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Safe Medication
SAFE MEDICATION Hypoglycemia management in patients with diabetes
By Stephanie Lau, Andrew Tu, and Certina Ho
At the senior home this morning, Marie noticed that her hands were shaking more than usual. She just thought her Parkinson’s was getting worse today, but she progressively felt more lightheaded. When the nurses came to assist for her daily walk, they found her collapsed by the foot of her bed. Marie was immediately transferred to the closest hospital and her admitting diagnosis was determined to be hypoglycemia, which was likely caused by the insulin therapy that she used to manage her diabetes.
Hypoglycemia is defined as low blood glucose levels of less than 4 mmol/L for patients with diabetes being treated with either insulin or an insulin secretagogue (i.e. medications that help our body make and release insulin); while normal fasting blood glucose (FBG) levels are within 4-7 mmol/L. Patients can measure their blood glucose levels tthrough the use of a self monitoring device (e.g. together with the use of blood glucose test strips) that can be purchased from any pharmacy. The effects of hypoglycemia can be severe and potentially fatal if untreated; therefore, timely and quick recognition and management of hypoglycemia are critical to improve patient safety and outcome.
RECOGNIZING HYPOGLYCEMIA: SIGNS AND SYMPTOMS
In the above case scenario, we saw Marie experiencing some signs of hypoglycemia, such as shakiness, lightheadedness, dizziness, and eventual unconsciousness, but other symptoms of hypoglycemia may include hunger, poor concentration, confusion, irritability, sweating, and increased heart rate, as well as more severe effects such as seizures, coma, and death if untreated. Since the effects of hypoglycemia are rapid, it is, therefore, often considered a medical emergency. (For further information regarding signs and symptoms of hypoglycemia, refer to the 2018 Diabetes Canada Clinical Practice Guidelines: Hypoglycemia, available at http://guidelines.diabetes. ca/cpg/chapter14#sec5)
Figure 1. Management of Hypoglycemia: “Rule of 15”
POPULATIONS AT RISK
In addition to the potentially severe consequences of hypoglycemia, the increasing prevalence of populations at risk of diabetes further demonstrate the need for awareness and education on hypoglycemia management. Populations at greatest risk of hypoglycemia include patients with diabetes who use certain types of anti-diabetic medications (such as insulin and sulfonylureas) as well as those who exercise a lot, consume alcohol, undergo fasting, or have renal impairment.
MANAGING HYPOGLYCEMIA
“Rule of 15”
If a patient is experiencing symptoms of hypoglycemia, it is important to measure the blood glucose levels immediately. If the reading is less than 4 mmol/L (and as mentioned above, our target FBG is 4-7 mmol/L), the “Rule of 15” should be employed immediately (Figure 1). If the patient is unconscious and unable to take anything orally (i.e. by mouth), glucagon may be needed. Glucagon is a regulatory hormone that can rapidly increase blood glucose levels in our body. It is available as an subcutaneous, intramuscular, or intravenous injection; and it is also available as an intranasal spray.
Use the “Five to Drive” rule for safe driving: Ensure your FBG is at least 5 mmol/L for at least 40 to 60 minutes prior to driving. If your blood glucose is below 4 mmol/L, apply the “Rule of 15” (Figure 1). If you plan to drive for a long period of time, it is best to take FBG readings every 4 hours to ensure driving is safe and appropriate. Having regular meals, snacks, and taking breaks during a long driving trip may also help. (For further information regarding diabetes and driving, refer to the 2018 Diabetes Canada Clinical Practice Guidelines: Diabetes and Driving, available at http://guidelines. diabetes.ca/cpg/chapter21.)
For further information on diabetes and hypoglycemia management, refer to the full 2018 Diabetes Canada Clinical Practice Guidelines along with the 2020 Updates at http://guidelines.diabetes.ca/cpg. ■ H
Other Lifestyle Considerations: Alcohol and Exercise Alcohol Consumption Physical Activity • Alcohol can impair the liver from releasing glucose into the blood, and this effect may last up to 24 hours after alcohol consumption. • Exercise consumes glucose and can lower blood glucose levels.
• Consuming food or having a meal with alcohol can help prevent hypoglycemia by providing a source of sugar. • Avoid exercise immediately after insulin administration. Careful timing of meals and insulin with exercise is necessary to avoid hypoglycemia episodes. • Monitor FBG before and after exercise. For prolonged exercise, it is best to measure FBG during exercise and adjust insulin doses accordingly. Apply the “Rule of 15” (Figure 1) to ensure safe engagement (or re-engagement) in physical activities.
NEWS How do we stop the most devastating outcome of diabetes and poor circulation?
By Ana Gajic
Dr. Charles de Mestral was drawn to vascular surgery because it offered him the opportunity to directly treat a patient’s health concern through an invasive intervention and also advise patients on how to prevent complications of vascular disease.
“As vascular surgeons, we’re part of treating the problem when it happens, but also looking at how to prevent it from ever happening.” says Dr. de Mestral, of St. Michael’s Hospital of Unity Health Toronto.
In his medical practice, Dr. de Mestral saw a devastating pattern repeat itself: many people with diabetes and poor circulation – known as peripheral arterial disease – got to a point in their journey where they had to have their leg amputated due to their disease.
The most frustrating part, he said, was the fact that with the right preventative care, these patients’ limbs and by extension, quality of life could be saved. Dr. de Mestral, a scientist at Li Ka Shing Knowledge Institute, set out to study how access and use of health care services impacted amputation rates. “We’ve been heavy on anecdotal evidence and we know there’s a problem, but it’s not that easy to lay out data around it – and that’s what my research has aimed to do.”
In Ontario, five people lose a leg to diabetes and poor circulation every day and that number is rising. Fortunately, four out of every five can be prevented with the right type of care, such as frequent foot checks for wounds, foot assessments by a trained health care provider, and prompt evaluation of foot wound infections.
To understand how access to healthcare impacts amputation rates, Dr. de Mestral and his team identified 11,658 patients with lower extremity amputation in Ontario.
Their research, published last year in CMAJ Open, found that in areas where there were assessments done by vascular surgeons and where procedures to restore blood flow were performed more frequently had less amputation.
In particular, rural Northern Ontario areas had the highest rates of amputation, and areas in more urban settings had lower rates. Dr. de Mestral attributes that to the fact that disparities in community prevention and access to expertise in limb salvage. The reality is, however, that gaps exist throughout the system.
“To prevent amputation, many layers of care are needed,” Dr. de Mestral says. “Irrespective of where you are in the process, we know there are gaps in preventative care and what my research is trying to do is begin describing the current context of care and what works well in the real-world.”
This study is part of a greater body of work that first documents the burden of disease and identifies who’s at greatest risk of losing a leg. With this information, researchers can begin to understand who’s at greatest risk of not receiving the right type of preventative care so that they can then come up with regional solutions that have targeted initiatives to address amputation prevention.
“Amputation is the most feared complication for people with poor circulation,” Dr. de Mestral says. “It has impacts on a person’s mobility, their financial situation, their family members who have to help care for basics of daily living, and their overall quality of life. Sadly, I see this outcome on a weekly basis.”
No one person is responsible for reducing amputations – it takes a team of primary care providers, chiropodists/podiatrists, medical specialists and surgeons. Ideally, Dr. de Mestral said each Ontarian would have access to a team of people to help them with a foot problem.
“I’m sitting on the prevention side and the treatment side – that’s not always the case depending on the field of medicine you’re in. In this field, the successes are so motivating because you’ve prevented the most feared complication of this disease.” ■ H
Dr. Charles de Mestral
Ana Gajic is a senior communications advisor at Unity Health Toronto.
