Page 292 - fbkCardioDiabetes_2017

268 Hypoglycemia How Critical it is?

Patient Related Others mic episodes should be avoided as it can lead to
trauma from falls or seizures, often extending the
Older age Long duration of diabe- hospital stay.
tes
A number of case reports, mostly in children, have
Impaired hypoglycemia Nil per oral without
awareness change in treatment shown that hypoglycemia can be fatal in 4–10% of
patients with Type 1 diabetes. In the adult population,
Severe illness Food malabsorption: eg prolonged or severe hypoglycemia can cause brain
Coeliac disease, gastro- injury, but most cases of fatal hypoglycemia have
enteritis been attributed to ventricular arrhythmias, the so-
Septic shock Drug dispensing error called ‘dead in bed syndrome’.
Mechanical ventilation Recent literature supports the concept that sponta-
Renal failure Drugs neous, but not necessarily iatrogenic hypoglycemia
Hepatic dysfunction Beta blockers is associated with risk of death. Among the major
Quinine inpatient trials of intensive glycemic management,
Malignancy
Sulphonylureas only NICE-SUGAR, a large multicenter trial, reported
Severe trauma Salicylates an overall increase in mortality with intensive insulin
1
Sulfonamides therapy . Also, in a retrospective analysis of patients
Trimethoprim with diabetes admitted to the general wards a cor-
relation of hypoglycemia with increased mortality
Clinical mimics was found, but this association held true even at 1
year postdischarge, implying that hypoglycemia was
• Addison Disease
a marker of disease burden rather than a direct cause
• Adrenal Crisis of mortality . By contrast, several studies demonstrat-
3
• Alcoholism ed a decrease in mortality with intensive insulin con-
trol, while others failed to show any significant as-
• Anxiety Disorders sociation, and two multicenter randomized-controlled
• Cardiogenic Shock trials (VISEP and Glucontrol) had to be terminated
early owing to high rates of severe hypoglycemia,
• Hypopituitarism (Panhypopituitarism) but there was no evidence of increased mortality. The
• Insulinoma only trials carried out in patients with diabetes are
the DIGAMI trials that showed a decrease in mortality
• Pseudohypoglycemia with tight glycemic control at 1 and 5 years follow-up.
The DIGAMI-2 trial failed to show a long-term benefit
Complications & Consequences with more aggressive insulin regimens as compared
5
Hypoglycemia can lead to significant morbidity and with conventional therapy . For a summary of the re-
occasional mortality, with recurrent hypoglycemia be- sults of inpatient trials on the association between
ing the most common complication . This places pa- hypoglycemia and mortality. A post hoc analysis of
2
tients at risk of more severe hypoglycemia risk with a the NICE-SUGAR trial demonstrated attenuated haz-
dose-dependent response, with mortality increasing ard ratios after adjustment for baseline characteris-
proportionally with the frequency and severity of hy- tics and post-randomization factors. They also noted
poglycemia . Inpatient hypoglycemia is also associ- that the hazard ratio for death was greater (and the
4
ated with increased cost mainly owing to increased time to death shorter) among patients who had hypo-
length of stay. glycemia not being treated with insulin, as compared
with the patients treated with insulin. These findings
Hypoglycemia can affect cognitive function in adults, support the notion that spontaneous hypoglycemia,
although the effects are more significant in children rather than iatrogenic hypoglycemia, is associated
under the age of 5 years. Large data obtained in with increased mortality .
3
adults during the 18 year follow-up of the Diabetes
Control and Complications Trial (DCCT) showed tran- Other studies have also questioned whether hypo-
sient cognitive dysfunction but similar performances glycemia is truly a cause of mortality or simply a
on cognitive tests between patients with and with- biomarker of increased disease burden and poor
out a history of severe hypoglycemia reassuring no prognosis. One study of patients with acute myo-
permanent brain damage . In hospitalized patients, cardial infarction found that hypoglycemia (glucose
3
short-term cognitive impairment during hypoglyce- <60 mg/dl or 3.3 mmol/l) was a predictor of in-hos-

GCDC 2017