8/3/2019 Hypo Guidelines Brochure

http://slidepdf.com/reader/full/hypo-guidelines-brochure 1/2

References

1.Yale J-F, Begg I,Gerstein H, et al. 2001 Canadian

Diabetes Association clinical practice guidelines for theprevention and management of hypoglycemia in diabetes.

Can J Diabetes, 2002;26:22-35.

2.Meltzer S, Leiter L,Daneman D, et al.1998 clinicalpractice guidelines for the management of diabetes in

Canada. CMAJ.1998;159 (Suppl 8):S1-S29.

15 Toronto Street

Suite 800Toronto,OntarioM5C 2E3

Phone:416 363-0177Fax: 416 363-7465

E-mail:info@diabetes.ca www.diabetes.ca

416515 00-090 08/02 Q-30M

Definitions

The definition of hypoglycemia continues to be

debated, but can be classified as:

Mild: autonomic-mediated symptoms, patient

can self-treat (blood glucose ≤ 4.0 mmol/L);

Moderate: autonomic and neuroglycopenic-mediated

symptoms, patient can self-treat;

Severe: patient may be unconscious or require

assistance (blood glucose < 2.8 mmol/L).

Incidence and causes

The incidence of hypoglycemia with the use of anti-

hyperglycemic agents is probably underestimated,

occurring in up to 20% of patients.Sulfonylureas,

repaglinide and/or combination therapy increases

the risk of hypoglycemia,so patient education is

essential.

Reports that 85% of hypoglycemic episodes are

related to self-care activities (such as less food, more

insulin, and more activity) stress the need to educate

patients, on both traditional and intensive therapies,

to make appropriate adjustments based on blood

glucose levels. Patients on lispro insulin are at higher

risk of exercise-induced hypoglycemia,and must beeducated on prevention.

Severe hypoglycemia

Major risk factors for se

prior episode of severe h

HbA1c, hypoglycemia u

diabetes, and autonomic

Severe episodes are repo

Adolescents are found to

nocturnal hypoglycemia

tomatic nocturnal hypog

insulin therapy should p

 blood glucose levels at a

peak action of their over

The potential long-term

hypoglycemia are mild i

permanent neurologic s

a more consistent negati

cially those under age 5

of diabetes.These childr

frequent episodes of hyp

This document highlights key messages,revised recommendations and new recommen

Canadian Diabetes Association Clinical Practice Guidelines for the Prevention and Ma

in Diabetes.(1) Readers are referred to the complete guideline document for evidence-

references and exact wording.

& 

UPDATE ON

PreventionManagementof Hypoglycemia

in DiabetesHIGHLIGHTS FOR

HEALTHCARE PROFESSIONALS

8/3/2019 Hypo Guidelines Brochure

http://slidepdf.com/reader/full/hypo-guidelines-brochure 2/2

Treatment

Little evidence is available to support the widely

recommended treatment of 10 g of fast-acting

CHO. Newer research suggests that 15 g of glucose

(monosaccharide) is required to produce a bloodglucose rise of approximately 2.1 mmol/L within

20 minutes.Twenty grams (20 g) oral glucose will

produce a glucose rise of approximately 3.6 mmol/L

at 45 minutes. Milk and orange juice are slower to

raise blood glucose levels. Glucose gel is quite slow –

less than 1 mmol/L rise at 20 minutes – and must be

swallowed to have a significant effect.There is no evi-

dence to support the practice of administer ing glucose

gel buccally, since absorption through the mucosa is

minimal, if any.

New Recommendations

The full document contains 16 new recommendationsfocused on insulin use in type 1 diabetes and treatment

of hypoglycemia.

Highlights include:

◆ Strategies to reduce the risk of nocturnal hypo-

glycemia.

◆ Identification of risk factors for severe hypoglycemia

and strategies to prevent hypoglycemia.

◆ Strategies for individuals with hypoglycemia

unawareness.

◆ Mild to moderate hypoglycemia should be treated

with 15 g of carbohydrate, preferably as glucose or

sucrose tablets. In smaller children,10 g of glucose

may be used initially.◆ Severe hypoglycemia in a conscious person should

 be treated with 20 g of carbohydrate, preferably as

glucose tablets or equivalent. Retreat with another

15 g glucose if blood glucose remains < 4.0 mmol/L

after 15 minutes.

◆ Severe hypoglycemia in an unconscious per son in

the home situation should be treated with 1 mg

glucagon subcutaneously or intramuscularly. In

children 5 years of age or younger,a dose of 0.5

mg should be used.

◆ For severe hypoglycemia with unconsciousness, IV

glucose, 10 to 25 g (20 to 50 cc D50W) given over1 to 3 minutes, is the standard medical and

paramedical treatment.

◆ Once hypoglycemia is reversed, the person should

have their usual meal or snack.A snack including 15 g

of carbohydrate and a protein source is recommended

if a meal is more than 1 hour away and in the absence

of complicating factors.

◆ A PRN order for glucagon should be considered

for any hospitalized patient at risk for severe hypo-

glycemia.

Revised Recommendations

To ensure integration, the numbering system below

refers to the numbered recommendations in the 1998

Clinical Practice Guidelines for the Management of Diabetes

in Canada.(2)

The following are highlights of revisedrecommendations.Unchanged recommendations are

not included. Readers are referred to the 1998 guide-

lines and hypoglycemia guidelines for evidence-based

grading and complete wording.

◆ General advice regarding physical activity includes:

- for those on insulin or insulin secretagogues,

ingest rapidly absorbed carbohydrate if pre-

exercise glucose level is < 5 mmol/L

- for those on insulin injections, administer insulin

into a site away from the most actively exercising

extremities. (Recommendation #30)

◆ Meformin should be considered as initial therapyfor

obese patients with type 2 diabetes. To avoid unnec-

essary hypoglycemia,metfor min, alpha-glucosidase

inhibitors and/or thiazolidinediones should be

considered before using the insulin s ecretagogues

(sulfonylureas and meglitinides) in patients at high

risk of hypoglycemia. (Recommendation #32)

◆ Aspart/Lispro insulin h

rates of hypoglycemia

insulin. Patients exper

episodes on regular inacting insulin analogue

◆ Extreme caution is re

in children age 5 yea

permanent cognitive

age group. (Recommen

◆ Gliclazide may be pre

sulfonylurea is to be u

reduced frequency of h

to glyburide. (Recomm