Say Goodbye, Conquering Hypoglycaemia in Diabetes

Introduction: Hypoglycaemia is a clinical syndrome with diverse aetiology. In diabetes, it is defined as all episodes of low plasma glucose with or without symptoms that expose the individual to harm. Over decades a variety of criteria have been used to define hypoglycaemia. However according to ADA 2016 guidelines it is defined as a blood glucose level less than 70 mg/dl or 3.88 mmol/l. It is a medical emergency that requires prompt recognition and treatment to prevent organ and brain damage. During the course of diabetes, it is reported that 1 out of 4 patients are at risk of developing hypoglycaemia. In the hospital setting, up to 26% of patients have been reported having hypoglycaemic events which not only increases hospital stay but also increases the risk of morbidity and mortality in the face of reduced quality of life and increased cost.

Materials and Methods: This study was conducted in Tata Main Hospital, Jamshedpur to evaluate the clinical spectrum and burden of hypoglycaemia in patients with diabetes mellitus and to implement adequate control and prevention measures. This is a prospective study. 200 cases of hypoglycaemia of both sex was taken in to the study design. Diagnosis is based on history, clinical examination and level of random blood sugar as per ADA guidelines-2016. Hypoglycaemia due to other causes, patients with plasmodium falciparum malaria fulminant hepatitis, sepsis and multi organ failure were excluded from the study. Detailed history was taken in all cases including drug history, dietary habits and history of any recent illnesses like fever, vomiting diarrhoea etc. The clinical presentation, laboratory parameters, precipitating factor for hypoglycaemic event was recorded and analysed in all cases. Corrective measures were taken in each of them and preventive measures designed to decrease the frequency of hypoglycaemia in diabetic patients.

Observation: Out of 780 patients of diabetes mellitus admitted to our hospital during the study period 200 cases had hypoglycaemia on admission. Their age varied from 20 to 83 years. 115 cases were male and 85 were female. The frequency rate of hypoglycaemia in our study was 25.64%. 192 patients had type 2 DM and six patients had type 1 DM. 87.5% of cases presented with feeling of uneasiness and sweating, 30.5% were admitted in a state of confusion. Twenty-four cases were unconscious at the time of admission. 9% of cases were asymptomatic. Glycosylated haemoglobin varied from 6.1 to 11.7% showing that both controlled and uncontrolled cases are at risk of developing hypoglycaemia. Renal insufficiency was found in 48% of patients. Majority (42%) of our cases had their blood sugar between 31-40 mg/dl. Blood sugar level was less than 20 mg/dl in 8 cases. Average plasma glucose at the time of admission was 41 mg/dl the lowest value documented was 17 mg/dl. 39% of cases were on combination therapy with insulin and oral diabetic drugs, 30% were on oral drugs and 28% were only on injection insulin during hypoglycaemic event. 48% of patients had a history of low oral intake prior to hypoglycaemic episode and 9% had history of acute illness before the event. Six patients had history of alcohol intake. Medication error was the key factor causing hypoglycaemia in three patients. Sulfonylurea agents were associated with higher rates of hypoglycaemia than other oral diabetic drugs. All of them were treated with IV dextrose, IV glucagon and oral glucose depending on the case and improved. However, 46 cases (23%) had second episodes of hypoglycaemia and 22 (11%) patients had more than two episodes of hypoglycaemia. Their hospital stay varied between 2-5 days with an average stay of 4.6 days. 99% of cases improved and discharged. But two patients expired probably due to prolonged hypoglycaemic encephalopathy leading to permanent brain damage. Their random blood sugar was less than 20 mg/dl on admission.

Conclusion: Despite limitations of our study we conclude that hypoglycaemia is a common complication in diabetes causing serious harm which needs to be addressed at a war foot basis. It is not only important to identify and treat the condition but also to prevent hypoglycaemic events. We can achieve lowering hypoglycaemic events by individualizing glycemic goals, addressing the risk factors and high risk patients and educating the patients along with their care givers.

Author(s): Mohanty Bijaya, Moharatha Harapriya and Prasad Satish

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