Hypoglycemia Presentation

Hypoglycemia
Prevention & Treatment

Gary Scheiner MS, CDE
Owner, Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
877-SELF-MGT (735-3648)
(610) 642-6055
www.integrateddiabetes.com
Gary@integrateddiabetes.com
Hypoglycemia:
Definitions
Mild: Adrenergic (BG<70)
(<4mmol)
Moderate: Cognitive (BG<50)

(<3mmol)
Severe: Unconscious (BG ???)
Hypoglycemia:
Cause
Imbalance between factors raising and
lowering blood glucose levels
Blood Glucose
Blood Glucose
Food
Counterregulatory
Hormones
Insulin/Oral Meds
Physical Activity
Hypoglycemia
The Greatest Limiting Factor

In Diabetes Management
The Great Limiting Factor

Performanc
e
Impairment
Accident
Risk
Anxiety /
Embarrassme
nt
Lasting
Damage?
Spatial
memory /
performance (if
before age 5)
Diminished
Symptoms
(Hypoglycemi
c
Unawareness)
Rebound
Weight Gain
Hypoglycemia:
Targets/Goals
Unable to recognize &
verbalize lows: >80 (4.5
mmol)
Able to recognize &

verbalize lows: >70
(4
mmol)
Pregnancy: >60
(3.3 mmol)
<10% of readings below

target at each time of day
No severe lows
Hypoglycemia
Prevention Strategies
1. Insulin Program Setup
(background/basal)
Avg
Basal
Needs
NPH /
Lente
at Bed
12am
3am
6am
9am
12pm 3pm
6pm
9pm
12am
Hypoglycemia
(background/basal)
Avg
Basal
Needs
NPH or
Lente
at Bed
& Bkfst
12am
3am
6am
9am
12pm 3pm
6pm
9pm
12am
Hypoglycemia
1. Insulin Program Setup (background/basal)
Avg
Basal
Needs
Ultra
Lente
at
Dinner
12am
3am
6am
9am
12pm 3pm
6pm
9pm
12am
Hypoglycemia
(background/basal)
Avg.
Basal
Needs
Morning
Lantus
or
Levemir
12am
3am
6am
9am
12pm 3pm
6pm
9pm
12am
Hypoglycemia
(background/basal)
Avg
Basal
Needs
Insulin
Pump
12am
3am
6am
9am
12pm 3pm
6pm
9pm
12am
Basal insulin should hold BG STEADY in the absence of

food, exercise and bolus insulin!
Hypoglycemia
1b. Insulin Program Setup
(Meal/Bolus)
Blood Sugar Rise After
Eating Carbs
Analog (Humalog or
Novolog taken with
meal)
Regular (taken 30 min.
pre-meal)
NPH / Lente (taken 4
hours prior)
Only rapid analogs work when needed right after eating!
Hypoglycemia
2. Meal/Snack Timing
Major issue w/a.m. NPH/Lente
Minor issue w/Lantus or Levemir

Not usually an issue with pump use
Hypoglycemia
3a. Proper Correction Doses
1500-Rule (aggressive) (83 rule)
1800-Rule (conservative) (100 rule)
(Total Daily Ins.)/1500 or 1800
May vary day vs. night
(nighttime often 50% more than day)
Hypoglycemia
3b. Appropriate BG Targets
Premeal:
100 (5.5) (aggressive)
120 (6.7) (typical)
140-150 (7.6-8.3)
(cautious)
Postmeal (1-2 hrs):

<160 (9) (aggressive)
<180 (10) (typical)
< 200 (11) (cautious)
Hypoglycemia
4. Proper Meal/Bolus Doses
I:C Ratio that matches pre-meal BG
3-4 hours (not 2!) after eating
I:C Ratio often varies from meal to
meal
(bkfst dose > lunch & dinner)
Hypoglycemia
5. Account For Unused Insulin*
Time since
meal insulin
1 Hr
2 Hrs
3 Hrs
Conservative
Approach
70% left 40% left 10% left
Aggressive
Approach
67% left 33% left
4 Hrs
0% left
0% left
* Newer pumps figure this automatically

based on the insulin duration you set.
Hypoglycemia
5. Account For Unused Insulin
Example:
Gave 6.0 units at 7pm, BG 200 at 9pm.
Conservative approach: 40% remaining (6 x .4) = 2.4 units left
Aggressive approach: 33% remaining (6 x .33) = 2 units left
Subtract the unused insulin from your
usual correction dose!
Hypoglycemia
6. Carb Counting Accuracy
Proper Portion Measurement
Look Up Unknown /
Restaurant Foods
Use Carb Factors
Subtract 100% of Fiber
Subtract 50% of Sugar Alcohols
Hypoglycemia
7. Extend Meal Insulin When Necessa

Use When:
Portions are very large
Meal is prolonged
Food is low-glycemic index (pasta, legumes,
dairy)
Apply Via:
Square/Dual/Extended/Combo bolus on pump
Delayed or Split bolus on injections
Hypoglycemia
8. Adjustment for Physical
Activity
Exercise, recreation, chores: all count!
Reduce meal insulin (25%, 33%, 50%)
for after-meal activity
Snack prior to before/between meal activity
Lower long-acting/basal insulin during and
after prolonged activity
Hypoglycemia
8. Watch Out for DOH!
(Delayed Onset Hypoglycemia)
Following High-Intensity Exercise
Following Extended Duration Activity
May Occur Up to 24 Hours After
Adjustments to food/insulin after activity:

o lower basal insulin for 8-12 hours
o low-G.I. Snacks
o lower mealtime boluses
Hypoglycemia
9. Adjustment for Alcohol
Alcohol reduces the livers output
of glucose and masks

hypoglycemic symptoms
Delayed BG drops can occur
Decrease basal insulin (or overnight
long-acting insulin) after
drinking
Hypoglycemia
10. Consistent Monitoring
Before All Meals & Snacks
Pre/Post Exercise
Bedtime
3 a.m. (occasionally)
Hypoglycemia
11. Recording & Analysis
Record all pertinent data
BGs
Carb
Activity
Insulin
Use an organized form (multiple days on
single page, if possible)
Gary Scheiner, MS, CDE

INTEGRATED DIABETES SERVICES
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
Phone: (610) 642-6055 Fax: (610) 642-8046
Date:
Name:
Weekly Diabetes Record
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bedtime
Night
Notes
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Date:
Blood Sugar
Insulin Dose
Grams Carb
Phys. Activity
Hypoglycemia
11. Recording & Analysis
Review every 7-10 days
Look for patterns

> 10% below target range @ given time
Lows during/post-activity
Lows on School/Work vs. off-day
Lows Post-Menstrual
Hypoglycemia
12. Continuous Glucose
Monitoring
Alarms to alert user/family of pending lows
Hypoglycemia
R isk s
12. Continuous Glucose

Monitoring
Hypoglycemia
Complications
w/CGM
HbA1c
Hypoglycemia Treatment
Mild/Moderate Low
Check BG First
Treat w/High-Glycemic
Index Food
Treat w/Proper Amount
Re-Check in 15 Minutes
High-GI Foods
Glucose Tablets
Dry Cereal
Pretzels
Graham Crackers
Vanilla Wafers
Jelly Beans
Gatorade
Use of Glycemic Index
Fastest
Glucose
Lower GI foods digest &

convert to glucose more slowly
Dextrose
High-fiber slower than low
Fructose
Hi-fat slower than low
Starch (straight-chain)
Solids slower than liquids
Galactose
Cold foods slower than hot

Type of sugar/starch affects GI
Starch (branched-chain)
Sucrose/Corn Syrup
Lactose
Slowest
Sugar Alcohols
Use of Glycemic Index (contd)
High GI
Med GI
Low GI
0 hrs
1 hr
2 hrs
3 hrs
4 hrs
Always Carry Rapid-Acting Carbs!
DEXTROSE Rules!
Glucose Tablets
Sweet Tarts
Smarties
Spree
Air Heads
Wt-lbs (BG rise/g)
BG 70s
(4)
BG 60s BG 50s BG 40s

(3.5)
(2.5)
(3)
BG <40
(2)
<40 ( 9-10) (.5)
6g
7g
8g
9g
10g
40-70 ( 7-8) (.4)
7g
8g
10g
11g
13g
70-100 ( 5-6)(.35) 8g
10g
12g
14g
16g
100-160 ( 4) (.3) 11g
13g
16g
19g
21g
160-220 ( 3) (.2) 14g
17g
21g
24g
27g
20g
25g
30g
35g
40g
>220 ( 2) (.15)
Once BG has risen, give rapid-acting insulin to

cover any overtreatment!
Idiosyncracies
Treatment amt. for insulin on board
Treatment amt. for recent exercise
Treatment amt. for previous low-G.I. foods
Severe Low
Unconscious /
Unresponsive
Seizure
Uncooperative
Take-Home Messages
Quantify Your
Lows
Strategize to
Minimize
Plan for Proper
Treatment
The Source of My
Highs and Lows

Hypoglycemia Presentation

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Hypoglycemia Presentation

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Hypoglycemia

Prevention & Treatment

Moderate: Cognitive (BG<50)

Severe: Unconscious (BG ???)

The Greatest Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

The Great Limiting Factor

Able to recognize &

<10% of readings below

Basal insulin should hold BG STEADY in the absence of

Only rapid analogs work when needed right after eating!

Major issue w/a.m. NPH/Lente

Minor issue w/Lantus or Levemir

Postmeal (1-2 hrs):

70% left 40% left 10% left

67% left 33% left

* Newer pumps figure this automatically

7. Extend Meal Insulin When Necessa

Following High-Intensity Exercise

Following Extended Duration Activity

May Occur Up to 24 Hours After

Adjustments to food/insulin after activity:

of glucose and masks

Gary Scheiner, MS, CDE

Weekly Diabetes Record

Look for patterns

Alarms to alert user/family of pending lows

12. Continuous Glucose

Lower GI foods digest &

High-fiber slower than low

Hi-fat slower than low

Solids slower than liquids

Cold foods slower than hot

BG 60s BG 50s BG 40s

<40 ( 9-10) (.5)

40-70 ( 7-8) (.4)

100-160 ( 4) (.3) 11g

160-220 ( 3) (.2) 14g

Once BG has risen, give rapid-acting insulin to

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