I. Definition of diabetes-related hypoglycemia
(I) Mild hypoglycemia.
1.With the symptoms of hypoglycemia, the blood glucose test confirmed that the blood glucose level is lower than 3,1mmol/l, and the patient can manage the symptoms by himself after taking sugary food or glucose.
2.No hypoglycemic symptoms, but the blood glucose test confirmed that the blood glucose level is lower than 3,1mmol/l.
(B) Symptomatic hypoglycemia.
1.With hypoglycemic symptoms, and the patient can handle it by himself, but no blood glucose test confirms it.
2.With hypoglycemic symptoms, the patient can manage by himself, and the blood sugar is more than 3,1mmol/l (56mg/dl).
(iii) Nocturnal hypoglycemia.
Hypoglycemia occurs during sleep from the time of going to sleep to the time of waking up in the morning.
(iv) Severe hypoglycemia.
It is accompanied by the central nervous system symptoms of hypoglycemia, and cannot be handled by itself, and has blood sugar < 3, 1mmol/l, or the symptoms improve after the injection of glucagon or glucose.
Second, the goal of blood sugar control and hypoglycemia
Clinical blood glucose control goal: as normal as possible, without unacceptable hypoglycemia.
Hypoglycemia is the main limiting factor of glycemic control in type 1 diabetes (also including type 2 diabetes).
Clinical data show that DCCT/intensive therapy significantly reduces blood glucose and microvascular complications.
Clinical data also show that intensive treatment is associated with increased hypoglycemic events.
Clinical data show that glycemic control is associated with the occurrence of hypoglycemic events.
DCCT: The cost of improved diabetes control C hypoglycemia: In the DCCT study, the risk of retinopathy increased with worsening glycemic control (measured by HbA1c). Conversely, the risk of severe hypoglycemic events increased when glycemic control improved. Thus, the intensive treatment group, which improved glycemic control and thus reduced the risk of retinopathy, was accompanied by a 30% increased risk of hypoglycemic events.
Clinical data: UKPDS/intensive therapy increases the risk of hypoglycemic events.
Clinical data show that intensive treatment increases the risk of hypoglycemia.
Clinical data show that: Intensive glucose therapy comes at the cost of increased hypoglycemia.
1. Reasons for fewer hypoglycemic events in patients with type 2 diabetes receiving insulin therapy compared to type 1.
Presence of insulin resistance.
There is endogenous insulin secretion.
Less impaired counter-regulatory mechanisms against hypoglycemia.
The impairment of the ability to detect hypoglycemia is less.
2. Most patients with type 2 diabetes are not treated with insulin:
Patients treated with diet, metformin, acarbose and gliponetics: No hypoglycemia occurs.
Patients treated with sulfonylureas and glinides: hypoglycemia may occur.
3. Patients with type 2 diabetes treated with insulin have less blood glucose fluctuation and are less likely to have hypoglycemia for the following reasons.
β-cell remnants have some function (C-peptide can be measured)
Hormonal regulation against insulin still exists
Insulin resistance is more likely to be present
Hypoglycemic coma is less likely to occur
The more frequent and longer the duration of hypoglycemia, the worse the patient’s prognosis
4. Risk factors for severe hypoglycemia in patients with type 2 diabetes
Older age
Long duration of disease
Insulin treatment for more than 10 years
High fluctuation of daily blood sugar
Impaired ability to detect hypoglycemia
Impaired feedback regulation mechanism to combat hypoglycemia
5. Characteristics of hypoglycemia in patients with type 2 diabetes.
In the early stage of the disease.
(1) The incidence of severe hypoglycemia is significantly less than that of type 1 diabetes.
(2) The feedback regulation of anti-hypoglycemic response is less impaired, the threshold of protective hormone secretion is higher than that of type 1 diabetic patients, and the feedback regulation has a stronger protective effect on the organism.
(3) The ability to detect hypoglycemia is less impaired.
With the prolongation of the disease and the aggravation of β-cell damage, the feedback regulation ability of the body gradually decreases, and the serious hypoglycemic events increase.
6. Risk factors and risk markers in type 1 diabetes.
Risk factors include: insulin overdose or wrong injection technique, missed or delayed meals and alcohol consumption in the diet, unpredictable exercise, sleep and some unexplained reasons.
Risk markers include: unawareness, dysregulation of antagonistic factors, undetectable C-peptide levels, genetic factors, overly strict glycemic control, long duration of diabetes, advanced age, enhanced insulin sensitivity and other factors.
7. Characteristics of nocturnal hypoglycemia.
Most of the nocturnal hypoglycemia is asymptomatic hypoglycemia, some patients have decreased sleep quality (nightmares), morning headache, chronic fatigue, mood changes (mainly depression), and some diabetic patients have impaired “wake up” mechanism of nocturnal hypoglycemia and cannot wake up when hypoglycemia occurs during night sleep. This can aggravate the vicious cycle of recurrent hypoglycemia, which can be fatal to the patient.
8. Importance of reducing nocturnal hypoglycemia.
Repeated episodes of nocturnal hypoglycemia can damage the body’s feedback regulation mechanism against hypoglycemia and make the hypoglycemic events worsen, therefore, nocturnal hypoglycemia will not only affect the occurrence of daytime hypoglycemia, but also the nervous system in severe cases.
9. Hazards of hypoglycemia.
Relax blood sugar control due to fear of hypoglycemia.
Affects daily life: driving (prone to traffic accidents), work, family life.
Behavior change.
Impaired cognitive function.
Macrovascular damage: Stroke, heart attack, acute heart failure, ventricular arrhythmia.
Coma/only blood glucose.