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Hypoglycemia in Hypoglycemia in the Hospital the Hospital Sara Alexanian, MD Sara Alexanian, MD Director, Inpatient Diabetes Director, Inpatient Diabetes Program Program Department of Endocrinology, Department of Endocrinology, Diabetes and Nutrition Diabetes and Nutrition

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Page 1: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hypoglycemia in the Hypoglycemia in the HospitalHospital

Sara Alexanian, MDSara Alexanian, MDDirector, Inpatient Diabetes Director, Inpatient Diabetes

ProgramProgramDepartment of Endocrinology, Department of Endocrinology,

Diabetes and NutritionDiabetes and Nutrition

Page 2: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

AgendaAgenda

Glycemic goalsGlycemic goals PhysiologyPhysiology Epidemiology and risks of Epidemiology and risks of

hypoglycemiahypoglycemia Preventing and avoiding Preventing and avoiding

hypoglycemiahypoglycemia

Page 3: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hyperglycemia in the Hospital: Hyperglycemia in the Hospital: the Factsthe Facts

Hyperglycemia is noted in 20-40% of Hyperglycemia is noted in 20-40% of hospitalized patients.hospitalized patients.

Hyperglycemia, irrespective of it’s cause, Hyperglycemia, irrespective of it’s cause, is unequivocally associated with adverse is unequivocally associated with adverse clinical outcomes.clinical outcomes.

Intervention studies directed at BG control Intervention studies directed at BG control have resulted in improved outcomes in have resulted in improved outcomes in some, but not all studies.some, but not all studies.

Insulin therapy, in particular (“intensive Insulin therapy, in particular (“intensive glycemic control”) carries a risk of glycemic control”) carries a risk of hypoglycemia. hypoglycemia.

Page 4: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

What are the recommendations What are the recommendations for glucose control in the for glucose control in the

hospital?hospital?

Page 5: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

AACE/ADA Target Glucose Levels AACE/ADA Target Glucose Levels in Nonin Non––ICU PatientsICU Patients

NonNon––ICU setting:ICU setting:– Premeal glucose targets <140 mg/dL Premeal glucose targets <140 mg/dL – Random BG <180 mg/dLRandom BG <180 mg/dL– To avoid hypoglycemia, reassess insulin To avoid hypoglycemia, reassess insulin

regimen if BG levels fall below 100 mg/dLregimen if BG levels fall below 100 mg/dL– Occasional patients may be maintained Occasional patients may be maintained

with a glucose range below and/or above with a glucose range below and/or above these cut-points these cut-points

Page 6: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

AACE/ADA Target Glucose Level AACE/ADA Target Glucose Level in ICU Patientsin ICU Patients

ICU setting:– Starting threshold of no higher than 180 mg/dLStarting threshold of no higher than 180 mg/dL– Once IV insulin is started, the glucose level should be Once IV insulin is started, the glucose level should be

maintained between 140 and 180 mg/dL maintained between 140 and 180 mg/dL – Lower glucose targets (110-140 mg/dL) may be Lower glucose targets (110-140 mg/dL) may be

appropriate in selected patients  appropriate in selected patients  – Targets <110 mg/dL or >180 mg/dL are not Targets <110 mg/dL or >180 mg/dL are not

recommendedrecommended Recommended

140-180Acceptable

110-140Not recommended

<110Not recommended

>180

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).

http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf.

Page 7: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #1Case #1

60 year-old female with a history of COPD admitted with respiratory failure, intubated, and started on tube feeds in the ICU.

The patient is started on an insulin drip to control glucose. After returning from a CT during which tube feeds were discontinued, her glucose is noted to be 55 mg/dL. The patient is asymptomatic, she is treated with dextrose and tube feeds are restarted.

Question: What, if anything, does this low glucose mean for the patients’ prognosis?

Page 8: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hypoglycemia: what and what Hypoglycemia: what and what is happeningis happening

Page 9: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

BackgroundBackground60-120 mg/dL

glucagon

Glucoseinsulin

“fed” state

“post-absorptive”state

G

GG

G

G

G

G

G

Page 10: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Defining HypoglycemiaDefining Hypoglycemia

Symptomatic hypoglycemia: symptoms Symptomatic hypoglycemia: symptoms and BG <70 mg/dLand BG <70 mg/dL

Severe hypoglycemia: event requiring Severe hypoglycemia: event requiring assistance from another person to assistance from another person to administer treatmentadminister treatment

Relative hypoglycemia: symptoms and Relative hypoglycemia: symptoms and BG >70 mg/dL in patient with chronically BG >70 mg/dL in patient with chronically poorly controlled DMpoorly controlled DM

Limited utility in studiesLimited utility in studies

<80 <60 <50 <40<70

Page 11: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition
Page 12: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

normalCounterregulatory hormone release

Adrenergic symptoms

Neuroglycopenic symptoms

lethargycomaseizure

9070

60

50

40

3020

Hypoglycemia Symptoms

Page 13: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Chronic and Recurrent hypoglycemia

Page 14: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hypoglycemia in Diabetes

Page 15: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Proposed mechanism of Proposed mechanism of increased mortalityincreased mortality

Prolonged, profound hypoglycemia Prolonged, profound hypoglycemia can cause brain death.can cause brain death.

Most deaths are presumed to be due Most deaths are presumed to be due to arrhythmia:to arrhythmia:– HypokalemiaHypokalemia– Sympathoadrenal activationSympathoadrenal activation– Prolonged QTProlonged QT

Page 16: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition
Page 17: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Potential mechanism of iatrogenic hypoglycemia-induced hypoglycemia-associated autonomic

failure (HAAF) mediated sudden death in diabetes

Cryer. Am J Med 24: 993-996, 2011

Page 18: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Inpatient Hypoglycemia: FrequencyInpatient Hypoglycemia: FrequencyHospital Location Frequency

SICU <40 mg/dL1

5.1%

MICU <40 mg/dL1

18.9%

SICU/MICU <40 mg/dL2

0.34%

ICU <40 mg/dL3

16%

ICU <45 mg/dL4

6.8%

ICU <81 mg/dL5

13.8%

Wards ≤50 mg/dL6

7.7%1. Van den Berge G et al, Intensive insulin therapy in mixed medical/surgical intensive care units. Diabetes 2006;55(11):3151-9. 2. Krinsley JS et al, The effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clinic Proc 2004;79(992-1000). 3. Arabi YM et al, Hypoglycemia with intensive insulin therapy in critically ill patients. Crit Care Med 2009;37(9):2536-44. 4. Vriesendorp TM et al, Evaluation of short term consequences of hypoglycemia in an ICU. Crit Care Med 2006;34(11)2714-8. 5. Bagshaw SM et al, the impact of early hypoglycemia and blood glucose variability on outcomes in critical illness. Crit Care Med 2009;13(3):R91. 6. Turchin A et al, Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 2009;32(7):1153-7.

Page 19: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Inpatient Hypoglycemia: MortalityInpatient Hypoglycemia: Mortality

1. Egi M et al, Hypoglycemia and outcomes in critically ill patients. Mayo Clin Proc 2010;85(3):217-24. 2. Bagshaw SM et al, the impact of early hypoglycemia and blood glucose variability on outcomes in critical illness. Crit Care Med 2009;13(3):R91 3. Van den Berge et al, Intensive insulin therapy in mixed medical/surgical intensive care units. Diabetes 2006;55(11):3151-9. 4. Kosiborod M et al, Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction. JAMA 2009;301(15):1556-64. 5. Turchin A et al, Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 2009;32(7):1153-7.

Hospital Location No hypos Hypos

ICU (<81 mg/dL)1 19.7% 36.6%

ICU (<81 mg/dL)2 15.5% 25.6%

ICU (≤40 mg/dL)3 23% 52%

AMI (<60 mg/dl)4 9.6% 12.7%

Wards (≤50 mg/dL)5 0.82% 2.96%

Page 20: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Bagshaw SM et al, the impact of early hypoglycemia and blood glucose variability on outcomes in critical illness. Crit Care Med 2009;13(3):R91

<36 mg/dL

38-4445-52

53-6263-70

71-80≥80

Page 21: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

We hold these truths to be self-We hold these truths to be self-evident…evident…

is all hypoglycemia equal?is all hypoglycemia equal?

Page 22: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

““Spontaneous” HypoglycemiaSpontaneous” Hypoglycemia

Hypoglycemia occurring without prior Hypoglycemia occurring without prior insulin or anti-hyperglycemic therapy.insulin or anti-hyperglycemic therapy.

Increased in critical illness: mechanical Increased in critical illness: mechanical ventilation, sepsis, renal insufficiency, ventilation, sepsis, renal insufficiency, higher APACHE II score.higher APACHE II score.

Frequency: Frequency: – 26% of all ICU pts with hypoglycemia26% of all ICU pts with hypoglycemia

1 1

– 28% of patients admitted with acute MI28% of patients admitted with acute MI22

1. Krinsley JS et al, The effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clinic Proc 2004;79(992-1000). 2. Kosiborod M et al, Relationship between spontaneous and iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction. JAMA 2009;301(15):1556-64.

Page 23: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Risk of therapy or marker of Risk of therapy or marker of illness?illness?

Treated with insulin?: AMITreated with insulin?: AMI– Mortality with spontaneous Mortality with spontaneous

hypoglycemia: 18.4%( increased from hypoglycemia: 18.4%( increased from control)control)

– Mortality of insulin-associated Mortality of insulin-associated hypoglycemia: 10.4% (NO increase from hypoglycemia: 10.4% (NO increase from control)control)

Kosiborod M et al, Relationship between spontaneous and iatrogenic hypoglycemia and mortality in

patients hospitalized with acute myocardial infarction. JAMA 2009;301(15):1556-64.

Page 24: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Kosiborod M et al, Relationship between spontaneous and iatrogenic hypoglycemia and mortality in

patients hospitalized with acute myocardial infarction. JAMA 2009;301(15):1556-64.

Page 25: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Risk of therapy or marker of Risk of therapy or marker of illness?illness?

Correct for comorbid illness:Correct for comorbid illness:– Study #1: case control correcting for Study #1: case control correcting for

age, sex, duration of ICU stay, APACHE II age, sex, duration of ICU stay, APACHE II score: no association with incidental score: no association with incidental hypoglycemia and death (41% vs. 27%, hypoglycemia and death (41% vs. 27%, not significant)not significant)11..

– Study #2: case control correcting for Study #2: case control correcting for diagnosis, APACHE II, age diabetes diagnosis, APACHE II, age diabetes history: Increase mortality associated history: Increase mortality associated with hypoglycemia (55.9% vs. 39.5%)with hypoglycemia (55.9% vs. 39.5%)22..

1. Vriesendorp TM et al, Evaluation of short term consequences of hypoglycemia in an ICU. Crit Care Med 2006;34(11)2714-8. 2. Krinsley JS et al, The effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clinic Proc 2004;79(992-1000).

Page 26: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

……butbut

Time from hypoglycemic episode to Time from hypoglycemic episode to death:death:– 221 hours (54-530 hours)221 hours (54-530 hours)11 – 152 hours (87-407 hours)152 hours (87-407 hours)11

– 11 days (0-204 days)11 days (0-204 days)22

1. Van den Berghe, Intensive insulin therapy in mixed medical/surgical intensive care units. Diabetes 2006;55(11):3151-9. 2. Vriesendorp TM et al, Evaluation of short term consequences of hypoglycemia in an ICU. Crit Care Med 2006;34(11)2714-8.

Page 27: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #1Case #1

60 year-old female with a history of COPD admitted with respiratory failure, intubated, and started on tube feeds in the ICU.

The patient is started on an insulin drip to control glucose. After returning from a CT during which tube feeds were discontinued, her glucose is noted to be 55 mg/dL. The patient is asymptomatic, she is treated with dextrose and tube feeds are restarted.

Question: What, if anything, does this low glucose mean for the patients’ prognosis?

?????

Page 28: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

So…hypoglycemia is bad. So…hypoglycemia is bad. However there is confounding from However there is confounding from

illness, and spontaneous illness, and spontaneous hypoglycema.hypoglycema.

However, we should avoid it. However, we should avoid it.

So what can I do?So what can I do?

Page 29: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Know the Risk FactorsKnow the Risk Factors

Advanced ageAdvanced age Slender and or longstanding diabetesSlender and or longstanding diabetes MalnutritionMalnutrition Active cancerActive cancer Renal diseaseRenal disease Liver disease Liver disease Congestive heart failureCongestive heart failure History of heavy alcohol intakeHistory of heavy alcohol intake Chronic pancreatitisChronic pancreatitis Critical illnessCritical illness

Page 30: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Know who is at most risk to suffer Know who is at most risk to suffer adverse consequencesadverse consequences

Inability to recognize or communicate Inability to recognize or communicate hypoglycemic symptomshypoglycemic symptoms

Stroke patientsStroke patientsDementiaDementiaAltered Mental Status: sedation, Altered Mental Status: sedation,

intubated, previous hypoglycemiaintubated, previous hypoglycemia

Page 31: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Treating your patients’ Treating your patients’ hyperglycemiahyperglycemia

Always use weight-based insulinAlways use weight-based insulin Do not simply order a patients’ outpatient Do not simply order a patients’ outpatient

regimen if it does not appear safe. Beware regimen if it does not appear safe. Beware of programs > 1 unit/kg/day.of programs > 1 unit/kg/day.

Review your patients glucose levels at Review your patients glucose levels at least twice per dayleast twice per day

Consider a change if a glucose is <100.Consider a change if a glucose is <100. Ask yourself, why is my patient low? Why Ask yourself, why is my patient low? Why

is my patient high?is my patient high?

Page 32: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #2Case #2

76 yo M with DM2 on admitted from 76 yo M with DM2 on admitted from NH when found confused, BG 58 NH when found confused, BG 58 mg/dL.mg/dL.

Patient with prior CVA, CKD, HTN.Patient with prior CVA, CKD, HTN. Labs on admit: BG 121, Cr 2.72 Labs on admit: BG 121, Cr 2.72

mg/dL, normal LFTs.mg/dL, normal LFTs. Weight: 98 kg.Weight: 98 kg.

Page 33: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #2Case #2

Outpatient program: glargine 45 Outpatient program: glargine 45 units at HS, novolog 35 units units at HS, novolog 35 units prebreakfast and presupper.prebreakfast and presupper.

Per NH, FS run 90-180Per NH, FS run 90-180 Most recent A1c 1 month ago 5.1%.Most recent A1c 1 month ago 5.1%.

Page 34: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #2Case #2

What are the red flags here?What are the red flags here?– High outpatient doseHigh outpatient dose– Low A1cLow A1c– DementiaDementia– CKDCKD– Advanced ageAdvanced age

Page 35: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

What insulin program do YOU What insulin program do YOU recommend?recommend?

Average insulin need: 0.5 u/kg/day Advance age: -0.1 u/kg/day Renal insufficiency: -.0 1 u/kg/day Initial TDD : 0.3 u/kg/day

50% basal15 units of glargine

50% nutritional5 units lispro TID

CorrectionCF 1:50, start at 200 HS

98 kg x 0.3 = apx 30 u/day

Page 36: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

How did he do?How did he do?

Fasting Bg on chemistry: 99 mg/dLFasting Bg on chemistry: 99 mg/dL

2 POC: 127 mg/dL, 157 mg/dL2 POC: 127 mg/dL, 157 mg/dL

Page 37: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #3Case #3

23 yo M with type 1 diabetes.23 yo M with type 1 diabetes. Weight: 58 kgWeight: 58 kg Inpatient insulin program: 16 units Inpatient insulin program: 16 units

of glargine at HS, lispro 5 TID with of glargine at HS, lispro 5 TID with meals, lispro SS. TDD: 30 units. meals, lispro SS. TDD: 30 units.

Page 38: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Case #3Case #3

C7287

lunch313

supper330

Bedtime257

MN>600

5:40 AM30

Meal insulin and SS

Lispro 9SS

Lispro 10X 1

2:45 AM405

Lispro 10X 1

TDD 30 units/day

Page 39: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Truth and ConsequencesTruth and Consequences Hyperglycemia is a common problem that Hyperglycemia is a common problem that

requires treatment.requires treatment. Insulin treatment carries a risk of Insulin treatment carries a risk of

hypoglycemia (even just “sliding scale”).hypoglycemia (even just “sliding scale”). Both hyper- and hypoglycemia are Both hyper- and hypoglycemia are

associated with an increase in hospital associated with an increase in hospital mortality, hospital cost, and increase LOS.mortality, hospital cost, and increase LOS.

Frequency of hypoglycemia can be Frequency of hypoglycemia can be mitigated by following current guidelines mitigated by following current guidelines for BG targets, tailoring insulin programs, for BG targets, tailoring insulin programs, and being active in assessing your insulin and being active in assessing your insulin program.program.

Page 40: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

What can you do? What can you do? Critically evaluate your patients insulin Critically evaluate your patients insulin

program, on admission and daily.program, on admission and daily. Tailor your program to your patientTailor your program to your patient Be aware of insulin “stacking” and Be aware of insulin “stacking” and

appropriate correction insulin dosesappropriate correction insulin doses Always re-evaluate a program if the BG is low, Always re-evaluate a program if the BG is low,

and reconsider if <100.and reconsider if <100. Take the time to figure out what is happening.Take the time to figure out what is happening. Consult the GLUC or NP service if you need Consult the GLUC or NP service if you need

help.help.

Page 41: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Thanks!Thanks!

Page 42: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

What do i do for an insulin What do i do for an insulin program?program?

Page 43: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition
Page 44: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Remaining QuestionsRemaining Questions

What cutoffs should define What cutoffs should define hypoglycemia in studies?hypoglycemia in studies?

How do we sort out the risk of How do we sort out the risk of iatrogenic hypoglycemia from iatrogenic hypoglycemia from hypoglycemia as a marker of hypoglycemia as a marker of disease?disease?

How does hypoglycemia increase How does hypoglycemia increase mortality?mortality?

Page 45: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hypoglycemia in Patients with Diabetes: Hypoglycemia in Patients with Diabetes: contributing factorscontributing factors

Medication/iatrogenic: insulin, Medication/iatrogenic: insulin, sulfonylureas, meglitinidessulfonylureas, meglitinides

Abnormal hormonal counter-regulationAbnormal hormonal counter-regulation Hypoglycemic unawarenessHypoglycemic unawareness autonomic dysregulationautonomic dysregulation exerciseexercise

Page 46: Hypoglycemia in the Hospital Sara Alexanian, MD Director, Inpatient Diabetes Program Department of Endocrinology, Diabetes and Nutrition

Hypoglycemia in patients with Hypoglycemia in patients with Diabetes: contributing factorsDiabetes: contributing factors

Medications/iatrogenic: insulin, Medications/iatrogenic: insulin, sulfonylureas, meglitinidessulfonylureas, meglitinides

Abnormal hormonal counter-regulationAbnormal hormonal counter-regulation Hypoglycemic unawarenessHypoglycemic unawareness Renal and hepatic dysfunctionRenal and hepatic dysfunction Autonomic dysregulationAutonomic dysregulation AgeAge ExerciseExercise AlcoholAlcohol