Risks of severe hypoglycaemia associated with

different diabetes treatment

50
40
30
20
10
0
P
a
t
i
e
n
t
s

a
f
f
e
c
t
e
d

p
e
r

y
e
a
r

(
%
)

Sulphonylurea-
treated type 2
diabetes
Insulin-
treated type 2
diabetes
Standard insulin
therapy in type 1
diabetes
Intensively
Treated in type 1
diabetes (DCCT)
Excessive
dosage
Error by patient, doctor or pharmacist
Increased
insulin
bioavailability
Accelerated absorbtion (exercise, injection into
abdomen, change to human insulin)
Insulin antibodies, Renal failure, Honeymoon periode
Increased
insulin
sensitivity
Counter-regulatory hormon deficiencies (Addison,
Hypopituitarism)
Weight loss, physical exercise, postpartum,
menstrual cycle variation
Inadequate
carbohydrate
response
Missed, small or delayed meals
Anorexia nervosa, Vomiting (gastroparesis), breast
feeding, failure to cover exercise
Other factors Exercise, alcohol, drugs
Heller SR. Textbook of Diabetes 1, 2003, p.33.1
Autonomic Neuroglycopenic Malaise
Sweating
Pounding heart
Tremor
Hunger

Confusion
Drawsiness
Speech difficulty
Incoordination
Atypical behaviour
Visual disturbance
Circumoral paraesthesia
Nausea
Headache
Heller SR. Textbook of Diabetes 1, 2003, p.33.1
Glycaemic thresholds
for release of
epinephrine and
activation of
autonomic symptoms
and for
neuroglycopenic
effects in diabetic
subject who are aware
or unaware of
hypoglycaemia
Blood glucose (mmol/L)
Hypoglycaemia unaware
4
3
2
1
Epinephrine
release
Sweating,
tremor
Start of brain
dysfunction
Confusion/loss
of concentration
Coma/seizure
Permanent brain damage
Blood glucose (mmol/L)
Hypoglycaemia aware
4
3
2
1
Epinephrine
release
Sweating,
tremor
Start of brain
dysfunction
Confusion/loss
of concentration
Coma/seizure
Permanent brain damage
Principal metabolic effects of counter-regulation
in response to acute hypoglycaemia
+
+
+
Glucagon Vasopressin
Growth
hormone
Cortisol
ACTH
Hypoglycaemia
Relationships
between the
duration of
diabetes
0-9 10-19 20-29 30-39 > 40
100
50
0
Duration of diabetes (years)
(c)
Severe hypoglycaemia without warning
100
50
0
(b)
P
a
t
i
e
n
t
s

a
f
f
e
c
t
e
d

(
%
)

Sweating and/or tremor
Altered symtoms of hypoglycaemia
100
50
0
(a)
Established
diagnosis
Capillary blood sample
Oral glucose (liquid)
120 cc
Intramuscular glucagon
0.5 1 mg Repeat
after 10
Intravenous glucose 20
30 ml 50% dextrose
Evaluation
Maintainance
180 200 mg%
10% Dextrose
Dextamethasone
Komplikasi Kronik
Makroangiopati
Pembuluh darah jantung
Pembuluh darah otak
Mikroangiopati
Retinopati diabetik
Nefropati diabetik
Neuropati (perifer)

Komplikasi
kronik
DM
IDF AACE ADA
HbA1C (%) < 6.5 6.5 < 7.0
Fasting/preprandial glucose
(mmol/L / mg/dL)
< 6.0 / < 110 < 6.0 / < 110 3.9-7.2/ 70-130
2-h postprandial glucose
(mmol/L / mg/dL)
< 7.8 / < 140 < 7.8 / < 140 < 10.0 / < 180*
*ADA recommends that postprandial glucose measurements should be made 1-2h
after the beginning of the meal
IDF : International Diabetes Federation
AACE : American Association of Clinical Endocrinologist
GLYCEMIC GOALS IN ADULT
Principal metabolic effects of counter-regulation
in response to acute hypoglycaemia