Archive for the ‘Diabetes’ Category

How to Diagnose Hypoglycemia?

Diagnosis of hypoglycemia, especially recurrent hypoglycemia is not very difficult. Patient can understand he/she is having acute hypoglycemia from the symptoms of hypoglycemic attacks.

Hypoglycemia can also be established conclusively by documenting the Whipple’s triad: which include (1) consistency of symptoms (confusion, fatigue, behavioral changes, sweating, hunger, palpitations, tremor, anxiety etc.) with hypoglycemia, (2) low blood glucose level (precisely measured with right method and not by commonly used glucose monitor), (3) disappearance or relief of the above symptoms when blood glucose level is raised to normal.

Another way to diagnose hypoglycemia is by measuring blood glucose level below 55 mgs/100 ml (3.0 mmol/L) of blood with symptoms of mentioned above (all of the above mentioned symptoms seldom occurs in an individual with hypoglycemia and usually only few of the symptoms are present at a time) which are promptly relieved by raising blood glucose.

The most difficult part of the hypoglycemia is to find out the cause of hypoglycemia. To find out the cause of hypoglycemia it is important to collect blood during an episode of hypoglycemia for checking glucose level as fulfillment of Whipple’s triad is required to conclusively diagnose hypoglycemia.

If the cause of hypoglycemia is not clear additional measures should be taken to try to find out the cause. The additional measures should include insulin, C-peptide, and ethanol (alcohol) concentrations in blood, ideally blood sample taken during episode of hypoglycemic attack and before starting treatment of hypoglycemia like administration of glucose. The level of insulin secretagogues also should be checked to find out the cause of hypoglycemia. If it is not possible to collect blood at the time of hypoglycemic episode, it should be collected for checking blood levels of insulin, C-peptide, and ethanol, when a hypoglycemic episode would be expected like during fasting.


What is Hypoglycemia?

Hypoglycemia is blood glucose (ideally plasma glucose) level below its normal lower limit, which is generally accepted as approximately 70 mg/100 ml (3.9 mmol/Liter) of blood during fasting. So, in other word hypoglycemia is blood glucose level below 70 mg/100 ml. Hypoglycemia can be defined as “appearance of certain symptoms (headache, fatigue, confusion etc.) that disappear or are relieved promptly when blood glucose level is raised”.

Common causes of hypoglycemia:

Hypoglycemia is most commonly caused by antidiabetic medications (medicines used for treatment of diabetes), consumption of large quantity of alcohol and some other drugs. The antidiabetic medications that commonly cause hypoglycemia are insulin (especially if high dose is used), sulfonylureas (like glimepiride, glipizide, gliclazide, glibenclamide etc.) and other oral hypoglycemic drugs. Drugs that can sometimes cause hypoglycemia are quinine, pentamidine, sulfonamides etc.

Other than drugs certain other diseases like insulinoma, non-β-cell tumors, and organ failure, gastric surgery (may be immediately after surgery or even many years later hypoglycemia may develop), certain hormone deficiencies, certain inherited metabolic disorders, severe sepsis etc. can also cause hypoglycemia.

Clinical manifestations of hypoglycemia:

Hypoglycemia cause two types of symptoms neuroglycopenic symptoms and neurogenic (can also be called autonomic) symptoms of hypoglycemia. Neuroglycopenic symptoms of hypoglycemia are generally due to direct lack of glucose in CNS (central nervous system) and include symptoms like confusion, fatigue, behavioral changes etc. and in severe cases seizure, loss of consciousness and in extreme cases death can occur, especially if hypoglycemia is very severe and prolonged and without any proper treatment. Neurogenic symptoms of hypoglycemia are due to physiologic changes but mediated by CNS and include palpitations, tremor, anxiety etc. Sweating, hunger, and paresthesia are cholinergic symptoms of hypoglycemia, but they are also included in neurogenic symptoms of hypoglycemia. All these are non specific symptoms and occur in other diseases also.

The clinical signs (sign is what physician elicit after examining a patient) of hypoglycemia are pallor (paleness of skin), raised heart rate, increased blood pressure and diaphoresis.

Diabetes: the Silent Killer

Diabetes mellitus or simply known as DM refers to a group of common metabolic disorders that have a common presentation of hyperglycemia or high blood sugar level. There are several distinct types of diabetes mellitus that are caused by complex interaction between genetical and environmental factors. Some of the factors which can cause hyperglycemia are reduced insulin secretion (due to destruction of insulin producing cells in pancreas), insulin resistance, decreased glucose utilization, and increased glucose production.

It is estimated that in the year 2000 there were more than 175 million individuals with diabetes worldwide a significant rise of total number of approximately 30 millions in 1985. And it is estimated by using present trend of diabetes worldwide that by 2030 there will be more than 350 diabetes patients in the world and India will be leading in the total number of diabetes cases in the world (some people use the word “diabetes capital of the world”).

Diabetes can affect practically all the systems in our body as well as increase the risk of infection and delay healing/recovery after infection/injury. Diabetes commonly affects eyes (diabetic retinopathy is one of the leading cause of blindness throughout the world), kidneys, central nervous system, gastrointestinal and genitourinary system, cardiovascular system, lower extremities. All the systems are affected slowly and if the diabetic individual ignores (or in many cases complications of diabetes appear before diabetes is diagnosed and treatment commenced) the seriousness of the problem of diabetes, as it does not usually cause acute symptoms, it can slowly but steadily lead towards death of the diabetes patients without the patient realizing the outcome. That is the reason diabetes can be called a silent killer.

To prevent or delay the complications of diabetes and delay the fatal outcome of diabetes the most important is control of blood sugar level within normal limit 24 hours a day and to achieve the normal level of diabetes it is very important to follow the instructions and advice of treating physician or diabetologist properly. With the number of drugs available at present to treat diabetes, it is not difficult to maintain blood glucose level within normal limit and prevent/delay complications (both acute and chronic complication).

Prevent Exercise Problems in Diabetics

There may be high blood sugar or low blood sugar during and after exercise by diabetic patient, especially in type 1 diabetes. In patients with type 2 diabetes, exercise-related hypoglycemia is less common but can occur in individuals taking insulin.

A good diabetes and diabetic diet plan can help to reduce exercise related problem in diabetics. To prevent and avoid exercise-related hyperglycemia or hypoglycemia the following preventive precautions should be taken by the diabetic patients, especially by type1 diabetics while preparing for exercise:

  1. Blood glucose should be monitored before, during, and after exercise and continue with exercise if blog glucose is within normal limit.
  2. If the blood glucose is less than 100 mg per 100 ml of blood (5.6 mmol/liter), take carbohydrate (glucose, sucrose or other carbohydrates) before exercising.
  3. Delay exercise if blood glucose is more than 250 mg per 100 ml of blood (14 mmol/liter) and ketones are present.
  4. Reduce the doses of insulin, which should be based on previous experience, before exercise. The insulin should be injected into a non-exercising area like abdominal fat.
  5. Every diabetic patient will have different exercise tolerance and should learn to adjust the requirement of glucose and insulin.

The asymptomatic cardiovascular disease generally appears at a younger age in type 1 as well as type 2 diabetes, there should be exercise tolerance testing for every patient with diabetes (both type 1 and type 2diabetes). Diabetic diet weight loss plan can help in delaying cardiovascular disease risk to a great extent.This exercise tolerance testing should be done with any of the following:

  1. If the age of diabetic more than 35 years.
  2. The duration of diabetes more than 15 years for type 1 diabetes and more than 10 years for type 2 diabetes.
  3. Presence of micro vascular complications of diabetes like retinopathy, microalbuminuria, or nephropathy.
  4. PAD (peripheral artery disease)
  5. Other risk factors of coronary artery disease (CAD), or autonomic neuropathy.

N.B.: Untreated proliferative retinopathy is a relative contraindication to vigorous exercise, as this may lead to hemorrhage inside the eye or retinal detachment.

Importance of Exercise in Diabetes

For proper management of diabetes educating the patient about the disease (diabetes) is very important. The importance of patient education and proper understanding of the disease by the patient is essential part of management of diabetes. Understanding the diabetes and taking right steps is very important for long term management of diabetes. In the patient education the most important aspects are about the role of exercise and nutrition is very important, as well as little bit of understanding the disease itself and the mechanism of the development of the disease.

Role of exercise in diabetes management:

Exercise, especially regular aerobic exercise plays an important role in long term and proper management of diabetes. Exercise has multiple positive benefits in diabetes including reduction in risk of cardiovascular diseases or complications, in reducing blood pressure, maintenance of muscle mass, reduction in body fat, as well as weight loss.

Exercise also reduces blood sugar level (during and following exercise) in patients with type 1 or type 2 diabetes and in increasing insulin sensitivity. The ADA (American Diabetic Association) recommends 150 minute per week (which should be distributed over at least 3 days) of aerobic physical exercise. If patient is having type 2 diabetes, the exercise regimen should also include resistance training.

Caution during exercise:

Although there are several benefits of exercise, there may be problem of high or low plasma glucose (normally, insulin falls and glucagon rises during exercise) level during and after exercise, especially in type1 diabetes. This exercise induced hyperglycemia or hypoglycemia, depends on the pre-exercise plasma glucose, the circulating insulin level, and the level of exercise-induced catecholamines (mainly adrenalin and nor adrenalin). These are due to increased muscle activity during vigorous, aerobic exercise which greatly increases fuel requirements.

N.B.: If the circulating insulin level is excessive, this (relative hyper-insulinemia) may reduce glucose production in liver by decreased breakdown of glycogen to glucose, by decreased gluconeogenesis (production of glucose from non carbohydrate sources in liver) and by increased glucose entry into muscle, which may lead to hypoglycemia. Conversely if the insulin level is too low, there will be rise in catecholamines, which may increase the plasma glucose excessively, promote ketone body formation, and can lead to ketoacidosis.

Skin Manifestations of Diabetes

The commonest skin manifestation of diabetes mellitus is prolonged (protracted) wound healing time and skin ulcerations. The wound healing in diabetes is prolonged than usual is because of the high blood sugar level and also due to lower cell mediated immunity which makes it difficult for the body to fight organisms that may be present in the wound. Skin manifestations of diabetes, sometimes termed as “diabetic skin spots,” which begins as an erythematous area and evolves into an area of circular hyper pigmentation.

These lesions (diabetic skin spots) result from minor mechanical trauma in the pretibial (in the shin bone area) region and they are more common in elderly men with diabetes. Sometimes bullous diseases known as bullosa diabeticorum (shallow ulcerations or erosions in the pretibial region), are also seen.

Vitiligo also occur more frequency in patients with type 1 diabetes. Acanthosis nigricans which is hyper pigmented velvety plaques seen on the neck, axilla, or extensor surfaces of arms is sometimes a feature of severe insulin resistance and accompanying diabetes (type-1 diabetes). Generalized or localized erythematous plaques on the extremities or trunk and scleredema (areas of skin thickening on the back or neck at the site of previous superficial infections) are more common in the patients with diabetes. Lipoatrophy and lipohypertrophy can occur at insulin injection sites but are unusual with the use of human insulin. Xerosis and pruritus (itching) are common and both of these problems are relieved by skin moisturizers.

A rare skin manifestation of diabetes known as ‘Necrobiosis lipoidica diabeticorum’ is a rare disorder of diabetes generally predominantly affects young women with type 1 diabetes, neuropathy, and retinopathy. ‘Necrobiosis lipoidica diabeticorum’ usually begins in the shin bone area as an erythematous plaque or papules and gradually enlarges, darkened, and develop irregular margins, with atrophic centers and central ulceration. These lesions may be painful.

Infection in Diabetes Patients

Patients with diabetes have a greater frequency as well as greater severity of infection. The reasons for this greater frequency and severity of infection include abnormalities in cell-mediated immunity (although incompletely defined) and phagocyte function associated with hyperglycemia (high blood sugar level), as well as diminished vascularization. High blood sugar also aid colonization and growth of a variety of organisms (Candida and other fungal species are more common), by providing them with readily available food source.

Common infections are more frequent and severe in the diabetic patients. There are many rare infections seen almost exclusively in the diabetic patents. Examples of this (rare infections which are exclusive to diabetic patients) include rhinocerebral mucormycosis, emphysematous infections of the gall bladder and urinary tract, and “malignant” or invasive otitis externa. Invasive otitis externa (external ear) is generally secondary to Pseudomonus aeruginosa infection in the soft tissue surrounding the external auditory canal. This usually begins with pain and discharge, and which may rapidly progress to osteomyelitis and meningitis (both are very serious infection of bones and brain respectively). These infections should be investigated, in patients presenting with hypertropic hyperosmolar state of diabetes complication.

Pneumonia, urinary tract infections, and skin and soft tissue infections are more common in the diabetic patients. Urinary tract infections (UTI), either lower urinary tract or pyelonephritis, are generally the result of common bacterial agents such as Escherichia coli. But sometimes several yeast species (Candida and Torulopsis glabrata) may also cause UTI.

Complications of urinary tract infections are pyelonephritis and cystitis, both of which are emphysematous. Bacteriuria (bacteria in urine) occurs frequently in individuals with diabetic cystopathy. Susceptibility to furunculosis, superficial candidal infections, and vulvovaginitis are more in diabetes patients. Poor glycemic control is a common cause in individuals with these infections. Diabetic individuals have an increased rate of colonization of S. aureus in the skin folds. Diabetic patients also have a higher risk of postoperative wound infections. Strict glycemic control reduces postoperative infections in diabetic individuals undergoing coronary artery bypass grafting (CABG) and should be the goal in all diabetic patients with an infection.

Generally the organisms that cause pulmonary infections are similar to those found in the non-diabetic population.