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CDE Diabetes

Flashcards: In-Hospital Management of Diabetes (Chapter 16)

Hyperglycemia in the hospital setting is a strong predictor of adverse outcomes, including infection and mortality. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines recommendations for insulin regimens, glucose targets, and perioperative care, facilitating a shift away from reactive “sliding scale” management.

Key Topics Covered:

  • Glycemic Targets: Memorizing the specific glucose ranges for critically ill (6.0–10.0 mmol/L) versus non-critically ill patients (preprandial 5.0–8.0 mmol/L).
  • Insulin Regimens: Understanding the superiority of scheduled basal-bolus-correction insulin over correction-only (sliding scale) therapy for maintaining stability.
  • Monitoring Protocols: Reviewing the required frequency of blood glucose checks for patients on oral intake (pre-meal) vs. NPO or IV insulin (every 1–2 hours).
  • Perioperative Care: Identifying targets (5.5–10.0 mmol/L) and strategies to optimize glycemic control before and during surgery.
  • Discharge Planning: Recalling the essential components of a safe discharge plan, including medication reconciliation and sick-day education.
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CDE Diabetes

Practice Exam: In-Hospital Management of Diabetes (Chapter 16)

Hyperglycemia in hospitalized patients—whether they have a history of diabetes or not—is a common and serious condition associated with increased morbidity, infection rates, and mortality. This exam tests your ability to apply the 2018 Clinical Practice Guidelines to the acute care setting, focusing on the shift away from “sliding scale” monotherapy toward proactive, physiologic insulin regimens.

Key Concepts Covered in This Exam:

  • Glycemic Targets: Differentiating targets for critically ill versus non-critically ill patients (e.g., maintaining preprandial glucose between 5.0–8.0 mmol/L for most non-critically ill patients).
  • Insulin Protocols: Understanding why scheduled basal-bolus-correction regimens are preferred over correction-only (sliding scale) insulin to prevent “glycemic rollercoasters”.
  • Perioperative Care: Managing glycemic control before, during, and after surgery to minimize infection risk and improve wound healing.
  • Safety & Monitoring: Identifying the correct frequency for blood glucose monitoring (e.g., every 1–2 hours for IV insulin) and strategies to prevent inpatient hypoglycemia.
  • Transition of Care: Reviewing best practices for discharge planning to ensure safe transitions back to community settings.

1. What blood glucose level should trigger modification of antihyperglycemic therapy in hospitalized patients?

2. What percentage of patients admitted to a community teaching hospital were found to have hyperglycemia?

3. Case: A patient with poorly controlled type 2 diabetes is undergoing cataract surgery with moderate to severe nonproliferative diabetic retinopathy. What perioperative consideration is important?

4. What is a key factor that increases the risk of hypoglycemia in hospitalized patients?

5. Case: A 68-year-old patient with newly discovered hyperglycemia during hospitalization has an A1C of 6.2%. What follow-up is recommended?

6. What is the prevalence of corticosteroid-induced hyperglycemia among people without a previous history of diabetes?

7. Case: A 55-year-old person with type 2 diabetes is admitted for elective hip replacement surgery. The person is currently well-controlled on metformin and gliclazide. What is the most appropriate perioperative management?

8. What blood glucose range should be maintained for critically ill hospitalized people with diabetes?

9. What interventions at the time of discharge have been associated with post-discharge reduction in A1C?

10. Case: A diabetes educator is explaining to hospital staff why insulin is considered a high-alert medication. What approach should be used to reduce insulin administration errors?

11. A hospitalized person with type 2 diabetes requires more than 2 units of intravenous insulin per hour to maintain glycemic control. What does this suggest about the patient’s insulin needs?

12. What are the recommended preprandial blood glucose targets for noncritically ill hospitalized people with diabetes?

13. Case: A patient with type 1 diabetes is admitted to hospital and wants to continue using their insulin pump (CSII). What assessment should be performed to determine suitability?

14. How often should blood glucose be monitored for people on continuous intravenous insulin or those who are critically ill?

15. Case: A clinical team is evaluating the evidence for perioperative glycemic targets for minor and moderate surgeries. What is a reasonable target based on the guidelines?

16. Case: A hospital wants to implement an inpatient diabetes self-management program. According to the guidelines, what should be considered for patients using CSII (insulin pump) therapy?

17. Case: A diabetes educator is developing discharge instructions for a patient with diabetes. What essential information should be included?

18. Case: A clinical team is debating whether to use intravenous insulin for a patient post-acute stroke. Based on the evidence, what is the most appropriate conclusion?

19. When intermediate- or long-acting insulin is used during the transition from IV to subcutaneous insulin, how long before IV discontinuation should it be administered?

20. Case: A patient with type 2 diabetes is being managed by a glycemic management team during hospitalization. What outcomes have been associated with timely consultation of such teams?

21. A patient survey found that hospitalized patients with diabetes were more likely to be satisfied with their care under what circumstances?

22. Why should capillary blood glucose (CBG) point-of-care testing be interpreted with caution in critically ill patients?

23. Case: A patient with type 2 diabetes is started on high-dose prednisone for an acute COPD exacerbation. What monitoring is recommended?

24. What is the recommended intraoperative blood glucose target range for patients undergoing coronary artery bypass grafting (CABG)?

25. How often should bedside blood glucose monitoring be performed in people who are NPO (nothing by mouth)?

26. What type of insulin is preferred as the subcutaneous bolus and correction insulin in the hospital setting?

27. According to the guidelines, what is the preferred method for achieving glycemic control in hospitalized people with diabetes who are eating?

28. When comparing insulin glargine vs. detemir as basal insulin in a basal-bolus program in hospitalized patients, what was found?

29. Case: A patient’s parenteral nutrition is unexpectedly interrupted. What should be done to prevent hypoglycemia?

30. What percentage of the total daily insulin dose should be given as basal insulin when transitioning from IV to subcutaneous insulin in surgical patients?

31. Case: A patient in the ICU is being transitioned from intravenous insulin to subcutaneous insulin. When should subcutaneous rapid-acting insulin be administered relative to discontinuing the IV insulin?

32. What is the definition of in-hospital hyperglycemia according to Diabetes Canada guidelines?

33. What A1C threshold has been found to be highly specific for the diagnosis of dysglycemia in hospitalized patients

34. A diabetes educator is reviewing why correction-only (supplemental) insulin should be discouraged. What is the primary reason?

35. Case: A hospitalized patient with diabetes is receiving continuous enteral feeding. How should their insulin be managed?

36. In insulin-naive hospitalized patients, what is the typical starting dose of insulin per kilogram of body weight per day?

37. Case: A patient with diabetes undergoing CABG surgery needs glycemic management. What method has been shown to prevent postoperative infections?


 

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CDE Diabetes

Study Guide: In-Hospital Management of Diabetes (Chapter 16)

1. Overview & Pathophysiology

Hyperglycemia in the hospital setting is a strong predictor of adverse outcomes, including increased mortality, infection rates, and length of stay.

  • Definition: In-hospital hyperglycemia is defined as any glucose value .
  • Prevalence: Occurs in ~38% of hospitalized patients (26% known diabetes, 12% no prior history).
  • Stress Hyperglycemia: Acute illness increases stress hormones (cortisol, catecholamines) and inflammatory cytokines, which increase insulin resistance and hepatic glucose production.

2. Screening & Diagnosis

Identifying undiagnosed diabetes is a key opportunity during admission.

  • A1C Screening:
    • Perform on admission for all patients with diabetes or hyperglycemia if not done in the past 3 months.
    • Helps differentiate stress hyperglycemia from undiagnosed diabetes.
    • Interpretation: An A1C is highly specific for diagnosing dysglycemia post-hospitalization.
  • Monitoring Frequency:
    • Eating: Before meals and at bedtime.
    • NPO/Enteral Feeds: Every 4–6 hours.
    • IV Insulin/Critical Care: Every 1–2 hours.

3. Glycemic Targets

The guidelines distinguish between critically ill and non-critically ill patients.

Patient PopulationGlycemic
Target
(mmol/L)		Notes
Non-Critically Ill

Preprandial: 5.0 – 8.0


Random: < 10.0

Applies to the majority of medical/surgical patients.

 

 

Critically Ill6.0 – 10.0

Avoid < 6.0 to minimize mortality/hypoglycemia risk.

 

 

CABG (Intraoperative)5.5 – 11.1

Continuous IV insulin preferred to reduce sternal wound infections.

 
 

 

Perioperative (General)5.0 – 10.0

For minor/moderate surgeries.

 

 

4. Pharmacologic Management

Insulin is the preferred agent for in-hospital management due to its safety, efficacy, and adjustability.

A. Non-Critically Ill (Subcutaneous Insulin)
  • Preferred Regimen: Basal + Bolus + Correction (Basal-Bolus-Supplemental).
    • Basal: Long-acting (e.g., glargine, detemir) controls fasting/inter-meal glucose.
    • Bolus: Rapid-acting (e.g., aspart, lispro) covers meals.
    • Correction: Rapid-acting covers hyperglycemia above target.
  • Discouraged Regimen: Correction-only (Sliding Scale) insulin alone is strongly discouraged as it results in “reactive” management and poorer control.
  • Insulin Naïve: Start 0.4–0.5 units/kg/day (50% basal, 50% bolus).

B. Critically Ill (Intravenous Insulin)

  • Indication: Critically ill, NPO, or hyperglycemic emergencies (DKA/HHS).
  • Protocol: Continuous IV insulin infusion targeting 6.0–10.0 mmol/L.
  • Transitioning IV to SC:
    • Calculate Total Daily Dose (TDD) based on the last 6–8 hours of stable IV requirements.
    • Give 60–80% of this extrapolated dose as SC basal insulin.
    • Overlap: Administer SC basal 2–3 hours (or rapid 1–2 hours) before stopping the IV drip to prevent rebound hyperglycemia.

C. Non-Insulin Agents

  • Oral agents (e.g., metformin, sulfonylureas) are often discontinued due to contraindications like renal variation, contrast dye exposure, or irregular eating.

     

5. Special Clinical Situations

Enteral & Parenteral Nutrition:

  • Parenteral (TPN): Insulin can be added to the TPN bag (Regular insulin) or given SC.
  • Enteral (Tube Feeds):
  • Continuous: Basal insulin or longer-acting insulin (NPH) helps match the continuous carb load.
  • Bolus Feeds: 50% Basal / 50% Bolus (divided to match feed times).

Corticosteroid Therapy:

  • Steroids cause significant insulin resistance and postprandial hyperglycemia.
  • Management: Basal-Bolus-Correction is superior to sliding scale. NPH may be used to match the steroid profile.
  • Monitoring: Monitor BG for at least 48 hours after starting high-dose steroids.

Self-Management & Pumps (CSII):

  • Patients who are mentally competent and physically able may continue self-management (including pumps) if hospital policy permits.
  • Requirements: Must utilize a flowsheet, provide own supplies, and demonstrate competency (e.g., changing sets, calculating bolus).

6. Diabetes Canada Clinical Practice Guidelines Recommendations

  1. Screening: Measure A1C on admission for all with diabetes (if not done in 3 months) and those with new hyperglycemia [Grade D/C].
  2. Monitoring: Individualize frequency; usually AC+HS for eating, q4-6h for NPO/Enteral, q1-2h for IV insulin [Grade D].
  3. Preferred Therapy: Use proactive Basal-Bolus-Correction insulin rather than correction-only (sliding scale) [Grade A, Level 1A].
  4. Targets:
    • Non-Critically Ill: 5.0–8.0 mmol/L (preprandial) [Grade D].
    • Critically Ill: < 10.0 mmol/L and > 6.0 mmol/L [Grade B/D].
  5. CABG: Use IV insulin to target 5.5–11.1 mmol/L intraoperatively to reduce infection risk [Grade A, Level 1A].
  6. Safety: Implement nurse-initiated hypoglycemia protocols (including glucagon) [Grade D].
 

Reference:

Malcolm J, Halperin I, Miller DB, et al. In-Hospital Management of Diabetes. Canadian Journal of Diabetes. 2018;42:S115-S123. doi:10.1016/j.jcjd.2017.10.014
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CDE Diabetes

Flashcards: Hyperglycemic Emergencies in Adults (Chapter 15)

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are medical emergencies that require immediate recognition and a structured management approach to prevent mortality. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the diagnostic criteria, precipitating factors, and critical treatment steps outlined in the 2018 Clinical Practice Guidelines.

Key Topics Covered:

  • Diagnostic Criteria: Differentiating DKA from HHS based on arterial pH, anion gap, serum bicarbonate, and plasma osmolality.

  • Treatment Priorities: Memorizing the strict “order of operations” for management: Fluid resuscitation (ECFV restoration) first, followed by potassium correction, and then insulin.

  • Precipitating Factors: Identifying common triggers such as infection, insulin omission, myocardial infarction, and medications like SGLT2 inhibitors.

  • Euglycemic DKA: Recognizing that DKA can occur with normal or mildly elevated blood glucose levels, particularly in pregnancy or with SGLT2 inhibitor use.

  • Sick Day Management: Reviewing patient counselling points for illness, including the frequency of blood glucose/ketone monitoring and hydration protocols.

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CDE Diabetes

Practice Exam: Hyperglycemic Emergencies in Adults (Chapter 15)

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are critical, life-threatening complications that demand rapid assessment and precise intervention. This exam tests your ability to navigate the 2018 Clinical Practice Guidelines to effectively diagnose these conditions, manage electrolyte imbalances, and safely resolve hyperglycemia.

Key Concepts Covered in This Exam:

  • Diagnosis & Differentiation: Distinguishing between DKA and HHS based on arterial pH, serum bicarbonate, anion gap, and plasma osmolality.

  • Precipitating Factors: Identifying common triggers such as infection, insulin omission, myocardial infarction, and new-onset diabetes.

  • Treatment Protocol: Mastering the “order of operations” for management: prioritizing fluid resuscitation (restoring ECFV) and potassium correction before insulin administration.

  • Electrolyte Safety: Understanding the critical importance of monitoring potassium levels to prevent fatal arrhythmias during insulin therapy.

  • Special Situations: Recognizing “euglycemic DKA” (normal or mildly elevated blood glucose with ketoacidosis), particularly in patients taking SGLT2 inhibitors or during pregnancy.

Please go to Practice Exam: Hyperglycemic Emergencies in Adults (Chapter 15) to view this quiz

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CDE Diabetes

Study Guide: Hyperglycemic Emergencies in Adults (DKA & HHS) (Chapter 15)

1. Definitions & Pathophysiology

Hyperglycemic emergencies are medical emergencies requiring immediate treatment. They are distinct but can overlap.

  • Diabetic Ketoacidosis (DKA):

    • Mechanism: Severe insulin deficiency + elevated counter-regulatory hormones (glucagon, catecholamines) hyperglycemia, lipolysis, and ketone production (acidosis).

    • Population: Primarily Type 1 Diabetes, but can occur in Type 2 (especially “Ketosis-Prone Diabetes”).
    • Main Feature: Ketoacidosis.
       
  • Hyperosmolar Hyperglycemic State (HHS):
    • Mechanism: Relative insulin deficiency (enough to prevent ketosis but not hyperglycemia) profound hyperglycemia + osmotic diuresis severe dehydration (ECFV depletion).
    • Population: Type 2 Diabetes, often elderly.
    • Main Feature: Hyperosmolarity and dehydration.

Key Concepts:

  • Incidence: DKA is more common in Type 1, but Type 2 patients can experience it (approx. 0.32-2.0 per 1,000 patient-years). HHS is less common but has higher mortality (12-17%).
  • Ketosis-Prone Diabetes (KPD): A term for patients who present with DKA but lack typical Type 1 features (often have very little beta-cell function).
  • Euglycemic DKA: DKA presenting with normal or mildly elevated blood glucose, commonly associated with SGLT2 inhibitor use or pregnancy.

2. Clinical Presentation & Risk Factors

Feature

Diabetic
 Ketoacidosis
(DKA)

Hyperosmolar
Hyperglycemic
State (HHS)
OnsetRapid (hours to days)Slow/Insidious (days to weeks)
SymptomsPolyuria, polydipsia, weight loss, nausea, vomiting, abdominal pain, air hunger (Kussmaul breathing).Polyuria, polydipsia, weakness, altered level of consciousness (confusion, coma, seizures).
SignsAcetone breath (fruity odor), tachycardia, hypotension, Kussmaul respirations.Profound dehydration (poor skin turgor, dry mucous membranes), neurological deficits (stroke-like state).
PrecipitantsInsulin omission/reduction, new diagnosis, infection, pump failure, SGLT2 inhibitors, cocaine.Infection (40-60% of cases), MI, stroke, diuretics, glucocorticoids, restricted fluid intake (elderly).

3. Diagnosis & Lab Findings

DKA Criteria:

  • Arterial pH:

  • Serum Bicarbonate: mmol/L

  • Anion Gap: mmol/L

  • Ketones: Positive in serum and/or urine.

  • Glucose: Usually mmol/L (but can be lower in “Euglycemic DKA”).

HHS Criteria:

  • Plasma Osmolality: mOsm/kg

  • Glucose: Typically mmol/L

  • pH & Bicarbonate: Usually normal (minimal acid-base disturbance).

Beta-Hydroxybutyrate (beta-OHB): Measuring blood ketones (beta-OHB) is preferred over urine ketones. A level mmol/L warrants further testing for DKA.

  • Note: Negative urine ketones cannot rule out DKA (as they measure acetoacetate, not beta-OHB).

4. Management Algorithm

Management focuses on 4 pillars: Fluid resuscitation, Potassium correction, Insulin therapy, and Acidosis resolution.

Step 1: Fluid Resuscitation (ECFV Restoration)

  • Initial: 0.9% NaCl (Normal Saline).

    • Shock: 1–2 L/h.

    • No Shock: 500 mL/h for 4 hours, then 250 mL/h.

  • Maintenance: Once euvolemic, switch to 0.45% NaCl (half-normal saline) to match ongoing losses.
  • Preventing Hypoglycemia: Once Plasma Glucose reaches 14.0 mmol/L, add dextrose (D5W or D10W) to the IV fluids to maintain glucose between 12.0–14.0 mmol/L.
    • CDE Pearl: Do not stop insulin when glucose drops; add dextrose instead to allow continued insulin for clearing ketones.

Step 2: Potassium () Management

  • Hypokalemia ( mmol/L): HOLD INSULIN. Give (40 mmol/L) until mmol/L. Insulin drives K+ into cells and can cause fatal arrhythmias if started too early.
  • Normokalemia ( mmol/L): Give (10-40 mmol/L) with insulin to prevent drop
  • Hyperkalemia ( mmol/L): Do not give initially. Wait until it falls and diuresis begins

Step 3: Insulin Therapy

  • Standard Dose: IV short-acting insulin infusion at 0.1 units/kg/h.
  • Bolus? Not routinely recommended for adults; definitely avoided in children (risk of cerebral edema).
  • Target: Continue insulin infusion until the anion gap normalizes (resolution of ketoacidosis), not just until glucose is normal.

Step 4: Acidosis Management

  • Bicarbonate: Only recommended if pH is extremely low () or in severe shock. Routine use does not improve outcomes.

 

5. Sick Day Management (Prevention)

Educating patients on “Sick Day Rules” is a key CDE responsibility.

Medications:

  • S.A.D.M.A.N.S.: Hold Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, and SGLT2 inhibitors if dehydrated/vomiting.
  • Insulin: Never stop insulin completely (even if not eating) for Type 1 diabetes. Doses may need adjustment.

Monitoring: Check BG every 2–4 hours.

Ketones: If T1D and BG mmol/L (or symptoms present), check for ketones.

Hydration: Drink plenty of sugar-free fluids. If unable to retain fluids, go to ER.

 

6. Diabetes Canada Guidelines Recommendations

  • Protocol Use: All adults with DKA/HHS should be managed using a standard protocol focusing on fluid, potassium, insulin, and precipitating causes.
  • Screening: Use capillary beta-hydroxybutyrate (beta-OHB) to screen for DKA if BG mmol/L. Do not use negative urine ketones to rule out DKA.
  • Fluid Rate: For DKA, start 0.9% NaCl at 500 mL/h for 4 hours, then 250 mL/h (unless in shock).
  • Insulin Rate: Use 0.1 units/kg/h IV infusion. Maintain until anion gap normalizes.
  • Add Dextrose: Start IV dextrose when plasma glucose drops to 14.0 mmol/L to prevent hypoglycemia while continuing to treat acidosis.
  • SGLT2 Inhibitors: Suspect DKA in symptomatic patients on SGLT2 inhibitors even if BG is not elevated (Euglycemic DKA).

Reference:

Goguen J, Gilbert J. Hyperglycemic Emergencies in Adults. Canadian Journal of Diabetes. 2018;42:S109-S114. doi:10.1016/j.jcjd.2017.10.013
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CDE Diabetes

Flashcards: Hypoglycemia in Adults (Chapter 14 Update)

Sharpen your ability to prevent and manage the most common complication of insulin therapy.

The 2023 Guidelines mark a paradigm shift in hypoglycemia management—moving beyond simple treatment protocols to a proactive focus on prevention, risk stratification, and the use of advanced technology. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the critical updates regarding prevention strategies, glucagon administration, and the management of impaired awareness.

Key Topics Covered:

  • Prevention vs. Treatment: Understanding why prevention is the primary goal and the requirement to reassess insulin/secretagogue doses at every visit.

  • Impaired Awareness (IAH): Memorizing the recommendation to screen all individuals with Type 1 diabetes (and relevant Type 2 patients) for Impaired Awareness of Hypoglycemia.

  • Acute Management: Reviewing the specific “15 g” protocol for fast-acting carbohydrates (e.g., glucose tablets) to ensure the fastest rise in blood glucose.

  • Severe Hypoglycemia: Identifying the indications for glucagon prescription and the mandatory counseling of support persons on its administration.

  • Technology & Education: Recognizing the evidence-based role of Continuous Glucose Monitoring (CGM) and structured education programs for high-risk individuals.

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CDE Diabetes

Practice Exam: Hypoglycemia in Adults (Chapter 14 Update)

Hypoglycemia remains the most frequent and potentially dangerous complication for many individuals treated with insulin or insulin secretagogues. The 2023 Guidelines emphasize a shift from simply treating low blood glucose to actively preventing it through risk stratification, education, and the use of technology.

This practice exam tests your ability to apply the latest recommendations regarding the prevention, recognition, and management of hypoglycemia, including protocols for severe events and impaired awareness.

Key Concepts Covered in This Exam:

  • Prevention First: Understanding that preventing hypoglycemia is safer and more effective than treating it, and knowing how to reassess medication doses at every visit.

  • Impaired Awareness of Hypoglycemia (IAH): Screening all individuals with Type 1 diabetes (and those with Type 2 on insulin/secretagogues) for IAH and implementing structured education or technology solutions.

  • Treatment Protocols: Applying the correct treatment steps—administering fast-acting carbohydrates (e.g., glucose tablets) to achieve the fastest rise in blood glucose, followed by a snack or meal to prevent recurrence.

  • Severe Hypoglycemia: Mastering the management of severe events, including the prescription of glucagon and the critical role of counseling support persons on its administration.

  • Role of Technology: Identifying when Continuous Glucose Monitoring (CGM) should be used to detect and prevent hypoglycemia in high-risk individuals.

Please go to Practice Exam: Hypoglycemia in Adults (Chapter 14 Update) to view this quiz

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CDE Diabetes

Study Guide: Hypoglycemia in Adults (Chapter 14)

1. Chapter Overview

Hypoglycemia is the major barrier to achieving glycemic targets. For the CDE exam, you must distinguish between the “levels” of hypoglycemia (a change in terminology from mild/moderate/severe) and know the specific treatment protocols for conscious versus unconscious individuals. The 2023 update places a heavy emphasis on prevention using technology (CGM) and the use of nasal glucagon.

2. Definition and Classification

Hypoglycemia is defined not strictly by glucose levels alone but by the severity of symptoms and the risk of adverse outcomes.

  • Alert Value: A glucose level of should alert the individual and clinician to potential hypoglycemia in those treated with insulin or insulin secretagogues.
Level 1 ( but
  • Autonomic symptoms present.
  • No neuroglycopenic symptoms.
  • Self-treatable
Level 2 (
  • Neuroglycopenic symptoms appear.
  • Usually self-treatable (does not require assistance).

Level 3 (Severe) (No specific glucose threshold)

  • Characterized by altered mental/physical status.
  • Requires external assistance for recovery (cannot self-treat).

3. Clinical Presentation

Symptoms typically progress from adrenergic (autonomic) to neuroglycopenic.

  • Adrenergic (Early/Warning): Trembling, palpitations, sweating, anxiety, hunger, nausea, tingling.
  • Neuroglycopenic (Brain Glucose Deprivation): Difficulty concentrating, confusion, weakness, vision changes, slurred speech, dizziness, headache.
    • Note: Individuals with Impaired Awareness of Hypoglycemia (IAH) may experience neuroglycopenic symptoms without prior adrenergic warning signs

4. Risk Factors

Identifying “high-risk” patients is a core competency for the CDE exam.

Key Risk Factors for Severe Hypoglycemia:

  • History: Prior episode of severe hypoglycemia.

  • Demographics: Advancing age, long duration of diabetes, low health literacy, food insecurity.
     
  • Physiological: Impaired Awareness of Hypoglycemia (IAH), autonomic neuropathy, chronic kidney disease (CKD), cognitive impairment.
  • Treatment: Use of insulin or insulin secretagogues (sulfonylureas/meglitinides), strict glycemic targets (low A1C).

Impaired Awareness of Hypoglycemia (IAH):

  • Occurs when the threshold for autonomic warning symptoms drops lower than the threshold for neuroglycopenia.
  • Screening: All individuals with type 1 diabetes and those with type 2 diabetes on insulin/secretagogues should be screened for IAH.
  • Reversibility: Strict avoidance of hypoglycemia for 2 days to 3 months can restore awareness.

5. Prevention Strategies

Prevention is preferred over treatment

Pharmacotherapy Adjustments:

  • Insulin: Switch from NPH to long-acting basal analogues (glargine U-300, degludec) to reduce nocturnal hypoglycemia.

    • CDE Gem: Degludec and glargine U-300 are “second-generation” analogues with lower hypoglycemia risk than glargine U-100 or detemir.
  • Type 2 Agents: Prioritize agents with low hypoglycemia risk (GLP-1 RA, DPP-4 inhibitors, SGLT2 inhibitors) over sulfonylureas where possible.

Technology:

  • CGM: Continuous Glucose Monitoring (rtCGM or isCGM) is recommended for those with T1D or T2D on insulin/secretagogues to reduce time in hypoglycemia.

Technology:

  • CGM: Continuous Glucose Monitoring (rtCGM or isCGM) is recommended for those with T1D or T2D on insulin/secretagogues to reduce time in hypoglycemia.

Education:

  • Counsel support persons on glucagon administration.

  • Screen for Fear of Hypoglycemia (FoH), which can lead to “defensive snacking” and maintaining high BG.

6. Treatment Protocol

A. Level 1 & 2 (Conscious & Able to Swallow):

Treat: Ingest 15 g of fast-acting carbohydrate (glucose tablets, sucrose solution).

  • Examples: 4x 4 gm glucose tablets, 150 mL (2/3 cup) juice or regular soft drink, 1 tablespoon honey

Wait: Wait 15 minutes.

Retest: Check BG. If still , treat again with another 15 g.

Maintain: Once BG is safe ():
  • Eat usual meal if due within 1 hour.
  • If meal is hour away, eat a snack (15 g carb + protein source).

B. Level 3 (Conscious but requires help):

  • Oral: 20 g carbohydrate if able to swallow.
  • Glucagon: If unable to swallow, administer Glucagon (3 mg Intranasal OR 1 mg SC/IM).

C. Level 3 (Unconscious):

  • No IV Access: Glucagon 1 mg SC/IM or 3 mg Intranasal. Call emergency services.
    IV Access (Hospital): 10–25 g glucose IV (D50W) over 1–3 minutes.

Important Notes on Glucagon:

  • Intranasal (IN) Glucagon: Effective for both T1D and T2D; easier and faster to administer than injectable.

  • Alcohol: Glucagon effectiveness is reduced if the patient has consumed standard drinks recently.
  • Sulfonylureas: Glucagon is less useful for hypoglycemia caused by secretagogues as it may stimulate further insulin release.

7. Special Considerations

  • Driving: Review safe driving guidelines at every visit.
  • Exercise: To prevent exercise-induced lows, reduce insulin or increase carbs 60-90 minutes pre-exercise.

7. Diabetes Canada Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section of the Guidelines (Pages 552-554).

Counseling & Screening

  • Universal Counselling: All individuals on insulin or insulin secretagogues (and their support persons) must be counselled on risk, prevention, recognition, and treatment of hypoglycemia.

  • Every Visit Review: At every clinical encounter, review the recent history of hypoglycemia, including frequency, causes, and driving safety.
  • Screen for IAH: Screen for Impaired Awareness of Hypoglycemia (IAH) using a careful history or validated questionnaires.
  • Screen for Fear: Screen for Fear of Hypoglycemia (FoH) and refer to mental health professionals if persistent.

Prevention Strategies (High-Risk Individuals)

  • Technology: Use Continuous Glucose Monitoring (CGM) or increased capillary monitoring to identify unrecognized hypoglycemia.
    • Note: Real-time CGM (rtCGM) is Grade A evidence for Type 1 Diabetes.
  • Insulin Choice:
    • Basal vs. NPH: Long-acting analogues (glargine, detemir, degludec) are preferred over NPH insulin to reduce risk.
    • 2nd Gen vs. 1st Gen: Second-generation basal analogues (glargine U-300, degludec) are preferred over first-generation (glargine U-100, detemir) to reduce nocturnal hypoglycemia.
  • Education: Structured diabetes education and psychobehavioural interventions (e.g., Blood Glucose Awareness Training) should be utilized.

Management of Recurrent/Severe Hypoglycemia

  • Strict Avoidance: For those with IAH or recurrent severe episodes, aim for strict avoidance of hypoglycemia and potentially relax glycemic targets for up to 3 months to restore awareness.
  • Pumps & Sensors: Consider CSII (pumps), CGM, or sensor-augmented pumps for Type 1 Diabetes.
  • Transplantation: Islet cell or pancreas transplantation may be considered for T1D with recurrent severe hypoglycemia.

Treatment Recommendations (The Protocols)

  • Level 1 & 2: Ingest 15 g carbohydrate (glucose/sucrose preferred). Retest in 15 mins. Retreat if BG .
  • Level 3 (Conscious):
    • If able to swallow: 20 g carbohydrate.
    • Or: Glucagon 3 mg Intranasal or 1 mg SC/IM.
  • Level 3 (Unconscious):
    • No IV: Glucagon (3 mg IN or 1 mg SC/IM). Call emergency services.
    • With IV: 10–25 g glucose (20–50 mL of D50W) intravenously over 1–3 minutes.
  • Support Persons: Must be taught how to administer glucagon (SC, IM, or IN).
  • Post-Treatment: Eat usual meal or snack (15 g carb + protein) if meal is hour away.

Reference:  

Lega IC, Yale JF, Chadha A, et al. Hypoglycemia in Adults. Canadian Journal of Diabetes. 2023;47(7):548-559. doi:10.1016/j.jcjd.2023.08.003
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CDE Diabetes

Flashcards: Pharmacologic Glycemic Management of Type 2 Diabetes (Chapter 13 Update)

Master the 2024 updates to pharmacotherapy for Type 2 diabetes.

The 2024 Update to the Clinical Practice Guidelines introduces critical shifts in the management of Type 2 diabetes, prioritizing cardiorenal protection alongside glycemic control. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the latest evidence-based recommendations for selecting antihyperglycemic agents based on comorbidities like heart failure, chronic kidney disease (CKD), and cardiovascular risk.

Key Topics Covered:

  • Initial Therapy: Confirming metformin as the first-line agent for most patients and knowing when to initiate insulin immediately.

  • Cardiorenal Protection: Identifying the specific indications for GLP-1 Receptor Agonists (GLP1-RA) and SGLT2 Inhibitors in patients with atherosclerotic cardiovascular disease (ASCVD), heart failure, or CKD.

  • Glycemic Targets: Recalling when to add second-line agents (e.g., when A1C is >1.5% above target) and the benefits of combination therapy.

  • Safety & Side Effects: Reviewing the risk of euglycemic DKA with SGLT2 inhibitors and contraindications for GLP1-RAs.

  • Weight Management: Understanding the role of specific agents (e.g., Semaglutide, Tirzepatide) in weight loss and metabolic health.