Hypoglyceamia and Exercise

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1 Hypoglyceamia and Exercise Noreen Barker Diabetes Specialist Nurse May 2016

2 Hypoglyceamia What is a hypo? Why are we concerned? Signs and symptoms Treatments Causes Hypo unawareness Managing diabetes and exercise

3 What is a hypo? Hypoglycaemia is defined as a blood glucose level below 4mmol/l.

4 Hypoglycaemia Mild hypoglycaemia can be self treated Severe hypoglycaemia requires third party assistance

5 Hypoglycaemia Why are we concerned?

6 Hypoglycaemia Mild symptomatic hypoglycaemia can negatively impact on a persons quality of life 52% of people surveyed believed hypos affected their quality of life 1in 10 people had to take at least one day off work as a result of hypoglycaemia Weight Gain, additional calories consumed to treat hypos Medication adherence, Reluctance to take medication because of fear of hypos Elderly more prone to falls and fractures

7 Hypoglyceamia Consequences of severe hypoglycaemia may include: Loss of consciousness, seizures, coma, acquired brain injury. Severe hypoglycaemia can precipitate cardiovascular and cerebrovascular events Severe hypoglycaemia is also associated with increased mortality In the UK, there are five fatal road traffic accidents each year and 45 serious events each month as a result of hypoglycaemia in people with diabetes

8 Epidemiology of hypoglycaemia in UK Severe hypoglycaemia Mild hypoglycaemia Proportion reporting at least one hypoglycaemic episode SU <2 yr >5 yr <5 yr >15 yr SU <2 yr >5 yr <5 yr >15 yr T2D T1D T2D T1D Requiring help for recovery Self-treated SU, sulphonylurea 1. UK Hypoglycaemia Study Group. Diabetologia 2007;50:

9 Hypoglycaemia rates: Sulphonylureas vs insulin % Patients treated with sulphonylureas or insulin for <2 years Severe hypoglycaemia Mild symptomatic hypoglycaemia Sulphonylureas Insulin Low interstitial glucose T2D: type 2 diabetes. No annual differences were observed between the two groups UK Hypoglycaemia Study Group. Diabetologia. 2007; 50:

10 Severe hypoglycaemia in type 1 DM occurs frequently during sleep often go unrecognised by patients 55% of severe hypoglycaemic episodes occur during sleep 36% of severe episodes that occurred while awake had no warning signs 216 participants with T1DM reported 714 episodes of severe hypoglycaemia, the majority of which occurred during sleep. Severe hypoglycaemia was defined as blood glucose <2.8 mmol/l requiring third-party assistance. American Journal of Medicine Diabetes Control and Complications Trial 1991;90:

11 Patients fear severe hypoglycaemia as highly as developing serious chronic complications* Very worried Men Women Not worried Mild hypoglycaemia Severe hypoglycaemia Thoughts about diabetes * Based on patient (n=411, T1DM) attitudes on hypoglycemia using a visual analogue scale Blindness Kidney complications 11 Pramming et al. Diabet Med 1991;8(3):217 22

12 The costs of hypoglycaemia in England are high All hypoglycaemia events (including diabetic and non-diabetic patients) Intervention Average annual cost Initial ambulance attendance and treatment at the scene 553,000 Transport to hospital by ambulance 223,000 Emergency department costs 140,000 Primary care follow-up 61,000 Total annual cost (severe hypoglycaemia) 13.6m Emergency call 263 per call Farmer AJ, et al. Diabet Med. 2012; 29(11):

13 What are the signs and symptoms of hypoglycaemia?

14 Signs Hormonal Pallor Tremor Perspiration Slowing heart rate Increasing heart rate Tingling mouth Neurological Confusion Mood swings Irritability Slurred speech Lethargy Coma Fitting Symptoms Sweating Shakiness Feeling anxious Nausea Hunger Palpitations Difficulty speaking Blurred vision Loss concentration Drowsiness Dizziness Headaches Seizures

15 How to treat a hypo

16 Hypo Treatment Food Dextrose tablets Glucotabs 20g CHO(2CP)is found in 6 5 lucozade 120ml 90ml Fizzy drink 200ml 150ml Jelly babies 5 3 Jelly beans Fruit pastilles gCHO(1.5CP) is found in 5 4

17 Hypo treatments Glucogel available in 25g tubes, containing 10g glucose Glucagon injection

18 Hypo treatment Perform blood test to confirm hypo Give 5-6 dextrose tablets/ 1 ½ to 2 tubes of Glucogel/ mls of Lucozade Wait mins and if no improvement repeat treatment Back up with snack (fruit/ biscuits/ sandwich/ next meal) If unconscious do not put anything into the persons mouth but call 999 Try to work out why hypo occurred to prevent in future

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20 Risk factors Antecedent hypoglycaemia Duration of diabetes Duration of insulin treatment in type 2 diabetes Age Strict glycaemic control Hypo unawareness Nocturnal hypos Impaired renal or liver function

21 Hypoglycaemia unawareness Adrenaline release Sweating tremor Confusion / loss of concentration Hypo Aware Start of brain dysfunction Coma / hypoglycaemic seizure Hypo Unaware Start of brain dysfunction Adrenaline release Sweating tremor Confusion / loss of concentration Coma / hypoglycaemic seizure 21

22 Assessing for Hypoglycemia Is the patient on a diabetes treatment that could cause a hypo? Some questions to ask What do you understand by the term hypoglycaemia? What symptoms of hypoglycaemia do you get /or how would you recognise you were hypo? At what blood glucose level do you know you are hypo? Are they always able to treat hypos yourself, have you ever needed help to treat a hypo? Can you always identify why they've had a hypo? How do you treat hypos and how long it takes to recover?

23 Oral treatments and Incretin Mimetics NAME OF DRUG Action Sulphonylureas eg Gliclazide Stimulates pancreas to make extra insulin Metformin Gliptins eg Sitagliptin, Linagliptin, Saxagliptin Pioglitazone SGLT2-inhibitors eg Canagliflozin, Dapagliflozin Byetta, Victoza, Lyxumia Bydureon, Trulicity (injections) Helps control the production of new glucose in the body Increase insulin secretion. Lowers glucagon secretion Reduces insulin resistance Increases urinary glucose excretion Reduces appetite. Similar action to Metformin and Gliclazide. Slows down speed of stomach emptying

24 Exercise and type 2 diabetes Risk of hypo minimal if not on insulin or sulphonylurea If on insulin or SU Use carbohydrate snacks to prevent hypos If pre -exercise blood glucose less than 5.6 mmols have 15g CHO snack May need CHO during and after exercise Can consider insulin dose reduction Caution if blood glucose level above 16.7 mmols Ensure are feeling well and adequately hydrated

25 Trends in glucose production and use in T1DM during prolonged aerobic exercise Glucose use Blood glucose Glucose production Counter-regulatory hormone response Meal 60 min training run AN A

26 Effect of different types of activity % max heart rate Type Typical exercise Effect on glucose level <60 Gentle A nice walk! Little perhaps a slight fall aerobic Jogging, swimming Fall after minutes mixed Running cross training at gym football rugby >85 anaerobic Sprint running, intense squash match Steady and marked fall Rising blood glucose level

27 Adjusting insulin and carbohydrates for physical activity in type 1 diabetes Factors to consider Type of insulin and regimen Timing of last insulin Duration and intensity/type of exercise Blood glucose level before exercise Previous hypoglycaemia

28 Adjusting insulin and carbohydrates for physical activity in type 1 diabetes Main strategies Insulin dose reduction Carbohydrate supplementation Combination of types of exercise Type of basal insulin Insulin pump treatment

29 Adjusting insulin and carbohydrates for physical activity in type 1 diabetes Check blood glucose prior to exercise Blood glucose to be above 6mmol If above 14 mmol check for ketones If no ketones delay exercise until BG below 14 If ketones present do not exercise

30 Adjusting insulin and carbohydrates for physical activity in type 1 diabetes Start with a 50% dose reduction of quick acting insulin dose providing the insulin is taken minutes before activity Use carbohydrates in divided doses before during and after exercise Rough guide is 1g CHO per kg of body mass per hour of planned activity, maximum 60g Sports drinks typically have 6-8gCHO/100mls

31 Adjusting insulin and carbohydrates for phyiscal activity in type 1 diabetes Meal after exercise aim for low GI and reduce quick acting dose by 50% Consider reduction of evening levemir by 10-20% to prevent nocturnal hypoglycaemia

32 Strategies for Glucose Replacement During Exercise AN A

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36 Summary of Clinical Strategies to Maintain Glycaemic Control With Exercise Strategy Advantages Disadvantages Reducing pre-exercise bolus insulin Reducing pre-exercise basal insulin Taking extra CHO with exercise Pre- or post-exercise sprint Insulin pump therapy Reduces hypoglycaemia during and following exercise; reduces CHO requirement As above Useful for unplanned or prolonged exercise Reduces hypoglycaemia following exercise Offers flexibility and rapid change in insulin infusion rates postexercise Needs pre-planning; not helpful for spontaneous exercise or for late post-prandial exercise As above, causes pre- and late post-exercise hyperglycaemia May not be possible with some exercises; not helpful where weight control is important; easy to overreplace causing hyperglycaemia Effect limited to shorter and less intense exercise Expensive; may not be practical for contact sports (e.g., rugby/ football/judo) Reducing basal insulin postexercise Reduces nocturnal hypoglycaemia Lumb AN, Gallen IW. Curr Opin Endocrinol Diabetes Obes. 2009;16: May cause morning hyperglycaemia Ian Gallen AN A

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