Natural Ways to Treat Hypoglycemia

Guide To Beating Hypoglycemia

Here's Just A Tiny Glimpse Of The Topics Covered: The 3 main types of hypoglycemia and which type you're most likely suffering from. How snacking on chocolate bars can actually make you Fat and worsen your condition! (If you thought those delicious dark brown bars were great energy- boosters.think again!) The No. 1 question most folks have when it comes to hypoglycemia and hyperglycemia. Why you should insist on a 6-hour Gtt and not a 5-hour one. ( Why it might not be a good idea to consult a doctor to confirm your hypoglycemia. Aside from taking a Gtt, what other methods can you use to determine whether or not you're suffering from this condition? Well, refer Chapter 4, Pgs. 23-26 to take a revealing 67-question test especially designed to find out if you've got the symptoms. An inspiring motivational exercise that will help you effectively banish all of your negative thoughts that prevent you from having peace of mind. 2 good reasons why you should keep a food journal. 3 powerful nutrients that limit the effect of glucose on your blood sugar level. This is vital to a hypoglycemic as it helps slow down the absorption of sugar in the food. The secret impulse that literally forces you to say 'yes' to a candy bar or chocolate whenever you feel the hunger pangs gnawing at you. 2 ingredients that are lethal to a hypoglycemic. 'Hidden sugars' you must know to avoid buying products that can easily worsen your condition. 8 essential rules of food planning that are crucial to your speedy recovery from hypoglycemia. Leave out one of them and it could hurt your chances of recovering. How to create a healthy food plan that's suitable for both vegetarian and non- vegetarian hypoglycemics. Most food plans only focus on non-vegetarians, but this one works great for everybody!

Guide To Beating Hypoglycemia Overview


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Hypoglycemia Associated With Insulin Therapy

A hypoglycemic reaction can vary in severity and may occur in anyone with diabetes. Insulin therapy significantly increases the risk, incidence, and severity of hypoglycemic reactions. Hypoglycemia can be the result of too much insulin, too little food (i.e., skipped or delayed meals and snacks), alcohol intake, or exercise. It can often be prevented by monitoring blood glucose levels, taking insulin and oral medications as prescribed, following a meal plan, limiting alcohol intake, and planning extra snacks if needed to cover the hypoglycemic effects of exercise. The symptoms of hypoglycemia include hunger, headache, irritability, confusion, lethargy, and, in severe cases, seizure or loss of consciousness. Patients treated with insulin or oral hypoglycemic medications should know how to recognize and promptly treat hypoglycemic reactions. Hypoglycemia should be treated immediately if the blood glucose level is less than 70 mg dl, even if the patient is not experiencing symptoms. The...

Control of hypoglycemia

Prevention of severe hypoglycemic episodes is another potential benefit of continuous glucose monitoring devices. One potential step towards prevention of these episodes is better identification of their occurrence. By enabling much more frequent measurement of glucose - especially at night - the continuous glucose monitoring devices could facilitate improved prevention of hypoglycemia. Several studies have demonstrated the ability of the MiniMed CGMS to detect frequent episodes of hypoglycemia that were asymptomatic and not detectable by conventional means 36,54,57 . One of these studies detected previously unrecognized hypoglycemia in 62.5 of type 1 and 46.6 of type 2 diabetes, mostly at night 57 . Similarly, one study demonstrated that GlucoWatch detected about 60 more cases of hypoglycemia than a control group which utilized conventional diabetes management 56 . Theoretically, by demonstrating previously undetected episodes of hypoglycemia, treatment can be tailored to avoid these...

Cortisol Signals Stress Including Low Blood Glucose

A variety of stressors (anxiety, fear, pain, hemorrhage, infections, low blood glucose, starvation) stimulate release of the corticosteroid hormone cortisol from the adrenal cortex. Cortisol acts on muscle, liver, and adipose tissue to supply the organism with fuel to withstand the stress. Cortisol is a relatively slow-acting hormone that alters metabolism by changing the kinds and amounts of certain enzymes synthesized in its target cell, rather than by regulating the activity of existing enzyme molecules.

Trauma Exercise and Hypoglycemia Stimulate the Medulla to Release Catecholamines

Neural stimulation of the cholinergic preganglionic fibers that innervate chromaffin cells triggers the secretion of catecholamines. Stimuli such as injury, anger, anxiety, pain, cold, strenuous exercise, and hypoglycemia generate impulses in these fibers, causing a rapid discharge of the catecholamines into the bloodstream.

Diabetes Mellitus and Hypoglycemia

Inadequate secretion of insulin, or defects in the action of insulin, produce metabolic disturbances that are characteristic of diabetes mellitus. A person with type 1 diabetes requires injections of insulin a person with type 2 diabetes can control this condition by other methods. In both types, hyperglycemia and glycosuria result from a deficiency and or inadequate action of insulin. A person with reactive hypoglycemia, by contrast, secretes excessive amounts of insulin and thus experiences hypoglycemia in response to the stimulus of a carbohydrate meal.


A person with type 1 diabetes mellitus depends on insulin injections to prevent hyperglycemia and ketoacidosis. If inadequate insulin is injected, the person may enter a coma as a result of the ketoacidosis, electrolyte imbalance, and dehydration that develop. An overdose of insulin, however, can also produce a coma as a result of the hypoglycemia (abnormally low blood glucose levels) produced. The physical signs and symptoms of diabetic and hypoglycemic coma are sufficiently different to allow hospital personnel to distinguish between these two types. Less severe symptoms of hypoglycemia are usually produced by an oversecretion of insulin from the islets of Langerhans after a carbohydrate meal. This reactive hypoglycemia, caused by an exaggerated response of the beta cells to a rise in blood glucose, is most commonly seen in adults who are genetically predisposed to type 2 diabetes. For this reason, people with reactive hypo-glycemia must limit their intake of carbohydrates and eat...

Immunoassay Of Endogenous Plasma Insulin In

For years investigators have sought an assay for insulin which would combine virtually absolute specificity with a high degree of sensitivity, sufficiently exquisite for measurement of the minute insulin concentrations usually present in the circulation. Methods in use recently depend on the ability of insulin to exert an effect on the metabolism of glucose in vivo or in excised muscle or adipose tissue. Thus, the insulin concentration in plasma has been estimated a) from the degree of hypoglycemia produced in hypophysec-tomized, adrenalectomized, alloxan-diabetic rats (1) b) from the augmentation of glucose uptake by isolated rat hemidiaphragm (2) or c) from the increased oxidation of glucose- 1-C14 by the rat epididymal fat pad (3). Since there have been reports indicating the presence, in plasma, of inhibitors of insulin action (4) and of noninsulin substances capable of inducing an insulinlike effect (5, 6), these procedures, while yielding interesting information regarding the...

Important Concepts of Epilepsy

In general, epileptic conditions can be thought of in three broad categories. In the first place seizures can occur in a normal brain, precipitated by specific factors (such as hypoxia or hypoglycemia). This type of seizure may be experienced by anyone, depending on the circumstances. Second, seizures can occur in an apparently structurally normal brain, but with a known tendency to seizures, whether genetic, biochemical, or otherwise. Finally, seizures can occur in a brain that has a definite structural abnormality, either focally or diffusely (24). While this may seem an obvious distinction, it is essential to determine which category any given patient fits into, and it is not always immediately obvious which situation applies. In order to make this distinction the clinical history (the context) and investigations such as EEG (function) and MRI (brain structure) may be essential. To begin the process of analysis (and subsequently to be able to communicate our findings) the following...

Identifying Medical Errors Through Review of the Medical Emergency Team Response

The University of Pittsburgh Medical Center introduced a MET in 1988 however, it was not until 1999 that the institution could reliably initiate the MET response when a patient developed a medical crisis. The keys to effective implementation are described by Foraida et al. (15) and include the creation of objective criteria, posting the criteria in every nursing unit, getting medical executive committee support to allow nursing staff to trigger a MET response without physician approval, and both positive and negative reinforcement through email. The MET quality improvement committee, which includes physicians, nursing staff, and others, reviews all MET responses to identify medical errors and provides this information to the appropriate department for follow-up and suggestions for improvement (16). The team identified errors in patient management in 114 (31.4 ) of the total MET responses over an 8-month period, including patient treatment errors such as hyperkalemia and narcotic...

From Symptom Perception to Action

Without the correct interpretation of the cause of the symptoms is equally dangerous. Furthermore, it is obvious that someone who does interpret symptoms correctly as being caused by hypoglycaemia, but who does not take action to treat the low blood glucose, will be at the same risk. These and other steps toward the avoidance of severe hypoglycaemia demonstrate the key role of education about symptoms in people with diabetes (Gonder-Frederick et al., 1997). The psycho-educational programmes of Blood Glucose Awareness Training (BGAT Schachinger et al., 2005) and Hypoglycemia Anticipation, Awareness and Treatment Training (HAATT Cox et al., 2004) have led to better recognition of hypoglycaemic states and reduced frequency of hypoglycaemia. Figure 2.2 outlines the stages that intervene between low blood glucose occurring in an individual and the implementation of effective treatment (Gonder-Frederick et al., 1997). It is interesting to note the importance of behavioural factors in...

Are the Cognitive Changes During Acute Hypoglycaemia Important and Valid

With very mild hypoglycaemia (blood glucose below 3.8mmol l) the diabetic drivers committed significant driving errors, and during hypoglycaemia the patients often drove very slowly, possibly using a compensatory mechanism to avoid errors. Despite this, more global errors of driving were committed and about half of the participants, despite demonstrating a seriously impaired ability to drive, said they felt competent to drive irrespective of their low blood glucose It cannot be stated with certainty that the findings obtained in a driving simulator will apply to real-life driving. However, studies that examine the practical cognitive effects of hypoglycaemia are invaluable and more are required.

Pharmacological Treatment of Obesity in Schizophrenia

Treatment of bipolar disorder, causes a decrease in appetite and sustained weight loss in obese individuals. It has not been systematically studied as primarily a weight loss agent but has demonstrated weight loss in patients with epilepsy and bipolar disorders (McElroy et al. 2000 Norton et al. 1997 Rosenfeld et al. 1997) and is being tested in binge-eating disorder (Yanovski and Yanovski 2002). The use of H2 antagonists for weight loss has been suggested in the literature, with speculation that H2 antagonism may affect weight either by decreasing appetite via increases in cholecystokinin, a hormone that may signal satiety to the brain, or through the suppression of gastric acid secretion, which may decrease appetite (Sacchetti et al. 2000). Nizatidine, a histamine H2 blocking agent, was recently compared with placebo as an adjunct to olanzapine treatment, and modest reductions in weight gain were seen in patients receiving 300 mg of nizatidine versus placebo however, weight gain...

Adverse Reactions

More than half of the patients receiving this drug by the parenteral route experience some adverse reaction. Severe and sometimes life-threatening reactions include leukopenia (low white blood cell count), hypoglycemia (low blood sugar), thrombocytopenia (low platelet count), and hypotension (low blood pressure). Moderate or less severe reactions include changes in some laboratory tests, such as the serum creatinine and liver function tests. Other adverse reactions include anxiety, headache, hypotension, chills, nausea, and anorexia. Aerosol administration may result in fatigue, a metallic taste in the mouth, shortness of breath, and anorexia.

Contraindications Precautions And Interactions

Rifampin is contraindicated in patients with a history of hypersensitivity to the drug. The drug is used with caution during lactation, in patients with hepatic and renal impairment, and during pregnancy. Serum concentrations of digoxin may be decreased by rifampin. Isoniazid and rifampin administered concurrently may result in a higher risk of hepatotoxicity than when either drug is used alone. The use of rifampin with the oral anticoagulants or oral hypoglycemics may decrease the effects of the anticoagulant or hypoglycemic drug. There is a decrease in the effect of the oral contraceptives, chloram-phenicol, phenytoin, and verapamil when these agents are administered concurrently with rifampin.

Neutropenia Associated with Metabolic Diseases

In glycogen storage disease type IB, there is impairment of glucose-6-phosphate-translocase, an enzyme necessary for the transport of glucose-6-phosphate from the cytoplasm to the endoplasmic reticulum, the site where glucose-6-phosphate is hydrolyzed to glucose and inorganic phosphate by an enzyme glucose-6-phos-phatase. As a result of the low availability of glucose, these patients develop hypo-glycemia, defective chemotaxis, and recurrent infections. The mechanism of neutropenia is not known in this disease. The bone marrow is hypercellular with abundant neutrophils.

Post Therapy Evaluation and Treatment of Hormone Deficiencies

Once the decision is made to evaluate the patient's GH axis, a stimulation test must be done, because basal GH or IGF-1 levels are not usually diagnostic. The most sensitive stimulation test for GH deficiency is an insulin tolerance test, in which subjects are rendered hypoglycemic with an insulin injection and the GH response is measured. However, this is a cumbersome test and is not recommended in older patients or those with cardiac disease or seizures. There is no consensus as to an acceptable alternative test, although a recent direct comparison of five commonly used tests (including the insulin tolerance test) suggests that a combination of arginine and growth hormone-releasing hormone (GHRH) provides the greatest reliability (38,39).

Recommended SBGM Test Frequency

Experience has shown that frequent monitoring augments patients' ability to meet their treatment goals and provides the needed feedback to pursue self-management. Still, the times and frequency of testing vary widely among individual patients, depending on their treatment goals, treatment regimen and its complexity, motivation, variability of dietary and exercise habits, physical and cognitive abilities, financial constraints, and concerns for hypoglycemia, ft is generally recommended that patients test often enough to be familiar with their usual glycemia pattern, including testing under various dietary, work, and exercise conditions. The most common practice is testing before meals and at bedtime, and occasionally between 1 and 3 a.m. Also, 2-hour post-meal testing is being increasingly recommended to ascertain postprandial glucose control, especially in patients taking rapid-acting insulin analogs or oral agents such as Repaglinide and Nateg-linide. All patients should have testing...

Diseases Associated With Kir Channels

Three inherited diseases have been associated with mutations in Kir channels to date, two of which are found in man and one in mouse. Bartter's syndrome is a renal tubular disorder characterised by salt-wasting, hypokalaemia and metabolic acidosis. Some Bartter's kindreds have mutations in the gene for Kir1.1. The weaver mouse results from a mutation in the pore region of Kir3.2 which makes the channel permeable to Na+ ions. The mutation leads to the selective death of brain neurones and thus to the ataxic gait that characterises the weaver phenotype. Familial persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI) is associated with mutations in the SUR1 or Kir6.2 subunits of the -cell KATP channel. These result in the lack of functional KATP channel activity and lead to unregulated insulin secretion and, as a consequence, very low blood glucose levels.

Therapeutic Implications

Consideration of the known derangements in platelet function, the coagulation system, and the fibrinolytic system and their probable contributions to exacerbation of macrovascular disease in type 2 diabetes give rise to several therapeutic considerations. Stringent glycemic control is an imperative to protect patients against microvascular complications including nephropathy, retinopathy, and neuropathy. However, we believe it should be achieved under conditions in which prevailing concentrations of insulin in blood are minimized. Furthermore, adjunctive measures are likely to be helpful. Empirical use of aspirin (160 to 325 mg day in a single dose) seems appropriate in view of the high likelihood that covert coronary artery disease is present even in asymptomatic subjects with type 2 diabetes and the compelling evidence that prophylactic aspirin reduces the risk of heart attack when coronary disease is present. Reduction of angiotensin-II and IV levels, known to stimulate PAI-1...

Classifying Symptoms of Hypoglycaemia

Hypoglycaemia has effects on more than one part of the body, and the symptoms of hypoglycaemia reflect this. First, the direct effects of a low blood glucose concentration on the brain - especially the cerebral cortex - cause neuroglycopenic symptoms. Second, autonomic symptoms result from activation of parts of the autonomic nervous system. Finally, there may be some non-specific symptoms that are not directly generated by either of these two mechanisms. It is only recently that scientific investigations have taken place to confirm the idea that these separable groups of hypoglycaemic symptoms exist.

Conventional Antipsychotic Agents Diabetes and Glucose Intolerance

Conventional antipsychotic agents, which have primarily antidopaminer-gic activity, may alter glucose-insulin homeostasis (Hagg et al. 1998). In particular, the low-potency phenothiazines may induce diabetes mellitus or aggravate existing diabetes mellitus (Hagg et al. 1998 Haupt and Newcomer 2001). Because of this finding, chlorpromazine has been used to prevent hypoglycemia in patients with malignant insulinoma. Furthermore, chlorpromazine has been shown to induce hyperglycemia in healthy volunteers as well as in patients with latent diabetes (Hagg et al. 1998).

Mechanisms Of Counterregulatory Failure

As mentioned previously, these defects in glucose counterregulation are not 'all or nothing' changes but can be influenced by the prevailing standard of glycaemic control and by the frequency of hypoglycaemic episodes. Various theories relate to the clinical observation that blood glucose thresholds for the release of counterregulatory hormone levels can change after periods of recurrent hypoglycaemia (Cryer, 2005). These may relate to changes at the level of the CNS, which co-ordinates the usual responses to low blood glucose levels. At present there is little evidence to suggest that the alterations associated with recurrent hypoglycaemia occur at glucose sensors outside the CNS, for example, within the portal vein.

Age Obesity And Glucose Counterregulation

Advanced age, in otherwise healthy people, does not appear to diminish or delay coun-terregulatory responses to hypoglycaemia (Brierley et al., 1995), although the magnitude of responses of epinephrine and glucagon is lower at milder hypoglycaemic levels (around 3.4mmol l ) compared to younger non-diabetic subjects, but is much more comparable with a more profound hypoglycaemic stimulus (2.8 mmol l) (Ortiz-Alonso et al., 1994) (See Chapter 11). The magnitude of counterregulatory responses to low blood glucose levels following preceding hypoglycaemia also appears to depend on the gender of experimental subjects, with men having blunted responses compared to women (Davis et al., 2000b).

Metabolic Signals Modulate Hypocretin Neuron Activity

In early studies of hypocretin2 reported that injections of the peptide into the CNS increased feeding. Food deprivation enhanced hypocretin mRNA, 2 leptin blocked the fasting-mediated rise in hypocretin mRNA,49 and 2-deoxyglucose reduced hypocretin mRNA.50 Hypocretin mRNA is also decreased in the genetically obese mice ob ob and db db.51 Hypocretin may alter insulin secretion.52 Insulin induced hypoglycemia enhances hypocretin mRNA and c-Fos.5354 The finding in hypocretin neurons that gene expression was shifted by changes in energy balance suggested the cells might respond to signals of metabolic state.

Pathogenesis Of Impaired Awareness Of Hypoglycaemia

Chronic exposure to low blood glucose Recurrent transient exposure to low blood glucose For many years, clinicians have recognised that the glycaemic threshold for the onset of hypoglycaemic symptoms is higher in patients with a long duration of type 1 diabetes who require a much lower blood glucose to provoke a symptomatic response. Lawrence (1941) wrote that 'as years of insulin life go on, sometimes only after 5-10 years, I find it almost the rule that the type of insulin reactions change, the premonitory autonomic symptoms are missed out and the patient proceeds directly to the more serious manifestations affecting the central nervous system'. He astutely suggested that 'the tissues may become attuned to a lower sugar concentration'. Recent studies in animals and humans have shown that the brain does adapt to chronic exposure to low blood glucose (see below) but this may not be beneficial to the individual with diabetes who is treated with insulin, i.e., it is a maladaptive...

Continuous glucose monitoring devices

One of the advantages of these kinds of devices over self-monitoring blood glucose devices (SMBG) is that frequent measurements allow for a more precise understanding of daily glucose fluctuations. In addition, when approved as a stand alone device, continuous glucose sensors devices could eventually be a component of the mechanical artificial pancreas and eliminate the dreaded pain and fear of frequent finger lancing. For example, it has been demonstrated with one of these devices (MiniMed Continuous Glucose Monitoring System) that there are often substantial postprandial increases in plasma glucose levels, even in patients with satisfactory HBA1c levels who use pre-meal doses of rapid acting insulin analogs 31,32,33,34 . This device has also revealed frequent episodes of asymptomatic hypoglycemia (< 60mg dL), especially at night 34,35 , although these readings must be interpreted carefully because the system is less accurate at low glucose levels and is considered generally...

Regulating Other Functions

The islets of Langerhans in the pancreas secrete two antagonistic protein hormones, insulin and glucagon. In response to high glucose levels in the blood (as in hyperglycemia), genes in beta cells produce and secrete insulin, which directs body cells, especially liver cells, to absorb glucose and store it as a polysaccharide called glycogen. Insulin production will stop once blood glucose levels are reduced to normal. An insulin deficiency leads to prolonged hyperglycemia, a serious and often fatal disorder called diabetes melli-tus. When blood glucose levels are too low (as in hypoglycemia), genes in the alpha cells of the islets of Langerhans produce and secrete glucagon, which directs body cells to break down their gly-cogen reserves and begin releasing glucose back into the bloodstream until normal blood glucose levels are reached, upon which glucagon production ceases.

Clinical Focus Box 241

Hyponatremia with hypoosmolality can occur in the presence of a decreased, normal, or even increased total body Na+. Hyponatremia and decreased body Na+ content may be seen with increased Na+ loss, such as with vomiting, diarrhea, and diuretic therapy. In these instances, the decrease in ECF volume stimulates thirst and AVP release. More water is ingested, but the kidneys form osmotically concentrated urine and plasma hypoosmolality and hyponatremia result. Hyponatremia and a normal body Na+ content are seen in hypothyroidism, cortisol deficiency, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). SIADH occurs with neurological disease, severe pain, certain drugs (such as hypoglycemic agents), and with some tumors. For example, a bronchogenic tumor may secrete AVP without control by plasma osmolality. The result is renal conservation of water. Hyponatremia and increased total body Na+ are seen in edematous states, such as congestive heart failure, hepatic...

Definition Of Hypoglycaemia

It is difficult to determine a frequency of hypoglycaemia without first defining what is meant by 'hypoglycaemia'. In many studies, hypoglycaemia is documented by self-reporting, which may be very unreliable (Heller et al., 1995). Retrospective analyses suffer from problems of recall, and accurate documentation of hypoglycaemia is obtained only in prospective research studies that require biochemical verification of low blood glucose concentrations (see Chapter 3). Various levels of blood glucose concentration have been used to define mild and moderate hypoglycaemia biochemically, but there is now recognition that the blood glucose concentrations which have been used arbitrarily to define pathological 'spontaneous' hypoglycaemia (such as < 2.2 mmol l) are unsuitable for defining hypoglycaemia in people with diabetes. An arterialised plasma glucose concentration of around 3.6 mmol l may be sufficient to cause physiological autonomic responses in healthy volunteers (Chapter 1). Subtle...

Long Term Management of Patients After Successful Pituitary Surgery for Cushings Disease

Spontaneous recovery of preserved corticotrophs usually occurs within 2 yr in most cases of successful cure of CD, but recovery may be delayed considerably beyond this time (19). After assessment of pituitary function and establishment of glucocorticoid replacement, patients should be periodically reassessed to determine recovery of the ACTH-adrenal axis. We favor re-admission for assessment initially after a 3- to 6-month interval, with subsequent reassessments at 6- to 12 month intervals. The reassessment after successful cure of CD includes successive daily measurements of early morning serum cortisol concentrations for 72 h after discontinuation of glucocorticoid. If values remain undetectable, replacement is reinitiated and the patient discharged to be evaluated at a later date. In those with detectable cortisol concentrations, particularly > 100 nmol L (3.6 Mg dL), a provocative test of ACTH reserve is performed, either in the form of the insulin-hypoglycemia test or a...

Growth Hormone Replacement

Not all subjects with GH deficiency have significant symptoms. In treated pituitary tumor patients, those with complaints relating to poor quality of life, altered body composition, with documented dyslipidemia or reduced bone mineral density, should undergo assessment for GH deficiency (Table 2). Severe GH deficiency has been defined as a peak GH response on provocative testing < 9 mU L (3.5 g L) and GH has a license for use in this group. The insulin-hypoglycemia test (see Appendix 1, p. 197) is the gold standard. In most patients, two tests of GH reserve are required and a dynamic test is usually combined with a GH day-curve and measurement of serum total IGF-1. Recombinant GH is manufactured by several companies and is often in the form of a powder for reconstitution before injection using a multidose pen device. A ready-to-use liquid form has recently been developed. Patients are taught to self-administer subcutaneous injections, usually at bedtime. Most centers advocate...

Acute and Chronic Complications

The major acute complications of diabetes occuring in children are hypoglycemia, hyperglycemia, and diabetic ketoacidosis. Hypoglycemia is caused by too little food, delayed or missed meals and snacks, increased exercise, excessive insulin, or alcohol intake without food. Hyperglycemia is caused by increased food intake, inadequate insulin dose, or a decrease in usual exercise. Diabetic ketoacidosis results from an absolute lack of insulin and the build-up of ketoacids in the blood.

What Are the Goals and Risks

The blood glucose goals of the American Diabetes Association (9,10) are shown in Table 2. The listed HbA,c of less than 7 is accepted around the world based on the findings of the Diabetes Control and Complications Trial (DCCT) performed in type 1 diabetes (see Table 3), which showed an acceptable balance of protection against microvascular complications versus risk of severe hypoglycemia with this HbAlc level (1). Equally important is to prevent rigidity of lifestyle by providing flexibility for exercise, sports, diet, work, travel, or whatever the patient wants for a happy life. The caregiver also needs to know the risks and problems with intensive insulin therapy so they can be openly discussed with the patient. Best known is the potential for hypoglycemia. The DCCT reported a threefold increase in severe hypoglycemia, which was defined as requiring aid from someone else, and a threefold increase in hospitalization for hypoglycemia, in patients with HbA c of 7.2 versus 8.9 (1)....

Origins of the Met A Solution to a Real Problem

Two different studies of antecedents to cardiac arrest demonstrated that 75 to 85 of the affected patients had some form of deterioration in the hours prior to the cardiac arrest (3,8). Nearly one-third of such abnormalities persisted for greater than 24 hours prior to cardiac arrest, with a population mean of 6.5 hours (3). In one series, the majority (76 ) of the disease processes eventually progressing to cardiac arrest were not considered intrinsically, rapidly fatal (8). In another series, over half of the cardiac arrests presented ample warning of decompensation the majority of patients had uncorrected hypotension, and half of these had systolic blood pressures less than 80mmHg for more than 24 hours (9). Other patients in this series had severe but correctable abnormalities such as hypokalemia, hypoglycemia, and hypoxemia. This collective experience suggests that quality of care, more so than the disease, may be responsible for the poor immediate survival of these patients....


SBGM is a necessary evil that makes having diabetes particularly difficult. Despite considerable improvement in meters over the past few years, the pain, inconvenience, expense, and sometimes emotional upset caused by a bad blood sugar make doing SBGM one of the most hated parts of the treatment program. Physicians need to discuss this issue openly with their patients. My own practice recommends four daily tests (pre-meal alternating with post-meal, and pre-bed) when insulin programs are initiated or changed, or when variable daily glycemia prevents obtaining the target HbAk. Also, the presence of hypoglycemia un-awareness mandates frequent testing. I impress on patients that the tests are done for them they need to know how different aspects of their lifestyle affect their blood glucose level. I also recommend the patient set aside a time to review and analyze that day's tests, often with the spouse so that there is a family approach to taking care of the patient's diabetes. Don't...

Clinical Focus Box 311

Tain reliable information about growth hormone secretion, endocrinologists employ a dynamic test of growth hormone secretory capacity. There are several variations of this test that are used at different hospitals. In one test, a bolus of arginine, which is known to stimulate growth hormone secretion, is given and a blood sample is taken a short time later for the measurement of growth hormone concentrations. Another test makes use of the fact that hypoglycemia is a known stimulus for growth hormone secretion. Mild hypoglycemia is induced by an injection of insulin, and a blood sample is drawn a short time later. Regardless of which test is used, by perturbing the system in a well-prescribed fashion, the endocrinologist is able to gain important information about growth hormone secretion that would not be possible if a random blood sample were used.

Hypocretin And Brain Reward Modulation

The mechanisms underlying food restriction-induced enhancement of central rewarding potency of both lateral hypothalamic self-stimulation and drugs of abuse remain unclear.3133 However, two hormones have been mainly involved in the modulation of the LHSS induced by food restriction, insulin30 and leptin.4276 Notably, intracerebroventricular (ICV) infusion of leptin attenuates the effectiveness of the rewarding electrical stimulation in areas of the LH where previous stimulations were enhanced by chronic food restriction, an effect that persists as long as 4 days after a single injection.42 Interestingly, Hcrt neurons express leptin receptors, and leptin regulates Hcrt neurons.3977 Secondly, neurons containing hypocretin orexin in the LH are activated by insulin-induced acute hypoglycemia.4078 Therefore, it is possible that the hypocretin system mediates both insulin and leptin effects on LHSS, and thus could be considered as the link between the controls of energy homeostasis and the...

Problems of Establishing the Cause of Death at Postmortem

In attempting to establish a post-mortem diagnosis of hypoglycaemia, the pathologist needs to perform biochemical tests, examine the brain for evidence of hypoglycaemic brain damage, and exclude any other possible cause of death (Tattersall and Gale, 1993). Carbohydrate metabolism continues after death, and post-mortem changes in blood glucose can cause difficulties in confirming a hypoglycaemic death forensically. The continuing breakdown of glycogen (glycogenolysis) increases the blood glucose concentration in the inferior vena cava, so that the presence of a normal or high blood glucose concentration on the right side of the heart does not exclude ante-mortem hypoglycaemia (a false negative result for a diagnosis of hypoglycaemia). In the peripheral circulation, glucose continues to be utilised by red blood cells, so that the presence of a low glucose concentration does not necessarily indicate ante-mortem hypoglycaemia. Indeed low blood glucose is often found after death in those...

Patients And Physicians Concerns About Insulin Use In Type 2 Diabetes

Hypoglycemia is the primary adverse event associated with insulin therapy. However, this acute complication of therapy is much less frequent with type 2 diabetes than type I disease. Severe episodes occur in 0.5-2.0 of insulin-treated patients (3,13). Likewise, hypoglycemia is generally less severe with type 2 diabetes. Although insulin-induced hypoglycemia may influence the insulin doses and specific insulin regimen, it does not preclude safe and effective insulin therapy. In type 2 diabetes, the progression from an insulin regimen using one injection at bedtime to more complex regimens is associated with increased frequency of hypoglycemia. The most common precipitating factor for hypoglycemia is skipped meals (up to 80 of hypoglycemic events). Other significant factors are unusually heavy exercise and excess doses. When using insulin, more frequent home glucose monitoring is appropriate in order to identify hypoglycemia and to facilitate optimal insulin dosing. the combination of...

Clinical Focus Box 321

In GH-deficient individuals, GH has a transitory insulin-like action. For example, intravenous injection of GH in a person who is GH-deficient produces hypoglycemia. The hypoglycemia is caused by the ability of GH to stimulate the uptake and use of glucose by muscle and adipose tissue and to inhibit glucose production by the liver. After about 1 hour, the blood glucose level returns to normal. If this person is given a second injection of GH, hypo-glycemia does not occur because the person has become insensitive or refractory to the insulin-like action of GH and remains so for some hours. Normal individuals do not respond to the insulin-like action of GH, presumably because they are always refractory from being exposed to their own endogenous GH. The actions of GH in humans are summarized in Table 32.3.

Myocardial Infarction

Only a few cases have been published of myocardial infarction and hypoglycaemia in diabetic patients (Purucker et al., 2000 Chang et al., 2007). This possible association is very difficult to establish because of the problems described above. In addition, the release of stress hormones such as glucagon, cortisol and epinephrine will raise blood glucose and make the contribution of preceding hypoglycaemia almost impossible to confirm.

Ongoing Assessment

The nurse must assess the patient for signs and symptoms of hypoglycemia and hyperglycemia (see Table 49-1) throughout insulin therapy. The patient is particularly prone to hypoglycemic reactions at the time of peak insulin action (see the Summary Drug Table Insulin Preparations) or when the patient has not eaten for some time or has skipped a meal. In acute care settings, frequent blood glucose monitoring is routinely done to help detect abnormalities of blood glucose. Testing usually occurs before meals and at bedtime (see section on Managing Hypoglycemia).

Summary Drug Table Antidiabetic Drugs Continued

Anorexia, nausea, vomiting, epigastric pain, heartburn, diarrhea, hypoglycemia, allergic skin reactions Hyperglycemia, hypoglycemia, nausea, diarrhea, upper respiratory tract infection, sinusitis, headache, arthralgia, back pain Headache, pain, diarrhea, hypoglycemia, hyperglycemia, fatigue, infections Hypoglycemia due to hyperinsulinism Hypoglycemia

Gerontologic Alert

Although elderly patients taking the oral antidiabetic drugs are particularly susceptible to hypoglycemic reactions, these reactions may be difficult to detect in the elderly. The nurse notifies the health care provider if blood sugar levels are elevated (consistently > 200 mg dL) or if ketones are present in the urine.

Quality Of Life And Obstacles To Care

The delivery of diabetes care and education has undergone a paradigm shift from giving advice and blaming the patient for failure to providing patients with the choice of aggressive, individualized treatment and an education plan tailored to their needs. This shift has melded health care providers and patients as partners in managing a devastating disease. The demands for daily self-management of diabetes are so formidable that each component of the diabetes education curriculum includes discussion of the psychosocial needs of the patient. The embarrassment of hypoglycemia and resultant fear, the social aspects of eating and dealing with well-meaning family members who comment on food choices, the

Treatment Of The Hormonal And Metabolic Abnormalities Of Diabetes

Because patients with type 2 diabetes are insulin-resistant, provision of exogenous insulin may be the most successful means for providing an adequate supply of substrate for energy in injured cells. By contrast, provision of additional insulin may have potentially deleterious effects such as promoting thrombosis. The provision of insulin may increase the potential for thrombin generation, increased reactivity of platelets, and decrease the fibrinolytic response. In combination, these effects may exacerbate thrombosis, predispose to reocclusion of in-farct-related vessels, and delay resolution of thrombotic occlusion. Accordingly, treatment with insulin in the setting of acute myocardial infarction may entail risk. In addition, induction of hypoglycemic episodes may be particularly deleterious in association with myocardial ischemia. Thus, further study is needed to determine the nature of optimal metabolic control and the method by which it can best be achieved.

Monitoring and Managing Adverse Reactions

When the androgens are administered to a patient with diabetes, blood glucose measurements should be done frequently because glucose tolerance may be altered. Adjustments may need to be made in insulin dosage, oral antidiabetic drugs, or diet. The nurse monitors the patient for signs for hypoglycemia and hyper-glycemia (see Chap. 49).

Glimepiride and Phosphoinositolglycans

Recent studies have identified two completely different exogenous stimuli which mimic the anti-lipolytic activity of insulin in insulin target cells (for a review see Ref. 477 ). They bypass activation of the insulin receptor, but rather act by triggering redistribution of signaling components between DIGs of different lipid and protein composition at the target cell plasma membrane. (i) Phosphoinositolglycan-(-peptides) (PIG -P ) prepared by chemical synthesis 478 or isolation from natural sources 475 reduce isoproterenol-stimulated lipolysis in concentration-dependent fashion to almost basal levels in primary and cultured adipocytes. PIG(-P) are derived from the polar core glycan head group of glycosylphosphatidylinositol (GPI) anchored proteins 480 consisting of 2',3'-cyclic phospho-myo-inositol coupled to five sugar moieties in typical glycosidic linkages (PIG portion) and, optionally, contain an additional terminal ethanolamine-linked tripeptide residue (P portion) 478, 479 ....

Prison And Police Custody Police Custody and Hypoglycaemia

Alcohol can promote hypoglycaemia in people treated with insulin, and may be a contributory factor to inducing the low blood glucose, so causing further difficulty with identification of the underlying metabolic problem. This emphasises the importance of an individual with insulin-treated diabetes carrying some form of identification to indicate that they are taking insulin and may be at risk of developing hypoglycaemia-induced coma. In addition to the risk of being arrested during an episode of hypoglycaemia because of aggressive or abnormal behaviour, low blood glucose may develop while in custody. The police may have limited comprehension of the needs of a person with diabetes and the risks of hypoglycaemia. The young male patient with undiagnosed Addison's disease, described earlier, who was arrested on a driving charge, was profoundly neuroglycopenic when taken into custody. He was detained without treatment for two hours. When his father arrived at the police station, he...

Environmental Factors

Thalidomide Infants

Factors responsible for these abnormalities have not been delineated, although evidence suggests that altered glucose levels play a role and that insulin is not teratogenic. In this respect, a significant correlation exists between the severity and duration of the mother's disease and the incidence of malformations. Also, strict control of maternal metabolism with aggressive insulin therapy prior to conception reduces the occurrence of malformations. Such therapy, however, increases the frequency and severity of hypoglycemic episodes. Numerous animal studies have shown that during gastrulation and neurula-tion, mammalian embryos depend on glucose as an energy source, so that even brief episodes of low blood glucose are teratogenic. Therefore, caution must be exercised in managing the pregnant diabetic woman. In the case of non-insulin-dependent diabetes, oral hypoglycemic agents may be employed. These agents include the sulfonylureas and biguanides. Both classes of agents have been...

Future medical devices for the management of diabetes Implantable insulin pumps

Both intraperitoneal and subcutaneous insulin delivery achieve and maintain similar levels of glycemic control over time 58 . Studies measuring mean HbA1c and mean blood glucose levels in both insulin dependent and non-insulin dependent diabetics showed that mean glucose levels are similar to that seen in the DCCT intensive group 59,60 . In addition, data from long-term studies have suggested that the route of insulin administration does not significantly affect HbA1c levels 61 . There are some studies that suggest that intraperitoneal insulin delivery may result in less hypoglycemic episodes than subcutaneous infusion 62,63 . The exact mechanism for this phenomenon is not known, however, more rapid clearance of peritoneal insulin delivery is suspected as one possible explanation. The rapid absorption of intraperitoneal insulin is thought to simulate physiologic insulin. Some short term studies have also suggested that the simulation of physiologic insulin delivery may also achieve...

Closed loop systems artificial mechanical pancreas

In the DCCT, the rate of hypoglycemia was three times more in the treatment (MDI) group when compared to the control (conventional) group 6 . Intensive and conventional insulin management require frequent daily finger sticks to monitor blood glucose levels. Diabetes management via needle injections results in poor quality of life, poor compliance, and increased incidence with disease transmission and problems with needle disposal. Though the benefit of tight blood glucose control in limiting the complications of the disease is well established, only 37 of diabetics achieve the level of control recommended by the American Diabetic Association 68 . Therefore, a safe and effective device to manage DM that eliminates the need for finger pricking, needle injections and their disposal is of a paramount public health importance. The creation of a closed-loop system (artificial mechanical pancreas) has been the holy grail'' in the management of DM. The closed loop system will consist of a...

Special Considerations

Since young children are not consistent in their eating habits and cannot recognize symptoms of hypoglycemia, strict blood glucose control is not usually attainable. Generally, higher blood glucose goals are accepted (see Table 23-5), and the main goal is to avoid hypoglycemia. Infants with diabetes may certainly continue to breastfeed. Toddlers are more independent in their eating habits. Their appetites are decreasing, and they are often more selective in their food choices. Toddlers should be allowed to eat in a calm, relaxed manner and should never be force-fed. Meal plans encouraging consistent meals and snacks should be taught at this age but the variability in a toddler's eating habits must be acknowledged and accepted. Parents are ultimately responsible for providing appropriate meals and snacks the child will decide how much and what to eat. Insulin can be given after meals for young children who are especially unpredictable in their eating habits, with the dose based on the...

Ketogenic Diet Therapy

Diet initiation is best done in an inpatient setting, due to the real potential for hypoglycemia, dehydration, and acidosis. The child is fasted until urinary ketones, measured as acetoacetic acid on urinary dipsticks, are large (80 to 160 mg dL). This usually occurs in 24 to 36 hours. Eggnog (composed of heavy cream, pasteurized egg. and artificial sweetener and flavoring) is given for the first 1 to 2 days to allow tolerance to develop to the high fat content of the diet. One-third of the estimated energy needs are given on the first day. and two-thirds on the second day. Once the full amount of calories are reached, either eggnog or real food may be served.

Acquired Erythrocyte Defects

(2) Factors that predispose to the development of kernicterus at lower levels of bilirubin, such as prematurity, hypoproteinemia, metabolic acidosis, drugs (sulfonamides, caffeine, sodium benzoate), and hypoglycemia, require exchange transfusions below 20 mg dL. c. Metabolic asphyxia, hypoxia, shock, acidosis, vitamin E deficiency in premature infants, hypoglycemia 2. Hyperplastic visceromegaly (Beckwith-Wiedemann syndrome), associated with hypoglycemia

External insulin infusion pumps

Hypoglycemia Initial studies raised concerns of severe hypoglycemia in patients using an insulin pump 22 . The incidence of hypoglycemia was noted to be about three times higher in the intensive therapy group (CSII and MDI) in the DCCT, and as a result, there was some reluctance to use CSII. However, a number of trials have suggested that when the pump is properly used the rate of hypoglycemic episodes are no more frequent, or are even less common, compared to MDI 23,24,25 . The decrease in hypoglycemic events is accompanied by an increase in self-reported warning symptoms of hypogly-cemia, as well as by an increase in counter regulatory hormonal responses to hypogly-cemia. Because of the reported lower incidence of hypoglycemia with pump therapy, some experts are now recommending hypoglycemia unawareness as an indication for pump use 26 . at a much slower rate compared to insulin delivered via CSII. Therefore, any interruption of insulin flow from CSII can result in rapid...

Protocol For Treatment And Followup

New hormone deficiency or deficiencies are identified by obtaining a thorough clinical history and physical examination and measurement of appropriate hormone concentrations. Fatigue, weight gain, decreased mental alertness, and constipation suggest hypothyroidism. Fatigue, orthostatic symptoms, diminished appetite, and weight loss suggest adrenal insufficiency. A decrease in libido or erectile dysfunction suggests hypogonadism in men and a change in menses (irregular menses, amenorrhea), diminished libido, or hot flashes suggest gonadal failure in women. The symptoms of GH deficiency overlap with other hormone deficiencies and include fatigue, decreased exercise tolerance, increase in abdominal adiposity, and diminished sense of well-being. Appropriate hormone studies include measurement of serum thyroxine (or free thyrox-ine, free T4), early morning cortisol, testosterone (men), and estradiol (women). Measurement of serum thyroid-stimulating hormone (TSH) is not helpful and may be...

The Somogyi Phenomenon The Concept Of Rebound Hyperglycaemia

Although fasting glucose concentrations were frequently high in the patients they studied, this was related directly to a waning of circulating plasma insulin concentrations. Some investigators have demonstrated that when hypoglycaemia is experimentally-induced during the night, this can raise blood glucose on the following morning, even if circulating plasma insulin concentrations are maintained (Perriello et al., 1988). However, the additional increase in the fasting blood glucose concentration is modest (around 2.0mmol l) and its clinical relevance is questionable. Other researchers have found no effect on daytime concentrations of blood glucose after lowering blood glucose to hypoglycaemic levels during the night (Hirsch et al., 1990). Careful analysis of data collected both by self-monitoring of blood glucose (Havlin and Cryer, 1987) and by continuous glucose monitoring (Hoi-Hansen et al., 2005) (Figure 4.3) during everyday activities, has also shown that nocturnal hypoglycaemia...

Diagnosis of Cushings Syndrome

Cushing Algorithm

(0.5 mg every 6 h for 2 d) dexamethasone and do not respond to insulin-induced hypoglycemia, contrasting the normal responses of depressed and other pseudo-Cushing patients. In addition, patients with CD (85 ) have a normal or exaggerated ACTH response to CRH, whereas patients with depression (75 ) show a blunted response. Whether these three tests, however, are considered individually or evaluated in combination, their diagnostic accuracy in the differential diagnosis of mild hypercortisolism does not exceed 80 .

Pyruvate Kinase Is Allosterically Inhibited by ATP

At least three isozymes of pyruvate kinase are found in vertebrates, differing in their tissue distribution and their response to modulators. High concentrations of ATP, acetyl-CoA, and long-chain fatty acids (signs of abundant energy supply) allosterically inhibit all isozymes of pyruvate kinase (Fig. 15-19). The liver isozyme (L form), but not the muscle isozyme (M form), is subject to further regulation by phosphorylation. When low blood glucose causes glucagon release, cAMP-dependent protein kinase phosphorylates the L isozyme of pyruvate kinase, inactivating it. This slows the use of glucose as a fuel in liver, sparing it for export to the brain and other organs. In muscle, the effect of increased cAMP is quite different. In response to epinephrine, cAMP activates glycogen breakdown and glycolysis and provides the fuel needed for the fight-or-flight response.

Hippocampus And Cortex

The prefrontal cortex is an organizer of attentional set shifting, cognitive appraisal, executive fuctions, and autonomic responses to hypoglycemia, hunger, and drowsiness.35,36,93 Hypocretins facilitate the release of catecholamines56,58 and through glutamatergic mechanisms they induce calcium transients in dendritic spines of distinct

Case Study - Medical Terminology - 78 Steps Health Journal

M.G. has managed her disease with meticulous attention to her diet, exercise, preventative health care, regular blood glucose monitoring, and twice-daily injections of regular and NPH insulin, which she rotates among her upper arms, thighs, and abdomen. She continues in a smoking cessation program supported by weekly acupuncture treatments. She maintains good control of her disease in spite of the inconvenience and time it consumes each day. She will be married next summer and would like to start a family. M.G.'s doctor suggested she try an insulin pump to give her more freedom and enhance her quality of life. After intensive training, she has received her pump. It is about the size of a beeper with a thin catheter that she introduces through a needle into her abdominal subcutaneous tissue. She can administer her insulin in a continuous subcutaneous insulin infusion (CSII) and in calculated meal bolus doses. She still has to test her blood for hyperglycemia and hypo-glycemia and her...

Cushings Syndrome With Unusual Laboratory Behavior Periodic Cushings Syndrome

Plasma Cortisol has a circadian rhythm similar to that of normal subjects, albeit at elevated concentrations, and responds normally to stress tests such as insulin-induced hypoglycemia. The most frequent manifestation of glucocorticoid resistance is adrenal hyperandrogenism in women and children and mild hypertension in both genders.

Catecholamines Have Rapid Widespread Effects

Catecholamines and the Metabolic Response to Hypoglycemia. Catecholamines secreted by the adrenal medulla and NE released from sympathetic postganglionic nerve terminals are key agents in the body's defense against hypoglycemia. Catecholamine release usually starts when the blood glucose concentration falls to the low end of the physiological range (60 to 70 mg dL). A further decline in blood glucose concentration into the hy-poglycemic range produces marked catecholamine release. Hypoglycemia can result from a variety of situations, such as insulin overdosing, catecholamine antagonists, or drugs that block fatty acid oxidation. Hypoglycemia is always a dangerous condition because the CNS will die of ATP deprivation in extended cases. The length of time pro found hypoglycemia can be tolerated depends on its severity and the individual's sensitivity. When the blood glucose concentration drops toward the hypoglycemic range, CNS receptors monitoring blood glucose are activated,...

Clinical Definitions of Hypoglycaemia

The inability to agree on a biochemical definition for hypoglycaemia requires instead the application of clinical criteria (Box 3.1). The difficulty here is that because the symptoms of hypoglycaemia are not specific, and vary between individuals (see Chapter 2), the use of symptomatology alone may be unreliable and may result in the inclusion of episodes that are not true hypoglycaemia. In one prospective study, where capillary blood glucose was measured whenever a patient had symptoms suggestive of hypoglycaemia, only 29 of such episodes were accompanied by evidence of biochemical hypoglycaemia (i.e., blood glucose < 3.0mmol l) (Pramming et al., 1990). For that reason, hypoglycaemia is usually defined as an episode in which typical symptoms occur and the symptoms are reversed by appropriate treatment to raise blood glucose. Ideally, corroborative evidence should be provided by the contemporaneous demonstration of a low capillary or venous blood glucose concentration but, as this...

Acute and Chronic Exercise Increases Insulin Sensitivity Insulin Receptor Density and Glucose Transport into Muscle

Insulin Exercise Response

Idation (thereby sparing carbohydrate stores), and oral carbohydrate intake during exercise. Frank hypoglycemia rarely occurs in healthy people during even the most prolonged or intense physical activity. When it does, it is usually in association with the depletion of muscle and hepatic stores and a failure to supplement carbohydrate orally. Exercise suppresses insulin secretion by increasing sympathetic tone at the pancreatic islets. Despite acutely falling levels of circulating insulin, both non-insulin-dependent and insulin-dependent muscle glucose uptake increase during exercise. Exercise recruits glucose transporters from their intracellular storage sites to the plasma membrane of active skeletal muscle cells. Because exercise increases insulin sensitivity, patients with type 1 diabetes (insulin-dependent) require less insulin when activity increases. However, this positive result can be treacherous because exercise can accelerate hypoglycemia and increase the risk of insulin...

ACTH Regulates the Function of the Adrenal Cortex

Lph Cortisol

Glucocorticoids act on many processes, mainly by altering gene transcription and, thereby, changing the protein composition of their target cells. Glucocorticoids permit metabolic adaptations during fasting, which prevent the development of hypoglycemia or low blood glucose level. They also play an essential role in the body's response to physical and emotional stress. Other actions of glucocorticoids include their inhibitory effect on inflammation, their ability to suppress the immune system, and their regulation of vascular responsiveness to norepinephrine.

Blood Glucose Regulation And Diabetes Eug Ackerman

The Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes 46(2) 271-286, 1997. 11. Cox DJ, Gonder-Frederick LA. Kovatchev BP, Young-Hyman DL, Donner TW, Julian DM, Clarke WL. Biopsychobehavioral model of severe hypoglycemia. 1 . Understanding the risk of severe hypoglycemia. Diabetes Care 22( 12) 2018-2025, 1999. 12. Kinsley BT, Weinger K, Bajaj M, Levy CJ, Simonson DC, Quigley M, Cox DJ, Jacobson AM. Blood glucose awareness training and epinephrine responses to hypoglycemia during intensive treatment in lype 1 diabetes. Diabetes Care 22(7) 10221028, 1999. 13. Deary 1J, Crawford JR, Hepburn DA, Langan SJ, Blackmore LM, Frier BM. Severe hypoglycemia and intelligence in adult patients with insulin-treated diabetes. Diabetes 42(2) 341-344, 1993. 14. Perros P, Deary IJ, Sellar RJ. Best JJ, Frier BM. Brain abnormalities demonstrated by magnetic resonance imaging in adult EDDM patients with and without a history of...

Glucocorticoids Play a Role in the Reactions to Fasting Injury and Stress

Fasting States Ketone Bodies Graph

During the fasting periods between food intake in humans, metabolic adaptations prevent hypoglycemia. The maintenance of sufficient blood glucose is necessary because the brain depends on glucose for its energy needs. Many of the adaptations that prevent hypoglycemia are not fully expressed in the course of daily life because the individual eats before they fully develop. Full expression of these changes is seen only after many days to weeks of fasting. Glucocorticoids are necessary for the metabolic adaptation to fasting. As a consequence, the individual cannot respond to fasting with accelerated gluconeogenesis and will die from hypo-glycemia. In essence, the glucocorticoids maintain the liver and kidney in a state that enables them to carry out accelerated gluconeogenesis should the need arise. The opposite situation occurs in the glucocorticoid-de-ficient individual. Little lipid mobilization and use occur, so there is little restriction on the rate of glucose use by tissues. The...

Gerontologie Alert

The thiazolidinediones, piogli-tazone and rosiglitazone, are given with or without meals. If the dose is missed at the usual meal, the drug is taken at the next meal. If the dose is missed on one day, do not double the dose the following day. If the drug is taken, do not delay the meal. Delay of a meal for as little as V2 hour can cause hypoglycemia.

Blood Carries Oxygen Metabolites and Hormones

Solutes Plasma

The concentration of glucose in the plasma is also subject to tight regulation. We have noted the constant requirement of the brain for glucose and the role of the liver in maintaining blood glucose in the normal range of 60 to 90 mg 100 mL. When blood glucose in a human drops to 40 mg 100 mL (the hypoglycemic condition), the person experiences discomfort and mental confusion (Fig. 23-23) further reductions lead to coma, convulsions, and in extreme hypoglycemia, death. FIGURE 23-23 Physiological effects of low blood glucose in humans. Blood glucose levels of 40 mg 100 mL and below constitute severe hypoglycemia.

Nutrition Strategies For Type 1 Diabetes

Be developed and communicated to the provider initiating the insulin therapy so that the insulin program can be tailored to the patient's usual patterns of eating and exercise. Patients with type 1 diabetes on a conventional insulin program, such as twice-daily injections of short- and intermediate-acting insulin, should exercise and eat their meals and snacks at the same time each day so that the insulin action can be coordinated with their food intake and activity levels. Following a consistent meal plan and exercise program will help optimize glycemic control and decrease the risk of hypoglycemic events in the patient following a conventional insulin program (4). Because of the complex and diverse nature of type 2 diabetes, it is important to individualize the macronutrient composition of the meal plan based on each patient's goals, to improve metabolic control and limit long-term complications of the disease. In patients with hyperlipidemia, a reduction in both total and...

Routine Laboratory And Neuroimaging Tests

Most routine laboratory and neuroimaging studies contribute to the diagnosis of spells primarily by helping to rule out other etiologies. EKG, cardiac Holter monitoring, CXR, or ventilation-perfusion lung scans may be diagnostic of cardiac-induced episodes. Serum glucose can point to fasting hypoglycemia, or an abnormal glucose tolerance test may reveal reactive hypoglycemia. Glucose tolerance testing would be done only for a high

Glycogen Storage Disease

Glycogen storage diseases (GSD) are disorders in which glycogen cannot be metabolized to glucose because of an abnormality in the enzymes involved in glycogenolysis. The major sites of glycogen deposition are liver and muscle tissue. Clinical manifestations include hypoglycemia, hepatomegaly, poor growth, muscle weakness, cramping, and fatigue. The most common types of GSD that respond to nutritional therapy are GSD type I and GSD type III. The goal of dietary treatment is to prevent hypoglycemia. Glycogen storage disease type I (glucose-6-phosphatase deficiency) results from a deficiency in the enzyme glucose-6-phosphatase. which is needed for the production of glucose from both glycogenolysis and gluconeogenesis. Biochemical abnormalities include hypoglycemia, hyper-lipidemia. hyperuricemia, and lactic acidemia. Because endogenous glucose production is limited, nutritional therapy involves supplying a constant exogenous source of glucose to prevent hypoglycemia. The diet should be...

Insulin Therapy in Children

The traditional goals of treatment of children and adolescents with diabetes were to use insulin, diet, and exercise to minimize symptoms of hypoglycemia and hyperglycemia, promote normal growth and development, and, using intensive education and psychosocial support, maximize independence and self-management in order to reduce the adverse psychosocial effects of this chronic disease. Since the results of the DCCT were published, additional primary aims of therapy are to lower blood glucose and glycosylated hemoglobin values to as close to norma as possible. In pediatric patients, achievement of such stringent treatment goals is best accomplished with a multidisciplinary team of clinicians to provide ongoing education and support of aggressive self-management efforts on the part of parents and patients. Matching the treatment to the patient (rather than vice versa) by taking a flexible and varied approach to insulin replacement, diet, and exercise is critically important. During the...

Insulin Therapy in Pregnancy

If a mother has hyperglycemia, the fetus will be exposed to either sustained hyperglycemia or intermittent pulses of hyperglycemia. Both situations prematurely stimulate fetal insulin secretion. Fetal hyperinsulinemia may cause increased fetal body fat (macrosomia), and therefore a difficult delivery, or inhibition of pulmonary maturation of surfactant, and therefore respiratory distress of the neonate. The fetus may also have decreased serum potassium levels caused by the elevated insulin and glucose levels, which may lead to cardiac arrhythmias. Neonatal hypoglycemia may cause permanent neurological damage. Maternal anti-insulin antibodies may contribute to hyperinsulinemia in utero and thus potentiate the metabolic aberrancy. Although insulin does not cross the placenta, antibodies to insulin do, and may bind fetal insulin this necessitates the increased production of free insulin to re-establish normoglycemia. Thus, the anti-insulin antibodies may potentiate the effect of maternal...


HCC may present in a number of atypical ways (6). These include presentations with obstructive jaundice, hypoglycemia, hypercalcemia, acute hemoperitoneum, Budd-Chiari syndrome, inferior vena caval obstruction, superior mediastinal syndrome, bone pain, Virchow-Trossier node, fever of unknown origin, arterial hypertension, feminization, or skin rashes. Although none is common, an awareness of these presentations may prevent the diagnosis being delayed or even missed.


iach child with diabetes should receive an individualized meal plan w ith the appropriate calorie level to promote normal growth and development. The meal plan is based on the exchange system created by the American Diabetes Association and the American Dietetic Association (Table 23-4). The exchange lists group specific servings of foods together because they have a similar amount of carbohydrate, protein, fat. and calories. One food can be substituted, or exchanged, for another within each exchange list. The meal plan sets consistent times and food composition for each meal and snack. Most children need to eat three meals and two to three snacks per day. spaced 21 to 3 hours apart. While day time snacks can contain exclusively carbohydrate, the bedtime snack should include protein and fat to minimize the risk of nocturnal hypoglycemia. The meal plan also encourages healthy, well-balanced meals and snacks by setting the portions of fruits, vegetables, and dairy products as well as...

Who Is Eligible

Every person with type I diabetes should be a candidate for intensive insulin therapy unless there is a contraindication. Exclusions can be medical (history of severe hypoglycemia, too old or too young, illnesses in which hypoglycemia could be life-threatening such as severe coronary, cerebrovascular, or hepatic disease) or nonmedical (unwillingness or inability to follow the program, drug or alcohol abuse, etc.). However, it must be emphasized these factors do not de facto exclude a candidate. There are many elderly patients who do spectacularly well on multishot insulin programs, and many persons with debilitating hypogly-

Endocrine disease

Supplemental short-acting insulin is then given as dictated by daily fingerstick determination of blood sugars. This approach can be continued until the patient resumes oral intake. For patients on oral hypoglycemic agents, these medications can be taken the day before surgery and resumed when the patient is eating. Chlorpropamide (Diabinese), because of its long half-life, should be discontinued 2 to 3 days before surgery.


There is an increased risk for hypoglycemia when products containing sulfamethoxazole are administered with oral antidiabetic drugs such as tolbutamide, tolazamide, and glipizide and an increased risk of hemorrhage when given with oral anticoagulants. An increased urinary pH decreases the effectiveness of methenamine. Therefore, to avoid raising the urine pH when taking methenamine, the patient should not use antacids containing sodium bicarbonate or sodium carbonate. Nalidixic acid may increase the effects of the anticoagulants.


Adverse reactions seen with the sulfonylureas include hypoglycemia, anorexia, nausea, vomiting, epigastric discomfort, weight gain, heartburn, and various vague neurologic symptoms, such as weakness and numbness of the extremities. Often, these can be eliminated by reducing the dosage or giving the drug in divided doses. If these reactions become severe, the health care provider may try another oral antidiabetic drug or discontinue the use of these drugs. If the drug therapy is discontinued, it may be necessary to control the diabetes with insulin.


Adverse reactions associated with the biguanide (met-formin) include gastrointestinal upsets (such as abdominal bloating, nausea, cramping, diarrhea) and metallic taste (usually self-limiting). These adverse reactions are self-limiting and can be reduced if the patients are started on a low dose with dosage increased slowly and if the drug is taken with meals. Hypoglycemia rarely occurs when metformin is used alone.


Adverse reactions associated with the administration of the thiazolidinediones include aggravated diabetes mel-litus, upper respiratory infections, sinusitis, headache, pharyngitis, myalgia, diarrhea, and back pain. When used alone, rosiglitazone and pioglitazone rarely cause hypoglycemia. However, patients receiving these drugs in combination with insulin or other oral hypo-glycemics (eg, the sulfonylureas) are at greater risk for hypoglycemia. A reduction in the dosage of insulin or the sulfonylurea may be required to prevent episodes of hypoglycemia.


Theses drugs are contraindicated in patients with hypersensitivity to the drug, type I diabetes, and diabetic ketoacidosis. Both repaglinide and nateglinide are Pregnancy Category C drugs and are not recommended for use during pregnancy and lactation. These drugs are used cautiously in patients with renal or hepatic impairment. Certain drugs, such as NSAIDs, salicylates, MAOIs, and beta adrenergic blocking drugs, may potentiate the hypoglycemic action of the meglitinides. Drugs such as the thiazides, cortico-steroids, thyroid drugs, and sympathomimetics may decrease the hypoglycemic action of these drugs. The nurse must closely observe the patient receiving one or more of these drugs along with an oral antidiabetic drug.

Review Questions

Which of the following would the nurse mostly likely choose to terminate a hypoglycemic reaction D. the patient is at increased risk for hypoglycemia 5. In patients receiving oral hypoglycemic drugs, the nurse must be aware that hypoglycemic reactions D. may occur more frequently in patients receiving oral hypoglycemic drugs.

Human Insulin

However, this issue generated much controversy and heated debate and stimulated several studies comparing human with animal insulins, which are not reviewed here. A systematic review of the extensive literature on this topic examined whether published evidence supported a difference in the frequency and awareness of hypoglycaemia induced by human and animal insulins (Airey et al., 2000). A total of 52 randomized controlled trials were identified, 37 of which were of double-blind design, whereas others reported hypoglycemic outcomes as a secondary or incidental outcome during comparative investigations of efficacy or immunogenicity. Seven of the double-blind studies reported differences in frequency of hypoglycaemia or of symptomatic awareness, and four of the unblinded trials reported differences in hypoglycaemia. None of the four population time trend studies found any relationship between the increasing use of human insulin and hospital admission for hypoglycaemia

Epidural Blood Patch

Increasing cerebral vascular resistance, and increasing CSF production. Other pharmacotherapeutic agents that have been described for treatment of CSF hypoglycemia include steroids and subcutaneous sum-itriptan. A bolus of saline or dextran (10-30 mL) may provide a tamponade effect and is an alternative treatment for a septic patient or a Jehovah's Witness. In patients lacking venous access for withdrawal of autologous blood, a fibrin patch might be an alternative. The fibrin patch is described in another section of this chapter.

Special Populations

The elderly are often undertreated in regard to blood glucose monitoring. Avoidance of hypoglycemia is of particular importance in this population. Moreover, labile blood glucose patterns and a tendency to hypoglycemia are a feature of many elderly patients as they become insulin-dependent. Thus, age should not be a limiting factor when considering fingerstick usage and frequency. Patient, personalized education is often required. Also, special attention should be paid to the patient's manual dexterity, vision, and potential memory deficits. Simplicity of use and need for only a small blood drop are particularly useful meter features for older patients.

Treatment of PPHN

Pre And Post Ductal Sats Pphn

In general, management of the newborn with PPHN includes the treatment and avoidance of hypothermia, hypoglycemia, hypocalcemia, anemia and hypovolemia correction of metabolic acidosis diagnostic studies for sepsis serial monitoring of arterial blood pressure, pulse oximetery (pre- and post-ductal) and transcutaneous PCo2, especially with the initiation of high frequency oscillatory ventilation (HFOV). Therapy includes aggressive management of systemic hemodynamics with volume and cardiotonic therapy (dobutamine, dopamine, and milrinone), in order to enhance cardiac output and systemic 02 transport. In addition, increasing systemic arterial pressure can improve oxygenation in some cases by reducing right-to-left extrapulmonary shunting. Failure to respond to medical management, as evidenced by failure to sustain improvement in oxygenation with good hemodynamic function, often leads to treatment with extracorporeal membrane oxygenation (ECMO) (82). Although ECMO can be a life-saving...

Empty Sella Syndrome

The overwhelming majority of patients with primary empty sella syndrome are asymptomatic, with their empty sellae being an incidental radiographic finding typically discovered during the investigation of an unrelated complaint. Of the minority of patients who are symptomatic, their clinical profile is often characteristic. More than 80 of symptomatic patients are middle-aged women, many of whom are obese, multiparous, and hypertensive (144). Long-standing headache is the most common and frequently the only presenting complaint. Only rarely are visual field deficits attributable to this syndrome, because symptomatic compression or intrasellar prolapse of the optic chiasm rarely occurs. Complaints of blurred vision or ophthalmologic findings such as papilledema, decreased acuity, enlarged blind spot, and optic atrophy are likely to be the result of coexisting intracranial hypertension. Isolated accounts of atypical facial pain and sensory loss in the distribution of the trigeminal nerve...

Time Of Birth

Fetus And Twisted Umbilical Cord

Intrauterine growth restriction (IUGR) is a term applied to infants who are at or below the 10th percentile for their expected birth weight at a given gestational age. Sometimes these infants are described as small for dates, small for gestational age (SGA), fetally malnourished, or dysma-ture. Approximately 1 in 10 babies have IUGR and therefore an increased risk of neurological deficiencies, congenital malformations, meconium aspiration, hypoglycemia, hypocalcemia, and respiratory distress syndrome (RDS). The incidence is higher in blacks than in whites. Causative factors include chromosomal abnormalities (10 ) teratogens congenital infections (rubella, cytomegalovirus, toxoplasmosis, and syphilis) poor maternal health (hypertension and renal and cardiac disease) the mother's nutritional status and socioeconomic level her use of cigarettes, alcohol, and other drugs placental insufficiency and multiple births (e.g., twins, triplets). Fetuses that weigh less


Although many anecdotal accounts exist of severe hypoglycaemia affecting employees with insulin-treated diabetes while at work, this does not appear to be a widespread problem. Although isolated episodes of severe hypoglycaemia occurring in the work place are inevitable, it appears that most hypoglycaemia is mild, quickly self-treated and does not cause disruption. The times of day at which hypoglycaemia is most common were observed in a prospective study of 60 patients with type 1 diabetes, half of whom had impaired awareness of hypoglycaemia (Gold et al., 1994b). Most episodes of severe hypoglycaemia occurred during the evening or night, or in the early morning before the subjects went to work (Figure 14.2). The higher frequency of severe hypoglycaemia in the evening or during the night was not attributable to the insulin regimens being used, and may be related to relaxed vigilance or different behaviour in the evening, when at home. A study of 243 people with insulin-treated...

Cerebral Adaptation

Glycaemic Thresholds

When hypoglycaemia occurs, the stimulus for counterregulation appears to be a fall in the cerebral metabolic rate of glucose. Boyle et al. (1994) measured arteriovenous differences in glucose concentration in the human brain during hypoglycaemia to show that the rate of uptake of glucose (and by implication of metabolism) falls before most of the counterregula-tory responses and cognitive changes occur. They also demonstrated that this fall in metabolic rate of the brain was reduced in healthy volunteers who were made acutely hypoglycaemic following a period of 56 hours of protracted moderate hypoglycaemia, suggesting that the metabolism of the human brain can adapt to prolonged exposure to low blood glucose. This enables the brain to maintain its metabolism and continue to function in response to subsequent hypoglycaemia. A further study in diabetic patients showed that diabetic patients with strict glycaemic control and impaired awareness of hypoglycaemia were able to maintain the...

Diagnostic Tests

With bacterial meningitis, the CSF generally has the characteristics shown in Table 3 and, in surveys of this disease in older adults, no differences were noted in the diagnostic criteria including pleocytosis, hypoglycorrhachia, or positive cultures. Additionally, the rate at which blood cultures were positive also seemed similar to that in younger patients. The determination of hypoglycorrhachia may be more difficult in patients with peripheral blood hyperglycemia or hypoglycemia. A serum glucose drawn at approximately the same time as the lumbar puncture is mandatory ratios of CSF glucose to serum glucose of less than 0.31 are consistent with hypoglycorrhachia and bacterial meningitis (20). A minority of patients with bacterial meningitis may demonstrate atypical CSF parameters, particularly a lymphocytic response or lower percentage of neutrophils or a Gram stain without organisms (19). This scenario is especially seen with L. monocytogenes meningitis in which the Gram stain is...