decompensated metabolic state due to

 severe insulin deficiency
 over-activity of glucagon & other counter-regulatory
hormone

 Common in Type 1; Rare in Type 2

 Potentially life-threatening

 High mortality

 Incidence : 5-8 /1000 diabetic persons/yr

 Mortality rates 9-14 % - Has improved with insulin use 2%

Watkins et al. In: Diabetes and its Management 2003

 Slide 15

Why are patients developing ketoacidosis

The most common events that cause a person with

diabetes to develop diabetic ketoacidosis are:

 infection such as diarrhea, vomiting, and/or high

fever (40%)

 missed or inadequate insulin (25%)

 newly diagnosed or previously unknown diabetes

(15%)

 Various other causes may include a heart attack,

stroke, trauma, stress, alcohol abuse, drug abuse, and
surgery.

 Approximately 5% to 10% of cases have no

identifiable cause
 Slide 16

How to Diagnose Diabetes Ketoacidosis

Symptoms Signs

 Anorexia  Tachycardia

 Nausea  Hypotension

 Vomiting  Hypothermia

 Thirst
 Impaired consciousness
 Polyuria
 Warm dry skin
 Weakness
 Kussmaul respiration
 Abdominal pain
 Acetone odour on breath
 Weight loss
 Slide 17

Diabetes Ketoacidosis Definitions

DKA is defined as:

 Increase serum concentration of ketones

greater than 5 mEq/L (beta
hydroxybutirate acid > 0,6)

 Blood glucose level greater than 250

mg/dL (although it is usually much
higher),

 Blood pH less than 7.3

 Ketonemia and ketonuria are

characteristic, as is a serum bicarbonate
level of 18 mEq/L or less (< 5 mEq/L is
indicative of severe DKA)

Diabetes Care, Vol. 29, Number 12, December 2006

 Slide 18

Objectives and Management of DKA Treatment

Objectives Management

1. To normalize blood 1. Search & treat

glucose as soon as precipitating cause
possible with Insulin
2. Replacing fluids
2. To replace fluids and
reverse ketoacidosis 3. Insulin iv (rapid / short-
acting)
3. Monitoring:
4. Replacing electrolytes -
• Vital signs potassium & magnesium-
if required
• Fluid and electrolyte
balance 5. For GPs: If you observe a
DKA case, immediately
• Glycaemia send the patient to the
hospital
 Slide 19

Initial DKA Treatment in Primary Care

1. Evaluate vital signs and urine

volume
2. IV line, start the rehydration Prepare the patient
3. Check the blood glucose for Hospital
periodically (per hour if possible)

12:00 12:30 1:00 2:00

30 min. 30 min. 60 min.

• Start insulin with bolus IV 180 mU/kgBW, and continue with insulin drip 90
mU/hour/kgBW
• Check blood glucose per hour with glucometer on the way to hospital
 Slide 20

Diabetes Acute Complication – Hypoglycemia and DKA

Lecture

Summary Main Learning Points

• The risk of hypoglycemia is one of the • Understand the hypoglycemia

key limiting factors in reaching optimal mechanism and how hypoglycemia
glucose targets should be treated
• For Insulin, hypoglycemia is mainly a • Understand how to adjust OAD - or
phenomenon occurring in Type 1 insulin dosage after hypoglycemic
diabetes patients events
• Prevention of hypoglycemia requires • Understand what causes a DKA event,
patient education, frequent blood how DKA is treated and what to do if
glucose monitoring and exercise you experience a patient with DKA
planning
• If hypoglycemia occur repeatedly,
reduce the dosage of OAD and/or
Insulin
• DKA should be regarded as an
emergency situation and prompt
treatment with insulin is vital