Hypoglycemia In Diabetic Patients Research Articles

The association between antidepressant use and hypoglycaemia in diabetic patients: a nested case–control study

Hypoglycaemia is a limiting factor for glycaemic management of diabetes with intensive insulin and/or oral antidiabetic drug (OAD) regimen. Case reports suggest that antidepressants may interfere with blood glucose metabolism in patients with diabetes mellitus potentially increasing the risk of clinically relevant hypoglycaemia. Comorbid depression treated with antidepressants could therefore further complicate glycaemic control. We have carried out a nested case-control study among diabetic patients to assess the risk of hypoglycaemia requiring hospitalisation associated with the use of antidepressants. Diabetic patients treated with insulin and/or OADs were selected from the Dutch Pharmo system. Exposure to antidepressants was the primary determinant investigated. Use of antidepressants was further subclassified based on the receptor binding profile to investigate whether specific pharmacological properties could explain a potential influence on glucose homeostasis. Conditional logistic regression was used to estimate odds ratios and to adjust for confounding factors. From the base cohort (40 600 patients), 549 (1.35%) cases were identified and 1897 controls were selected. Current use of any antidepressant was not associated with a significantly higher risk of hypoglycaemia requiring hospitalisation (OR: 1.36 (95%CI: 0.84-2.20)). A trend for a higher risk on hypoglycaemia was identified for antidepressants with high affinity for the serotonin reuptake transporter. The risk on severe hypoglycaemia was increased after 3 years of use (OR: 2.75 (95%CI: 1.31-5.77)). It is important for diabetic patients using antidepressants for more than 3 years to pay attention for symptoms of hypoglycaemia and strict blood glucose self-monitoring.

A dog’s detection of low blood sugar: a case report

One of the life threatening complications of diabetes is hypoglycaemia. It is a common complication, with times of greatest risk being before meals and during the night. Symptoms usually develop when the blood glucose level falls below 3.5 mmol/l. Many patients with long-standing diabetes report loss of warning symptoms. Prevention of such hypoglycaemic attacks is highly desirable. Recently a dog's ability to detect hypoglycaemia in diabetic patients has been recorded. This is the first recorded case of hypoglycaemia in a non-diabetic patient being detected by a dog and also we believe it to be the first report of hypoglycaemia being detected by a dog in this country (Ireland).

Intentional hypoglycaemia in diabetic patients treated with insulin

Introduction: Hypoglycaemia is the significant limiting factor in management of diabetes. It causes a recurrent morbidity and impairs quality of life in most patients, especially those with Type 1 diabetes. Non-iatrogenic hypoglycaemia in a diabetic patient presents a difficult diagnostic challenge. It could be a consequences of deliberately use of insulin or insulin secretegogues (factitious hypoglycaemia, malingering) or organic diseases (insulinoma). Cases report: Two diabetic patients with surreptitious episodes of hypoglycaemia due to intentional application of insulin are described. This condition has to be suspected in unexplained recurrent episodes of hypoglycaemia. In these cases determination of C-peptide and insulin levels should be considered prior to other more invasive and expensive diagnostic procedures Conclusions: The authors believe that early and correct diagnosis of intentional hypoglycaemia prevents unnecessary diagnostic and therapeutic procedures as well as possible morbidity and mortality. The aim of the present report is to remind the medical personnel, especially in the emergency departments, of this often overlooked condition.

Performance of glucose dehydrogenase (GDH) based and glucose oxidase (GOX) based blood glucose meter systems at moderately high altitude

Objective: Self-monitoring of blood glucose (SMBG) is a fairly efficient method of preventing hypoglycaemia in diabetic patients. Blood glucose meters (BGMs) are influenced by factors such as altitude, temperature, blood oxygen concentration, low atmospheric pressure or humidity. In this study we aimed at evaluating the performance of glucose dehydrogenase (GDH) or glucose oxidase (GOX) based glucometers at moderately high altitude.Method: A total of 286 female or male patients, most of whom had type 2 diabetes, were included in this study. The simultaneous readings made by two different glucometers were compared with the readings made at the reference laboratory.Results: Blood glucose levels measured by a GDH based glucometer at moderately high altitude were significantly (p = 0.007) higher compared to those measured at the reference laboratory. Although blood glucose levels measured by a GOX based glucometer were lower compared to those measured at the reference laboratory, the difference was not significant (p = 0.54). The difference between GOX and GDH readings with regard to blood glucose levels was also significant (p = 0.001). Blood glucometers were influenced by moderately high altitude.Conclusion: The use of a GOX based glucometer at moderately high altitude may be useful in detecting hypoglycaemia at these conditions, since significantly higher blood glucose levels were measured with a GDH based glucometer compared to reference readings.

Detection, Prevention, and Treatment of Hypoglycemia in the Hospital

In Brief Hypoglycemia is a worrisome condition for hospitalized patients. Nurses, physicians, and other health care workers must be vigilant in detecting, treating, and most of all preventing hypoglycemia in diabetic patients. Systems and protocols for treating patients with diabetes guide the health care team in achieving glycemic goals for healing and health promotion while providing a safe environment.

Perioperative Treatment of Patients With Diabetes Having Eye Surgery With Local Anesthesia in an Ambulatory Facility

To evaluate the incidence of hyperglycemia and hypoglycemia in diabetic patients on the morning of eye surgery scheduled under local anesthesia in an ambulatory surgery facility. A retrospective analysis of fasting blood glucose levels in 216 diabetic patients on 326 admissions. The fasting blood glucose level was 80 mg/dL or lower in 10 patient admissions (3%). Hyperglycemia (fasting blood glucose level of greater than 300 mg/dL) was present on 8 admissions (2.4%). Blood glucose levels need to be monitored in diabetic patients undergoing even short surgical procedures. The dosage of long-acting insulins or oral hypoglycemics given the night prior to surgery may have to be reduced to prevent hypoglycemia on the morning of surgery.

Preparation of Quickly Disintegrating Glucose Tablets for Treatment of Hypoglycemia and Analysis of Factors Influencing the Characteristics of the Tablets.

For the self-treatment of hypoglycemia in diabetic patients receiving oral hypoglycemic drugs or insulin injection, we attempted to prepare quickly disintegrating glucose tablets to make them easy to swallow without drinking water. Tablets containing 2, 5 and 10% microcrystalline cellulose were prepared by direct compression at forces of 0.04, 0.06 and 0.12t/cm2. The hardness and water absorption properties were measured as characteristics of the tablets. Changes in the blood glucose level after the oral administration of two tablets were examined using hypoglycemic male rabbits given a subcutaneous injection of one unit of insulin. The intra-oral disintegration time of the glucose tablets was measured in three healthy volunteers who were each administered five tablets.The hardness of the tablets increased as the concentration of microcrystalline cellulose and force of compression increased. The highest value of hardness was 5.27kg (10%, 0.12t/cm2), and the lowest was 1.11kg (2%, 0.04t/cm2). The water absorption rate increased with the concentration of microcrystalline cellulose. The intra-oral disintegration time of the glucose tablets increased as the compression force increased. The minimum value was 83s (2%, 0.04t/cm2) and the maximum 203s (10%, 0.12t/cm2). The results of a multiple regression analysis showed that the tablet hardness correlated closely with the concentration of microcrystalline cellulose in the tablets and the compression force applied. The factors influencing the characteristics of the glucose tablets prepared in this study could be quantitatively analyzed by a multiple regression analysis.

Prolonged sulfonylurea-induced hypoglycemia in diabetic patients with end-stage renal disease

Renal impairment is a recognized risk factor for prolonged hypoglycemia, but predisposing characteristics in patients with advanced renal impairment have not been studied. We observed prolonged hypoglycemia in a number of patients with end-stage renal disease (ESRD) and conducted a case-control study at two Canadian centers to identify such risk factors. Through hospital, pharmacy, and dialysis program records, we retrospectively identified 7 case patients and 31 controls with ESRD and type 2 diabetes using oral hypoglycemic monotherapy. Control patients had no history of hospital admission for prolonged hypoglycemia. All case patients and 28 controls were receiving glyburide (glibenclamide in Europe); the remainder were treated with tolbutamide. Duration of intravenous treatment for hypoglycemia ranged from 28 to 256 hours, with 83 g to 2 kg of glucose administered per episode. Preceding treatment with glyburide varied from 2 days to 13 years. Univariate analyses showed a recent decline in oral intake (odds ratio [OR], 81; 95% confidence interval [CI], 3.6 to 1,840), previous hypoglycemic episodes (OR, 15; 95% CI, 0.77 to 297), longer duration of diabetes (22 versus 12 years; P = 0.008), and a history of cerebrovascular disease (OR, 7.0; 95% CI, 1.0 to 47) to be associated with prolonged hypoglycemia. No association between prolonged hypoglycemia and age, sex, beta blockers, angiotensin-converting enzyme inhibitors, oral hypoglycemic dose, or duration of treatment was identified. This study describes the potentially devastating effect of sulfonylurea-based oral hypoglycemic therapy in ESRD. Patients at greatest risk appear to be those with reduced intake, previous hypoglycemic episodes, and longer duration of diabetes. We describe the mechanisms for observed hypoglycemia and suggest that alternative drugs may be considered in this patient group.

Association between antihypertensive drug use and hypoglycemia: A case-control study of diabetic users of insulin or sulfonylureas

Antihypertensive drags are commonly prescribed for the treatment of patients with both diabetes and hypertension. However, the role of selected agents in the development of hypoglycemia remains controversial. The main objective of this study was to evaluate the effect of antihypertensive agents on the risk of hypoglycemia in diabetic patients receiving insulin or sulfonylurea therapy. A matched case-control study was conducted using Pennsylvania Medicaid data. Five control subjects, matched for sex and age, with no reported medical condition of hypoglycemia, were randomly selected for each case patient admitted for hypoglycemia in 1993, resulting in a total of 404 cases and 1375 controls. With these sample sizes, we were able to detect a difference of 10% ( P < 0.05) for our primary outcome measure, hospitalization for hypoglycemia. The relative risk of hypoglycemia was estimated using an unconditional logistic regression. The risk of hypoglycemia was 5.5 times greater (95% confidence interval [CI], 4.0 to 7.6) in insulin versus sulfonylurea users and was not influenced by use of angiotensinconverting enzyme (ACE) inhibitors overall. However, use of the ACE inhibitor enalapril was associated with an increased risk of hypoglycemia (odds ratio, 2.4; 95% CI, 1.1 to 5.3) in sulfonylurea users, suggesting that analyzing the unintended side effects of a class of drugs can sometimes mask the adverse effects of individual drugs. Use of β-blockers was not associated with an increased risk of hypoglycemia, providing further empiric evidence that β-blockers are an appropriate treatment for persons with concomitant diabetes and hypertension. Per capita health care costs were ~3 times higher in patients hospitalized for hypoglycemia compared with controls ( P < 0.05). Hospitalization for hypoglycemia is expensive and may be prevented with appropriate monitoring of diabetic patients taking selected antihypertensive agents such as enalapril.

Risk of Severe Hypoglycemia in Diabetic Patients Taking ACE Inhibitors

Risk of Severe Hypoglycemia in Diabetic Patients Taking ACE Inhibitors

Monitoring set-up for selection of parameters for detection of hypoglycaemia in diabetic patients.

Recurrent severe hypoglycaemia is often an unsolved problem in diabetic patients under intensified insulin treatment. As no reliable long-term stable blood glucose sensor has yet been developed, registration of other body function changes could help to detect severe hypoglycaemia. A measuring system is described, capable on the one hand of recording EEG, heart rate, peripheral pulse, skin temperature, respiratory movements, skin impedance and arterial blood pressure, and capable of registering plasma glucose, counter-regulatory hormones, symptoms and cognitive performance under experimental conditions during hypoglycaemia, on the other. In a clinical study involving both insulin-induced hypoglycaemia in healthy subjects and insulin-dependent diabetic patients, the practical value and the character of changes of the recorded parameters are investigated. Currently insensitivity to hypoglycaemia, impracticability, complexity or susceptibility to artefacts make use of most parameters unsuitable for hypoglycaemia prevention. It is believed, however, that future efforts could result in indirect registration of hypoglycaemia, including a qualified combination of different parameters, individual adaptation in accordance with particular responses of individual patients, together with new measuring and sensor techniques.

Austria — Parameters for detection of hypoglycaemia in diabetic patients : In MED. BIOL. ENG. COMPUT. (34/1 (69–75) 1996) G. Heger, K. Howorka, H. Thoma, G. Tribl & J. Zeitlhofer of the University of Vienna report on ‘Monitoring set-up for selection of parameters for detection of hypoglycaemia in diabetic patients’

Austria — Parameters for detection of hypoglycaemia in diabetic patients : In MED. BIOL. ENG. COMPUT. (34/1 (69–75) 1996) G. Heger, K. Howorka, H. Thoma, G. Tribl & J. Zeitlhofer of the University of Vienna report on ‘Monitoring set-up for selection of parameters for detection of hypoglycaemia in diabetic patients’

ACE INHIBITORS AND HYPOGLYCEMIA.

Several drugs used to treat cardiovascular disease in diabetic patients can disturb glycemic control. Although some reports have linked angiotensin-converting-enzyme (ACE) inhibitors with hypoglycemia in diabetic patients, these drugs are not generally considered to be an important cause of hypoglycemia. This retrospective case-control …

Changes in renal function during acute insulin-induced hypoglycaemia in patients with type 1 diabetes.

The effect of acute hypoglycaemia on renal function was examined in eight male patients with Type 1 diabetes who had normal urinary albumin excretion. Insulin was given as a bolus intravenous injection (0.125 U kg-1) and plasma glucose fell to a nadir of 1.6 (SE 0.2) mmol l-1, with all patients experiencing an acute autonomic reaction. Renal plasma flow fell from 674 (106) to 540 (198) ml min-1 during hypoglycaemia (p less than 0.01) and returned to 655 (181) ml min-1 (NS vs baseline). Glomerular filtration rate (GFR) declined from 143 (23) to 110 (36) ml min-1 during hypoglycaemia (p less than 0.02), rising to 150 (44) ml min-1 in the recovery period (NS vs baseline). The urinary flow rate and urinary albumin excretion rate both fell significantly in response to hypoglycaemia (10.6 (1.2) to 4.7 (1.1) ml min-1; p less than 0.002, and 46.2 (10.6) to 26.0 (10.5) micrograms min-1, respectively). Urinary dopamine excretion also declined, from 322 (37) to 211 (29) mumol min-1 (p less than 0.005) but sodium excretion was unchanged. Plasma adrenaline concentration (0.2 (0.03) to 1.7 (0.4) nmol l-1; p less than 0.01) and plasma renin activity (0.49 (0.13) to 1.08 (0.17) ng-Ang 1 l-1 h-1; p less than 0.01) increased during hypoglycaemia, but changes in plasma noradrenaline and angiotensin II levels did not attain significance. These acute changes in renal function, observed during hypoglycaemia in diabetic patients, may result from direct stimulation of the efferent sympathetic nerves to the kidney, complemented by the hormonal changes induced by hypoglycaemia.

A new non-invasive method for treating insulin-reaction: intranasal lyophylized glucagon

The main therapeutic indication for glucagon is the treatment of hypoglycaemia in insulin overdosed Type 1 (insulin-dependent) diabetic patients. We have previously shown that an intranasal spray of 7.5 mg glucagon with deoxycholic acid as surfactant was able to correct an i.v. insulin-induced hypoglycaemia in diabetic patients. However, bioavailability and stability needed to be improved before intranasal glucagon could be introduced into clinical practice. This has now been achieved with a freeze-dried mixture of glucagon (1 mg) and glycocholic acid (1 mg) as a surfactant. Kinetics and efficacy have been controlled by (1) comparing subcutaneous and intranasal glucagon in 12 healthy non-hypoglycaemic subjects; (2) testing intranasal glucagon in six Type 1 diabetic patients in whom hypoglycaemia was induced by an i.v. bolus of insulin and (3) comparing subcutaneous and intranasal glucagon in six Type 1 diabetic patients in whom hypoglycaemia was induced by adding extra subcutaneous regular insulin to their usual morning dosage. Our results show that 1 mg of intranasal glucagon is as effective as 1 mg of subcutaneous glucagon in terms of the rise in blood glucose. Differences in kinetics between the subcutaneous and the intranasal routes may be observed: intranasal glucagon initiates the blood glucose rise earlier than does the subcutaneous form but the effect of the latter is more sustained. Glycocholic acid appears to be a perfectly tolerated agent in acute conditions. The use of intranasal lyophylized glucagon, for the reversal of hypoglycaemia in Type 1 diabetes, seems to be a clinically relevant alternative to its parenteral equivalent and should now be ready to be introduced in the market.

Lack of Cutaneous Hyperemia in Response to Insulin-Induced Hypoglycemiain IDDM

Cutaneous blood flow was measured with the laser Doppler technique and by recording cutaneous O2 tension on the forearm and forehead in nine young adult patients with insulin-dependent diabetes mellitus (IDDM) and nine sex- and age-matched healthy control subjects after induction of hypoglycemia. In the healthy subjects, cutaneous blood flow measured with the laser Doppler technique was increased by 120 +/- 26% in the forehead (P less than 0.01) and 196 +/- 50% in the forearm (P less than 0.01) at the glucose nadir (blood glucose 1.8 +/- 0.2 mM) compared with basal blood flow. In contrast, in diabetic patients, cutaneous blood flow was unchanged. The corresponding changes, at the glucose nadir, with cutaneous O2 tension recordings were 286 +/- 131% (P less than 0.05) in control subjects and -22 +/- 15% (NS) in diabetic patients. An impairment of sympathetic nervous function, not detectable by simple cardiovascular tests, could be responsible for the lack of cutaneous hyperemia and sweating and could contribute to unawareness of hypoglycemia in diabetic patients.

Differential Effects of Human and Pork Insulin–Induced Hypoglycemia on Neuronal Functions in Humans

Insulin has been found to cross the blood-brain barrier, and insulin receptors have been detected in different structures of the brain. However, the biological significance of insulin acting in the brain remains unclear. Reports of differential awareness of hypoglycemic symptoms during human insulin (HI)- and pork insulin (PI)-induced hypoglycemia hint at a modulatory influence of insulin on sensory processing. In a double-blind study, we recorded auditory-evoked potentials (AEPs), indexing neuronal transmission along sensory pathways, in 30 healthy male subjects during a baseline condition and HI- and PI-induced mild hypoglycemia of 2.65 mM. Fifteen subjects were tested after 20 min and another 15 after 50 min of constant hypoglycemia. During hypoglycemia, subjects had to indicate the severity of hypoglycemic symptoms and their current mood. Hypoglycemia increased latencies of the P3 component and reduced amplitudes of the N1, P2, and P3 components. Despite identical blood glucose and serum insulin levels in both sessions, effects of PI-induced hypoglycemia on AEP components were significantly stronger than those of HI-induced hypoglycemia (P less than 0.05). Differences between the effects of the insulins were consistently apparent after 20 min of hypoglycemia, indicating a short-term action of these hormones on central nervous system functions. Also, after 20 min, but not after 50 min, of steady-state hypoglycemia, subjects felt more excited during PI than HI infusion (P less than 0.05). The results indicate different influences of HI and PI on sensory function during hypoglycemia. These differences, occurring during early hypoglycemia, could contribute to the differential awareness of hypoglycemic warning symptoms during HI- and PI-induced hypoglycemia in diabetic patients.

Transient atrial fibrillation precipitated by hypoglycemia

Two noninsulin-dependent diabetic patients developed transient atrial fibrillation precipitated by hypoglycemia that reverted to sinus rhythm after administration of IV dextrose. Atrial fibrillation as a complication of hypoglycemia in diabetic patients has been reported in only two patients with insulin-dependent diabetes mellitus.

Arginine Vasopressin and Oxytocin Responses to Insulin-Induced Hypoglycemia in Type 1 (Insulin-Dependent) Diabetes*

In normal humans, arginine vasopressin and oxytocin are released acutely from the posterior pituitary gland in response to hypoglycemia, and their release may assist counterregulation. The responses of these hormones to insulin-induced hypoglycemia were measured in 16 insulin-dependent diabetic patients with no autonomic neuropathy (8 patients who had been diabetic less than 5 yr and 8 patients who had been diabetic greater than 15 yr) and in 6 normal subjects. The time of the onset of hypoglycemia and the mean blood glucose nadirs were similar in all groups, but the blood glucose recovery was delayed in the diabetic patients. In the normal subjects plasma arginine vasopressin rose from a mean basal value of 0.4 +/- 0.2 (+/- SE) pmol/L to a maximum of 1.3 +/- 0.6 pmol/L, and plasma oxytocin rose from 0.7 +/- 0.1 pmol/L to a maximum of 1.2 +/- 0.2 pmol/L 30 min after the onset of hypoglycemia. The plasma arginine vasopressin and oxytocin concentrations after hypoglycemia were significantly higher in both of the diabetic groups compared with those in the normal group. Arginine vasopressin and oxytocin rose in all control subjects after hypoglycemia. The individual hormonal profiles in the diabetic patients were variable, with an exaggerated rise of oxytocin in some diabetic patients and no rise in others. The arginine vasopressin responses were exaggerated in all of the diabetic patients. There was no correlation between the hormonal responses and the duration of diabetes. The exaggerated plasma arginine vasopressin and oxytocin responses to hypoglycemia in diabetic patients may indicate the failure of a normal inhibitory mechanism which modulates hormonal secretion or a compensatory response to impaired glucose recovery.

Liver function tests after hypoglycaemia in insulin‐dependent‐diabetic patients

AbstractLiver function tests were measure in 16 patients with insulin‐dependent diabetes mellitus following controlled insulin‐induced hypoglycaemia (Group A) and in 12 patients admitted to an Accident And Emergency Department in hypoglycaemic coma (Group B). Bilirubin, alanine aminotransferase and aspartate aminotransferase were normal in all patients. Gamma‐glutamyl transferase was elevated in three patients in Group B, of whom two were receiving phenytoin therapy and the third had a history of excessive alcohol consumption. It appears that significant abnormalities of liver function tests are not a common sequel of hypoglycaemia in diabetic patients in the absence of predisposing liver disease.