11 Prebreakfast hyperglycemia: Classification by blood glucose and insulin levels in Objective-C

Making QR-Code in Objective-C 11 Prebreakfast hyperglycemia: Classification by blood glucose and insulin levels

Table 27 11 Prebreakfast hyperglycemia: Classification by blood glucose and insulin levels
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Blood Glucose (mg/dL) 10:00 PM Somogyi effect Dawn phenomenon Waning of insulin dose plus dawn phenomenon Waning of insulin dose plus dawn phenomenon plus Somogyi effect 90 110 110 110 3:00 AM 40 110 190 40 7:00 AM 200 150 220 380 Free Immunoreactive Insulin (microunit/mL) 10:00 PM High Normal Normal High 3:00 AM Slightly high Normal Low Normal 7:00 AM Normal Normal Low Low
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levels than human NPH and may be effective in managing refractory prebreakfast hyperglycemia If this fails, insulin pump therapy may be required When the dawn phenomenon alone is present, the dosage of intermediate insulin can be divided between dinnertime and bedtime; when insulin pumps are used, the basal infusion rate can be increased (eg, from 08 unit/h to 09 unit/h from 6 AM until breakfast)
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Acceptable Levels of Glycemic Control
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A reasonable aim of therapy is to approach normal glycemic excursions without provoking severe or frequent hypoglycemia What has been considered acceptable control includes blood glucose levels of 90 130 mg/dL before meals and after an overnight fast, and levels no higher than 180 mg/dL 1 hour after meals and 150 mg/dL 2 hours after meals Glycohemoglobin levels should be no higher than 1% above the upper limit of the normal range for any particular laboratory It should be emphasized that the value of blood pressure control was as great as or greater than glycemic control in type 2 patients as regards microvascular as well as macrovascular complications
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Complications of Insulin Therapy
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A Hypoglycemia
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When the blood glucose falls around 54 mg/dL, the patient starts to experience both sympathetic (tachycardia, palpitations, sweating, tremulousness) and parasympathetic (nausea, hunger) nervous system symptoms If these autonomic symptoms are ignored and the glucose levels fall further (around 50 mg/dL), then neuroglycopenic symptoms appear, including irritability, confusion, blurred vision, tiredness, headache, and difficulty speaking A further decline in glucose can then lead to loss of consciousness or even a seizure With repeated episodes of hypoglycemia, there is adaptation, and autonomic symptoms do not occur until the blood glucose levels are much lower and so the first symptoms are often due to neuroglycopenia This condition is referred to as hypoglycemic unawareness It has been shown that hypoglycemic unawareness can be reversed by keeping glucose levels high for a period of several weeks Except for sweating, most of the sympathetic symptoms of hypoglycemia are blunted in patients receiving -blocking agents for angina pectoris or hypertension Though not absolutely contraindicated, these drugs must be used with caution in insulin-requiring diabetics, and 1-selective blocking agents are preferred Hypoglycemia in insulin-treated patients with diabetes occurs as a consequence of three factors: behavioral issues, impaired counterregulatory systems, and complications of diabetes Behavioral issues include injecting too much insulin for the amount of carbohydrates ingested Drinking alcohol in excess, especially on an empty stomach, can also cause hypoglycemia In patients with type 1 diabetes, hypoglycemia can occur during or even several hours after exercise, and so glucose levels need to be monitored and food and insulin adjusted Some patients do not like their glucose levels to be high, and they treat every high glucose level aggressively These individuals who stack their insulin that is, give another dose of insulin before the first injection has had its full action can develop hypoglycemia
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Counterregulatory issues resulting in hypoglycemia include impaired glucagon response, sympatho-adrenal responses, and cortisol deficiency Patients with diabetes of greater than 5 years duration lose their glucagon response to hypoglycemia As a result, they are at a significant disadvantage in protecting themselves against falling glucose levels Once the glucagon response is lost, their sympatho-adrenal responses take on added importance Unfortunately, aging, autonomic neuropathy, or hypoglycemic unawareness due to repeated low glucose levels further blunts the sympathoadrenal responses Occasionally, Addison's disease develops in persons with type 1 diabetes mellitus; when this happens, insulin requirements fall significantly, and unless insulin dose is reduced, recurrent hypoglycemia will develop Complications of diabetes that increase the risk for hypoglycemia include autonomic neuropathy, gastroparesis, and renal failure The sympathetic nervous system is an important system alerting the individual that the glucose level is falling by causing symptoms of tachycardia, palpitations, sweating, and tremulousness Failure of the sympatho-adrenal responses increases the risk of hypoglycemia In addition, in patients with gastroparesis, if insulin is given before a meal, the peak of insulin action may occur before the food is absorbed causing the glucose levels to fall Finally, in renal failure, hypoglycemia can occur presumably because of decreased insulin clearance as well as loss of renal contribution to gluconeogenesis in the postabsorptive state To prevent and treat insulin-induced hypoglycemia, the diabetic patient should carry glucose tablets or juice at all times For most episodes, ingestion of 15 grams of carbohydrate is sufficient to reverse the hypoglycemia The patient should be instructed to check the blood glucose in 15 minutes and treat again if the glucose level is still low A parenteral glucagon emergency kit (1 mg) should be provided to every diabetic receiving insulin therapy, and family or friends should be instructed how to inject it intramuscularly in the event that the patient is unconscious or refuses food Every diabetic person receiving hypoglycemic drug therapy should wear an identification MedicAlert bracelet or necklace or carry a card in his or her wallet The telephone number for the MedicAlert Foundation International in Turlock, California, is 1-800-IDALERT and the Internet address is wwwmedicalertorg If more severe hypoglycemia has produced unconsciousness or stupor, the treatment is 50 mL of 50% glucose solution by rapid intravenous infusion If intravenous therapy is not available, 1 mg of glucagon injected intramuscularly will usually restore the patient to consciousness within 15 minutes to permit ingestion of sugar If the patient is stuporous and glucagon is not available, small amounts of honey or syrup or glucose gel (15 g) can be inserted within the buccal pouch, but, in general, oral feeding is contraindicated in unconscious patients Rectal administration of syrup or honey (30 mL per 500 mL of warm water) has been effective
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