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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:[email protected] 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