Hypoglycemic Management in Diabetes

In Canada, it's estimated that there are 11 million people living with pre-diabetes or diabetes; a number that is steadily increasing. Diabetes has implications on cardiovascular health, eye health, kidney disease, foot and skin infections and neuropathic pain.

Given this information, regardless of the specialty you choose to work in, it's very likely that you will be providing care to patients with diabetes or managing complications that have arisen due to diabetes. 

The role of nurses in diabetes care is all encompassing and includes responsibilities such as urine and blood glucose monitoring, administering oral therapies and identifying and treating hypoglycemia or hyperglycemia. Diabetes (especially insulin dependent diabetes) also requires special management in exercise, travel and surgery. Patient education is an essential responsibility of every health professional on the team when it comes to diabetes management. In addition, given the prevalence of diabetes, a strong foundational knowledge on the management of diabetes is beneficial in everyday life as well! 

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What is Diabetes?

Diabetes is characterized either by the lack of insulin or the inability to use the insulin produced by the body. Insulin is a hormone produced by our pancreas that the body uses to regulate the amount of sugar in our body by allowing your body to convert glucose into food and energy through the movement of sugar out of the blood and into cells.

When the production or sensitivity to insulin is impaired, this results in high blood sugar levels. Early symptoms include increased urination, increased susceptibility to infections, excessive thirst, tingling or numbness and impaired or blurry vision. 

There are three main types of diabetes:

Type 1 Diabetes:

• A chronic autoimmune disease where pancreatic cells are destroyed resulting in little to no production of insulin resulting in hyperglycemia (high blood sugar).
  
  
• Absolute deficiency of insulin.
  
  
• Onset is typically (but not always) in childhood.
  
  
• Insulin is the mainstay of treatment.

Type 2 Diabetes:

• A multifaceted and progressive disease in which the insulin that body produces is less efficient at moving sugar out of the blood and into the cells resulting in hyperglycemia.
  
  
• Onset is typically (but not always) in adulthood.
  
  
• Lifestyle modifications are first line treatment.
  
  
• Oral medications are the mainstay of pharmacological treatment. Insulin will be used in situations such as the loss of ability of pancreas to produce insulin as the disease progresses or inadequate control of blood sugar levels are experienced despite multiple oral agents. 

It's estimated that 90% of those with diabetes are type 2 diabetics. 
 

Gestational Diabetes:

• Diabetes that first appears during pregnancy due to hormonal changes. Typically, this will resolve after the baby is born. 
  
  
• Increased blood sugar monitoring and intensive non pharmacological measures are the first line for management. 
  
  
• Insulin, metformin, and glyburide are the mainstay for pharmacological treatment.

 

This article will focus primarily on Type 1 and Type 2 diabetes, but the core principles of management are also applicable in gestational diabetes.  

Diagnosis

Diabetes is diagnosed by testing blood sugars. 

The two most relevant monitoring parameters are fasting blood glucose (FBG) or Hemoglobin A1c (HgbA1c). In the absence of asymptomatic high blood sugar (such as diabetic ketoacidosis), a confirmatory test will be performed on another day.  

HgbA1c:

• This is a measurement of the percentage of hemoglobin coated with sugar. This parameter gives a picture of the average blood sugar over the last 3 months. 
  
  
• The higher the A1c values, the higher their blood sugars have been.
  
  
• In the general population, an HgbA1c over 6.5% is considered diabetes. 

Fasting Blood Glucose:

• This is the measurement of the amount of glucose there is in the blood after no caloric intake for the last 8 hours. 
  
  
• In the general population, a fasting glucose over 7mmol/L is considered diabetes.

Signs and symptoms (i.e. obesity), age of onset and an antibody test help distinguish between Type 1 vs 2 diabetes. Management of  the different types of diabetes differ but both can result in the same complications. 

Management of Diabetes

In Type 2 diabetes, upon initial diagnosis, lifestyle modifications including smoking cessation, healthy diet and regular exercise are implemented as first line treatment for lowering blood sugars. In addition, lifestyle modifications have additional cardiovascular benefits such as lowering bad cholesterol levels and blood pressure which is also important in diabetes management. 

If lifestyle measures are non sufficient, medications need to be initiated. Unless there is an intolerance or a contraindication, metformin will be used initially. One medication is not always enough to control blood sugars. Two or more agents can be used working together in different ways to meet blood glucose targets. The choice of the additional agent will be based on patient factors such as renal function, side effects, cost, and preference of route of administration. Some medications confer a greater risk of unintentional low blood sugars than others. 

In Type 1 diabetes, insulin is always used due to the lack of natural production and is the mainstay of therapy. This includes a short acting (bolus) dose with each meal and a long-acting (basal dose) at bedtime. For better control of sugars, an insulin pump may be used. The use of insulin always confers a risk of hypoglycemia.  Lifestyle modifications are also recommended Type 1 diabetes. 

A tight control of blood sugars lowers the risk of microvascular complications such as eye damage (retinopathy) or blindness, foot and skin infections sometimes leading to amputation, nerve damage and nerve pain (neuropathies) and kidney damage (chronic kidney disease). These conditions significantly impact the quality of life of those with diabetes. 

A tight control also reduces the risk of diabetic ketoacidosis and will reduce symptoms of hyperglycemia such as tiredness, thirst, and frequent trips to the washroom. However, tight control comes with risks such as side effects from medications or unintentionally dangerously low sugars.  

Diabetes is a multifactorial disease and the role of nurses in many different aspects of management can be explored. However, the rest of this article will focus on hypoglycemia. With strict management of blood sugars comes the importance of understanding the risk factors, signs and symptoms and management of hypoglycemia. 

Hypoglycemia

Hypoglycemia is when blood sugar levels get dangerously low. While mild hypoglycemia is not that dangerous if managed properly, if it progresses to severe hypoglycemia it can result in seizures, lost consciousness, and injury. While uncontrolled blood sugars can result in long term consequences, severe hypoglycemia can result in immediate consequences. Therefore, the recognition of hypoglycemia and timely management is essential.

What is hypoglycemia?

• Blood sugar levels below 4mmol/L.
  
  
• Development of autonomic symptoms.
  
  
• Development of CNS (neuroglycopenic) symptoms due to shortage of glucose in the brain.
  
  
• Relieved with carbohydrate intake.

What are the signs and symptoms of mild-moderate hypoglycemia?

Primarily autonomic symptoms such as:

• Tremors

• Tachycardia

• Weakness

• Nausea

• Hunger

• Sweating

 
***Please note, a lot of patients have cardiovascular co-morbidities and are often using beta blockers (i.e. metoprolol, bisoprolol or carvedilol). These hide most of the autonomic symptoms except sweating.

What are the signs and symptoms of severe hypoglycemia?

Primarily neuroglycopenic symptoms such as: 

• Lost consciousness

• Mental status changes

• Vision changes

• Disorientation

• Trouble speaking

• Seizures 

 Blood glucose levels are typically below 2.8mmol/L.

What causes hypoglycemia?

There are many different causes of hypoglycemia. Use of insulin or medications that work by increasing the amount of insulin available in the body increase the risk of hypoglycemia. Drug classes implicated in increasing the risk of hypoglycemia are sulfonylureas and meglitinides. Changes in exercise, eating habits or medication administration times in conjunction with the use of these medications confers the greatest risk of experiencing a hypoglycemic event. An acutely ill diabetic patient admitted in hospital is always at risk of experiencing hypoglycemia. 

Sulfonylureas are older agents that are regularly used in practice due to the affordable price and rapid blood glucose lowering effect. Meglitinides are used in individuals with irregular eating habits as it has a quick onset and short duration of action and can be easily skipped.  

Below is an excel summary of the medications commonly used in diabetes management and their risk of causing hypoglycemia: 

To save a copy go to 'file,' then 'make a copy.'

Diabetes Management Common Medications

Every medication used in diabetes management has risks and benefits. The successful use of any of the above agents listed in diabetes management is in understanding what the side effects are and how to prevent or manage them. The use of sulfonylureas, insulin and meglitinides are well established in practice and will be continued to be used despite their risk of hypoglycemia.  

It's also important to understand that diabetes management is extremely patient specific. Depending on the site you work at, as well as the patient population you are caring for (i.e. elderly), diabetes management recommendations may differ. For example, in long term care or acutely hospitalized patients, targets for blood sugar levels are loosened and much higher blood glucose levels are considered acceptable. In community and outpatient treatment, targets for blood sugar levels are much more rigid. 

However, hypoglycemia, given the quick consequences it can have, has more rigid and standard recommendations. 

Management of Hypoglycemia

If you suspect hypoglycemia, the first thing you should do is test the blood sugars.

A reading below 4mmol/L requires immediate treatment!

In a conscious individual:

1. Administer 15g of carbohydrates. Examples include: 15g of glucose in the form of glucose tablets, 175mL (3/4 cup) of juice or regular soft drink or 3 packs of sugar diluted. Patients may carry their own preferred treatment on hand.
   
   
2. In 15 minutes, test blood sugar again (rapid acting sugar takes 15 minutes to be absorbed into the bloodstream). It's very important to check because the first 15g of carbohydrates may not have been sufficient in raising the blood sugars. 
   
   
3. If it's still below 4mmol/L, administer another 15g of carbohydrates. Wait another 15 minutes and then continue as above until the patient reaches over 4mmol/L. 
   
   
4. If the next meal is over an hour away, provide 15g of carbohydrate and one source of protein in order to maintain blood sugar levels and prevent recurrent hypoglycemia. Examples include: Bread with cheese, bread with peanut butter, 6-7 crackers with cheese or 1 container of Greek yogurt. 

In a unconscious individual:

Management of hypoglycemia in an unconscious individual in a hospital generally involves the prompt administration of Dextrose 50% (D50W) following site specific protocol. Typically, if a patient uses insulin, there is a standing order for D50W available so that it can be administered without delay. If unable to administer D50W, intramuscular or subcutaneous glucagon will be used.  

As this type of hypoglycemia is very serious, it often involves consultation with the physician for further treatment recommendations especially if a patient does not regain consciousness. 

If a patient regains consciousness, the protocol will be followed as in a conscious individual. 

After resolution of a hypoglycemic episode, it is often recommended that blood sugars be measured again in 60 minutes. This is done because patients are acutely ill and have difficulty identifying hypoglycemic symptoms and are at risk of experiencing recurrent hypoglycemia.  

The Essential Role of Nurses in Management of Hypoglycemic Episodes

Identification and Management: 

As nurses, you are on the floor and directly interacting with patients. You are often the first to notice signs and symptoms of hypoglycemia. Prevention and prompt identification are the most important principles of hypoglycemia management.

This is why an understanding of what medications increase the risk of hypoglycemia, signs and symptoms of hypoglycemia and management of hypoglycemia is essential when providing care to a diabetic patient. 

Identification of red flags:

If a patient is experiencing frequent hypoglycemic events (i.e. more than once in a 24-hour period), this should be flagged to the medical team and referral to a diabetes specialist may be warranted. Oftentimes, adjustments in medications or insulins may be necessary. 

Patient Education:

After a hypoglycemic episode is resolved, this is a great opportunity for education! Patient education is key in allowing patients  to successfully self-manage their disease. 

Hypoglycemia patient education can include the following:

1. Review the patient’s understanding of the hypoglycemic event.

2. Provide the patient (or the patient’s caretaker) with information on outpatient prevention of hypoglycemia. For example: 

• Regular blood sugar monitoring especially if using insulin, sulfonylureas or meglitinides.

• Consumption of adequate carbohydrates before exercise.
  
  
• Increasing monitoring of blood sugars and adjusting carbohydrate intake after consumption of alcohol.

3. Review the signs and symptoms of mild-moderate and severe hypoglycemia.

4. Review the treatment of mild-moderate hypoglycemia which is exactly the same as management led by nurses in a conscious individual. 

5. If a patient is at an ongoing risk of severe hypoglycemia, review the outpatient treatment of severe hypoglycemia. Ensure the patient has a glucagon kit on hand and that family/ caregivers are familiar with the proper injection technique. Family and caregivers should also be ready to call 911 immediately. 

If diabetes is not your area of expertise or you don’t feel like you are the most appropriate health care professional to provide the patient education, never be afraid to refer the patient to a Certified Diabetes Educator (CDE) or a diabetes specialist if further support is needed. 

Conclusion

Diabetes is a disease that is characterized by elevated blood sugars. In order to lower risk of complications to eyes, nerves, kidneys and feet, a tight control of blood sugars is targeted. However, a tight control of blood sugars creates a risk of dangerously low blood sugars. 

As nurses, you are the primary health care professional that identifies and treats hypoglycemia in patients. A strong understanding of risk factors for hypoglycemia, medications that can result in hypoglycemia and signs and symptoms of hypoglycemia are essential to provide prompt treatment. 

After a hypoglycemic episode has resolved, there is an opportunity to identify red flags that may be causing hypoglycemic episodes as well as providing education to patients so that they are able to self manage it. Through collaboration with the diabetes specialist on the team or the physician, this can be accomplished and patients will be able to better self manage their disease. 

Resources:

All the factual information in this post is supported by Diabetes Canada; a nationally trusted source of diabetes education, research, resources and services.

 

Author Bio  

Azra Chatur, BScPharm

Azra is a pharmacy graduate from the University of Alberta. All aspects of pharmacy and healthcare interest her but the majority of her experience has been focussed on long term care, geriatrics and community pharmacy. Writing is her passion and she is excited to be able to share her pharmaceutical knowledge with nurses! If you have questions don’t hesitate to connect with her on Linkedin.