How to Detect, Prevent, and Manage Hypoglycemia

Jonathan Halldorson BSN, RN

Registered Nurse

Endocrine and Diabetes Care Center

University of Washington Medical Center

Seattle, WA

Agenda

• How can monitoring blood glucose help manage

diabetes and detect hypoglycemia?

• What are some strategies for preventing and

reducing the risk of hypoglycemia?

• How is hypoglycemia treated?

• Patient story

Review: Hypo(low)glycemia(sugar)

• Defined by blood sugar less than 70mg/dL

• Greatest immediate danger with diabetes

• Different stages of hypoglycemia

• Mild (≤ 70 mg/dL)

• Moderate (≤ 54 mg/dL)

• Severe (severe cognitive impairment requiring assistance

from another person or blood sugar < 40 mg/dL)

How can monitoring blood glucose help manage diabetes and detect

hypoglycemia?

Self-Monitoring Blood Glucose

• Individualizes diabetes care

• People with diabetes will know if meeting specific blood glucose goal

• People with diabetes may adjust medication doses based upon blood

glucose measurements as advised by their medical provider

• Identify and in turn prevent hypoglycemia and hyperglycemia

• Essential component of the diabetes management

process

• Benefits all people who have diabetes

Many Blood Glucose Meters are Available

When Should Blood Glucose Be Tested?

Self-monitor blood glucose at different times in the

day

• Fasting (no food for 8 hours before testing) and/or

• Before or after meals and/or

• Before, during, and after exercise

• At 3:00 am

Self-monitor blood glucose if you feel symptoms of

hypoglycemia or have an illness

Can A1C Be Used To Check For Low Blood Sugar?

No, hemoglobin A1C (A1C) measures average blood sugar level

over past 2-3 months

• Self-monitor glucose meter is used to measure hypoglycemia

• Most people with diabetes should try to reach A1C goal of 7 percent

or less

• May have a normal or high A1C and still have hypoglycemia

Comparison of Two A1c Values of 5.9%

150

70

1 day Sun Sept 27, 2015 1 day Thur Oct 15, 2015

Average glucose 123 mg/dL

(CGM)

Average glucose 121 mg/dL

(CGM)

150

70

Self-Monitor Blood Glucose Patterns and Trends

• Keep track of blood glucose measurements in a journal or cell

phone app

• Identify blood glucose levels within target range – time in target

• Identify date and time when hypoglycemia happens

• Identify possible cause of the hypoglycemia

• Identify what was done to bring glucose level back up

• Discuss blood glucose levels with medical provider

• Difficult to manage diabetes if blood glucose not measured

What is Continuous Glucose Monitoring (CGM)?

• Tiny device used to constantly measure blood glucose

• Measures glucose automatically and continuously (every 5 minutes)

• Tells direction glucose level is moving

• Higher, lower, or stable

• Tells amount of time glucose has been at specific level

• Tells how frequently blood glucose is at a specific level

• Measures changes to blood glucose level throughout day

• Can help identify and in turn prevent hypoglycemia and hyperglycemia

Sample Continuous Glucose Monitoring Report

Reports Available from CGM

CGM Can Decrease Hypoglycemia

What are some strategies for preventing and reducing the risk of hypoglycemia?

• Eat meals consistently (avoid skipping meals)

• If you missed a meal and you are on mealtime insulin, skip the mealtime dose

• Careful with holiday fasting

• Careful if fasting before medical procedure

• Take correct dose of insulin or other diabetes medication

• Take insulin or other diabetes medication at correct time

• Use caution if consuming alcohol

• Eat snacks if you choose to drink

• Check your blood sugar regularly and whenever experiencing symptoms

Prevent Hypoglycemia? Sick Days

• Check blood sugar more frequently

• Drink plenty of water

• Avoid over the counter medications with sugar

or alcohol (i.e., cough medicine)

• Talk to your medical provider beforehand to set

up a sick day management plan that is

individualized for you

Prevent Hypoglycemia? Exercise

• Check sugar before and after exercise

• Avoid exercising when mealtime insulin hits peak

• Be careful with saunas or hot tubs

• Hot temperature can continue lowering sugar

• Avoid alcohol use after exercise

• Drink plenty of water

• Consider having a snack before exercise

• Consider adjusting insulin before exercise

Prepare for Hypoglycemia

• Always carry fast-acting sugar

• Wear diabetes ID

• Do not drive a car without knowing blood glucose is in safe range

• Tell your friends, family, and coworkers about your personal

symptoms of hypoglycemia

• Tell them where glucagon is kept and how to give it

• If low blood sugar at night, remember your bedtime snack

(e.g, yogurt or peanut butter & crackers)

• Use an extended-release snack substitute

• If it reoccurs, contact your medical provider for medication dose adjustment

Investigate - Why the Low Blood Sugar?

How is hypoglycemia treated?

Treatment of Hypoglycemia

Hypoglycemia

<70 mg/dL

Able to

take oral?

Give 15 grams fasting

acting carbohydrate

(e.g., 4-oz fruit juice)

Yes No

Give glucagon

shot (1 mg IM/SC)

Treating Hypoglycemia: Rule of 15

If glucose <70 mg/dL, and symptoms

present, Give 15 grams fast acting

carbs

Recheck glucose in 15 minutes

If <70 mg/dL, repeat with another 15

grams fast acting carbs

Repeat process until blood glucose >70 mg/dL and resolution of symptoms, then eat

a protein snack or your meal. Do not over treat with carbohydrates.

When self-monitoring

blood glucose reveals

a blood glucose ≤70

mg/dL

If blood glucose does

not return above 70

mg/dL after the

second treatment, call

your doctors office or

seek emergent care

Examples of 15 grams of Fast-acting Carbohydrates

• 4 ounces of juice or NON-diet soda

• 1 tablespoon of honey

• 15 grams of glucose tabs or gels

• 8 ounces of low-fat or nonfat milk

• 1 tablespoon of sugar

• 5 to 6 pieces of hard candy, such as

Lifesavers

• 8 candy corns

Important Points

• If meal time is not within 1 hour of treating the

hypoglycemia episode, eat a small snack

(protein/fat plus carbs) to prevent another

episode and monitor blood glucose levels.

• Foods high in fat, such as chocolate and

potato chips, are not ideal choices for treating

hypoglycemia, because fat delays

carbohydrate absorption.

You’re late to eat lunch, you feel a little dizzy and you check

your blood glucose. It is 65.

Which is better?

or

Which is better?

or Nothing

Severe Hypoglycemia

• Cases of severe hypoglycemia should be treated with a glucagon

injection.

• Severe (blood glucose less than 40 mg/dL or severe cognitive impairment

requiring assistance from another person)

• Those who use insulin, especially those with type 1 diabetes, should

have a glucagon emergency kit (available by prescription only)

• Glucagon typically works within 5 to 10 minutes. If the person with

diabetes is still unresponsive after administration, the caregiver should

be instructed to call 911 for further treatment.

• Read glucagon kit instructions before you need to use it or use

instructional app

Using a Glucagon Kit

• Glucagon kits have expiration dates; routinely check the dates and

replace accordingly to have one on hand in case of a severe

hypoglycemic emergency

• Use expired glucagon kit to practice injection on a piece of fruit

When to Call Health Care Provider

• Frequent or severe low blood sugar

• Very high blood sugar

• Illness

• Infections or non-healing sores on skin

• Questions

Hypoglycemia – It’s personal

• Missing work/school

• Multiple occurrences can affect memory

• Running high blood glucose by skipping

medication doses due to fear of lows

• Lack of sleep

• Spouse or caregiver fatigue, worry, arguments

• Weight gain due to overeating for lows

• Cost of strips, buying snacks, etc…

Patient Story: Bridgett

• Bridgett is a 53-year-old woman who takes metformin and glipizide 3 times a day. She is walking around the mall by herself all morning. It’s midday and she hasn’t had lunch yet but takes her pills because it’s noon. She walks to her car and immediately feels dizzy and weak. She doesn’t have her glucometer but does have hard candy and a juice box in her purse. She eats the candy and drinks the juice and feels better. She decides to drive back home so she can get lunch prepared.

• What can we learn from Bridgett’s example?

Patient Story: Sam

• Sam is a 45-year-old man who takes regular insulin. He knows he is supposed to take it 30 minutes before eating, but he forgot and took it in the middle of the meal. Two hours after eating, he is cleaning the dishes and feels shaky. He decides to go upstairs to find his glucose tablets and passes out on the stairs.

• What can we learn from Sam’s example?

Questions?

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