Driving Under the Influence of Insulin
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1 Driving Under the Influence of Insulin The Diabetic Driver California Association of Toxicologists Sacramento, CA March 11, 2005 William G Cushard Jr. MD Clinical Professor of Medicine University of California Davis
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3 Types of Diabetes Type 1 Younger Lean Require Insulin Injections Fluctuating Blood Sugars Throughout the Day Type 2 Older Overweight Oral Medicines Effective More Stable Sugars
4 Expected Blood Sugar Levels Normal Fasting Diabetes Fasting > 126 Target BG on Treatment Type 1 Type 2 After Eating < 140 After Eating >
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9 What s s so bad about high blood sugar? It s a toxic state!
10 Chronic Complications of Diabetes Microvascular Retinopathy Nephropathy Neuropathy Macrovascular Heart Attack Stroke Lower Limb Gangrene
11 Skyler, J. Endocrinol Metab Clin North Am 25:243,1996
12 Oral Anti-Diabetic Drugs Hypoglycemic Agents Glyburide (Micronase ) Glipizide (Glucotrol ) Glimeperide (Amaryl ) Repaglinide (Prandin ) Nateglinide (Starlix ) Anti-Hyperglycemic Agents Acarbose (Precose ) Rosiglitazone (Avandia ) Pioglitazone (Actos ) Metformin (Glucophage )
13 Insulin Treatment Different Types Quick, Slow Newer Insulins More Consistent, Predictable Effect Advanced Tactics Require Greater Skills
14 Sugar! Where Does It Come From?
15 Origins of Glucose Intestinal Absorption of Food Endogenous Glucose Production Glycogenolysis Gluconeogenesis Lactate Amino Acids Glycerol
16 Utilization of Glucose
17 Systemic Glucose Balance Hormonal Regulation To Lower Blood Sugar Insulin To Raise Blood Sugar Epinephrine Glucagon Cortisol Growth Hormone
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19 Dilemma One the One Hand Controlling High Blood Sugar to Prevent Chronic Complications On the Other Hand Increases Risk of Acutely Disabling Hypoglycemia
20 Wiethop, BV. Diabetes Care. 16:1131,1993
21 Protective Effect of Epinephrine Increases Hepatic Glucose Production Decreases Muscle Glucose Uptake Provokes Behavioral Response
22 Symptoms of Hypoglycemia Early Sweaty Hungry Tremulous Palpitations Anxious Tingling Late Tired/Drowsy Difficulty Thinking/Confused Difficulty Speaking Blurred, Darkened Vision Stuporous Seizures
23 Aoki, T. Neurology 63:392,2004
24 Circumstances of Disabling Hypoglycemia Brittle Type 1 Diabetes History of Hypoglycemic Impairment Aggressive Treatment Program
25 Disabling Hypoglycemia Risk Factors Excessive Insulin Dose Decreased Food Intake Increased Utilization Decreased Endogenous Production Increased Sensitivity to Insulin Decreased Clearance of Insulin
26 Holmes, CS. Diabetes Care 6:182,1983
27 Cox, DJ. Diabetes Care 23:163,2000
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30 Simulator Studies: Findings Blood Sugar mg % Examiners detect driving impairment Subjects detect driving impairment Increased theta-wave activity on EEG Blood Sugar 50 mg % Subjects delayed self-treatment until below this level Greatest theta-wave activity on EEG Blood Sugar mg % Cognitive motor impairment precludes appropriate corrective action
31 Caveat There is no legally hypoglycemic blood level.
32 Diabetes and Driving Mishaps A Retrospective Multicenter Multinational Survey Non-Diabetic Spouse Type 2 Type 1 Auto Crash 8% 12% 19% Moving Violation 10% 8% 15% Hypoglycemic Stupor - 5% 18% Required Assistance - 5% 17% Mild Symptom Hypo - 4% 22% Diabetes Care 26:2329, 2003
33 Driving Mishaps Among Diabetics Although greater than non-diabetic spouse group, various reports indicate the increased risk to be less than that seen in other chronic medical conditions such as: Attention Deficit Hyperactivity Disorder¹ Sleep Apnea² Alcohol Abuse³ 1. J Nerv Ment Dis 188:230, N Eng J Med 340:847, Recent Dev Alcohol 14:307, 1998
34 Avoidance of Driving Mishaps Driving Under the Influence of Insulin Education by Physician Test Before Driving and Periodically on Long Trips Maintain Vigilance for Early Symptoms Stop Driving and Ingest Sugar Promptly
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What the Pill Looks Like. How it Works. Slows carbohydrate absorption. Reduces amount of sugar made by the liver. Increases release of insulin
Diabetes s Oral s - Pills These are some of the pills that are currently available in Canada to treat diabetes. Each medication has benefits and side effects you should be aware of. Your diabetes team