31 May 2014

Clinical manifestations of hypoglycemia in diabetic patients

Hypoglycemia is a major side effect of insulin treatment. It is a cause of anxiety in patient and the care givers. Hypoglycemia occur more during night and before meals. This  is due to imbalance between insulin administration and requirement.

Recently there is an increase in incidence as an attempt to achieve tight glycemic control. Hypoglycemic episodes are more in those patients whose blood glucose levels are reasonably well controlled. There is a person to person variation in the blood levels at which each patient  experience symptoms of hypoglycemia. Those patients whose glycemic control is poor experience symptoms at somewhat higher level of blood glucose. Thus patients should take extraprecaution during driving ,swimming etc .Patients on insulin are always advised to carry some form of sugar with them.Incidence of hypoglycemia is less in patients taking anti-diabetic drugs.

Hypoglycemia is  defined as plasma glucose level <45-50 mg/dl.Whipple’s triad forms an important frame work for diagnosis of hypoglycemia.

Whipple’s triad include the following 
Symptoms consistent with hypoglycemia
  • Low plasma glucose concentration.
  • Relief of symptoms after plasma glucose level is raised.
  • clinical manifestations of hypoglycemia.
Clinical manifestation vary from mild tiredness to  unconsciousness .Most of the patients experience warning symptoms before severe manifestation occur .Sugar intake at this level can terminate further progression.  Warning symptom may be absent in patients on longstanding diabetes ,In such patients detachment from environment occur that can be easily detected by caregivers ..Most common warning symptoms are tremor and sweating. But periodical numbness is the most specific symptom. Manifestations of hypoglycemia can be neurogenic or neuroglycopenic. Symptoms of decreased glucose availability(neuroglycopenic symptoms) occur  only at later stages.

Symptoms of hypoglycemia
Early warning symptoms
  • Adrenergic symptoms
  • Palpitations(pounding heartbeat)
  • Tremor
  • Anxiety
  • Cholinergic symptoms 
  • Sweating
  • Hunger
  • Pins and needles in lips and tongue
  • Headache (occasionally)
Neuroglycopenia symptoms 
  • Double vision
  • Slurring of speech
  • Difficulty in concentrating
More advanced 
  • Confusion
  • Truculence
  • Change of behaviour in the form of clumsiness ,irritability  or aggressiveness
  • Naughtiness in children
  • Restlessness with sweating
  • Hemiplegia, especially in older people (but rare)
  • Convulsion

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