Treatment induced hypoglycaemia

Introduction

Hypoglycaemia refers to a blood glucose level below 3.6 mmol/L. Treatment induced hypoglycaemia on the other hand refers to an established hypoglycaemia as a result of treatment.
Hypoglycaemia is more common in elderly diabetics and those with kidney function impairment as well as those on long-acting oral anti-hyperglycaemic medications or insulin.
Severe hypoglycaemia (blood glucose < 2.2 mmol/L) may result in alteration of consciousness, fits, self-injury and various degrees of irreversible brain damage.
Following successful treatment of hypoglycaemia, its cause must be
determined and measures, including patient education and revision of anti-hyperglycaemic drug doses, should be taken to prevent its recurrence.

Causes of hypoglycaemia

  • Overdose of any anti-hyperglycaemic medication i.e. insulin or oral agent
  • Antihyperglycaemic medication use in renal impairment and the elderly
  • Omitted or inadequate amount of food
  • Unaccustomed physical overactivity
  • Excessive alcohol intake

Symptoms of hypoglycaemia

The following are the symptoms of hypoglycaemia

  1. Dizziness
  2. Blurred vision
  3. Headaches.
  4. Palpitation
  5. Sweating
  6. Shaking of the hands and body
  7. Unconsciousness
  8. Convulsions
  9. Irritability and abnormal behaviour especially in children

Signs of hypoglycaemia

The signs of hypoglycaemia are:

  1. Sweating
  2. Tremors
  3. Tachycardia and bounding pulse
  4. Confusion
  5. Unconsciousness
  6. Convulsions

Investigations

  • Random blood glucose (urgently done using a glucose meter)
  • Blood urea and electrolytes
  • Liver function tests

Treatment for treatment induced hypoglycaemia

Treatment objectives

The objectives of treating”treatment induced hypoglycaemia” include the following:

  1. To rapidly restore blood glucose levels to normal
  2. To maintain the level of blood glucose within the normal range until the patient can begin eating normally
  3. To identify and address the cause

Non-pharmacological treatment

Mild hypoglycaemia

  • 2-3 teaspoons of granulated sugar or 3 cubes of sugar or ½ a bottle of soft drink (sugar containing, not ‘diet’ drinks) to individuals who are conscious.
  • A glass of milk or fruit drink and a tablespoonful of honey are useful alternatives
  • The above measures should be followed immediately by a meal or snack

Moderate hypoglycaemia

  • Same as for mild hypoglycaemia, but repeat after 10 minutes.
  • If no improvement is observed, treat as for severe hypoglycaemia

Pharmacological treatment

A. Severe hypoglycaemia

1st Line Treatment
Evidence Rating: [A]
Dextrose, IV,
Adults:

  • 50% solution, 25-50ml 1-3 minutes through a large vein,

Then

  • 5-10% solution, 500 ml 4 hourly until the patient is able to eat normally

Children

  • 10% solution 4 ml/kg body weight over 1-3 minutes through a large vein

Then

  • 5% solution: According to total daily fluid requirement until blood glucose levels normalise

2nd Line Treatment
Evidence Rating: [A]
Glucagon, IV, IM or subcutaneous,
Adults: 1 mg stat.
Children

  • 8-18 years (bodyweight > 25 kg); 1 mg stat.
  • 8-18 years (bodyweight < 25 kg); 500 micrograms stat.
  • 1 month-8 years; 500 micrograms stat.
  • Neonate; 20 microgram/kg stat.

Referral Criteria

If the patient does not respond to recommendations, refer to a specialist.