Hypoglycemia in Type 2 Diabetes

1. Hypoglycemia symptoms are common in type 2 diabetes (38% of patients in one study)
2. Associated with:

• Increased morbidity and mortality
• Reduced quality of life
• Reduced treatment satisfaction
• Increased barriers to adherence
• More common at A1C < 7%

When Does Non-Severe Hypoglycemia Occur with Diabetes?

1/5 of all non-severe hypoglycemia occurs nocturnally

Symptoms of Hypoglycemia

1. Focal

• Blurred or double vision
• Slurred speech
• Paresthesias
• Tinnitus
• Hemiplegia

1. Neuroglycopenic Symptoms

Difficulty thinking	Confusion
Poor coordination	Headache
Hunger*	Weakness*
Dizziness	Faintness
Drowsiness	Irritability
Nightmares	Abnormal or belligerent behavior
Somnolence	Seizures
Coma

*These symptoms are sometimes classified as autonomic

Thresholds in Response to Hypoglycemia in Normal Subjects

Plasma Glucose	Clinical Response
<60	diaphoresis, anxiety, palpitations, hunger, tremor
<55	early cognitive dysfunction
<50	lethargy and obtundation
<30	coma
<20	convulsions, death

Plasma Glucose	Hormonal Response
<80	insulin secretion suppressed
<70	glucagon and epinephrine increased
<60	growth hormone and cortisol increased

Impaired Counterregulation in Type 1 Diabetes

• Deficient glucagon response to hypoglycemia
• Deficient epinephrine response to hypoglycemia (“HYPOGLYCEMIC UNAWARENESS”)
• Patients with diminished glucagon and epinephrine response have a 25 fold increase in the frequency of severe hypoglycemia
• Sleep further impairs epinephrine response to hypoglycemia

Potential Complications of Hypoglycemia

Central Nervous System

• Cognitive Dysfunction
• Intellectual Decline
• Coma
• Brain Damage
• Seizure
• Focal Neurological Lesions (Rare)
• TIA, Stroke

Heart

• Cardiac arrhythmias
• Myocardial ischemia

Eye

• Vitreous Hemorrhage
• Worsening of retinopathy?

Other

• Falls
• Accidents with injury