Home Cure for Hypoglycemia
Alcoholics are very susceptible to hypoglycemia. In addition to poor nutrition and the feet that alcohol is metabolized to acetate (acetyl CoA), the high amounts of cytoplasmic NADH formed by alcohol dehydrogenase and acetaldehyde dehydrogenase interfere with gluconeogenesis. High NADH favors the formation of
Complications are conditions that arise as a result of having diabetes. Some are short term, for example hypoglycaemia (low blood glucose), hyperglycaemia (high blood glucose) and ketoacidosis (very high blood glucose). Others are more long term and develop gradually over time and include heart disease, high blood pressure, damage to the kidneys, and eye and nerve damage.
Hypoglycaemia means low blood glucose, and in a person who does not have diabetes, the levels never fall much below 3.5 mmol l. This is because an individual's natural control system will sense the drop, and correct the situation by stopping insulin secretion and releasing other hormones such as glucagons, which boost blood glucose. The individual will also start to feel hungry and so do the right thing by eating, which raises the person's blood glucose.
Prevention is the key to dealing with hypoglycaemia. To keep your blood sugar from falling too low, eat your meals at around the same times each day - never skip meals. Recognise that hunger may be a sign that your blood sugar level is too low, and that you need to take steps to bring it back up to within a normal range. Also, make sure you take your medication as directed, in the correct dosage and at the proper times. Be vigilant about monitoring your blood sugar levels. In this way you will be able to detect low blood sugar, even if you are not experiencing any overt symptoms.
It has become increasingly clear for some years that people who have had diabetes for a very long time become less able to predict when they are about to have a hypo. The warning signs seem to become less noticeable after they have been on insulin for about 15 to20 years. Although no one knows quite why this should be so, it is true that the ability of the pancreas to release glucagons in response to low blood glucose diminishes over time. Some people say their symptoms change, while others say they come on so much faster that they do not have time to take corrective action. The problem is also more common in people whose average blood glucose levels are on the low side of normal. Sometimes, adjusting the treatment so as to allow the blood glucose level to rise slightly may mean that the person gets his or her old pattern of symptoms back, but any change of this kind must be discussed carefully with the diabetes care team.
Other types of activity include biking and stationary cycling, aerobic water exercises, and swimming, in addition to walking at a moderate pace (3-5 mph). Diabetic patients should always be encouraged to carry identification and to monitor blood glucose levels before and after exercise. In addition to constantly being aware of the signs and symptoms of hypoglycemia during subsequent workouts, diabetic patients should carry appropriate, readily available carbohydrate sources to treat hypoglycemia.
Metformin and sulfonylurea combination drugs should be given with meals, splitting the dose equally between breakfast and dinner. Caution should be exercised in treating patients with lower plasma glucoses or fasting glucoses less than 150 mg dL because of the increased risk of hypoglycemia. It is always preferable to start with a lower dose of the sulfonylurea in these combination products, because of the profound effect of the combination of sulfonylurea and metformin on glucose lowering. Metformin sulfonylurea combination products enhance patient compliance by providing two agents acting synergistically in one pill, but raise the added caution of increased potency and the potential for hypoglycemia or hypoglycemic reactions (5).
Risk of hypoglycemia is increased with the metformin repaglinide combination compared with either agent alone. Repaglinide is not indicated for combination use with any sulfonylurea and should be avoided in the elderly, debilitated, or malnourished patients, or in patients with adrenal or pulmonary insufficiency. Repaglinide should not be used in patients with severe liver disease and should be used only with caution in patients with impaired hepatic function.
Mice homozygous for the targeted deletion of the c ebpa gene died within 8 hours after birth due to hypoglycemia (Flodby et al., 1996 Wang et al., 1995). These mutant mice lack hepatic glycogen storage. C ebpa null mice also showed defects in the control of hepatic growth and lung development (Flodby et al., 1996). Specifically, the amount of c-myc, c-jun, -actin mRNA and proliferating cell nuclear antigen cyclin protein in the liver of mutant mice were increased, suggesting an active proliferative state of the liver. This demonstrates the importance of C EBPa in control of cell proliferation, which was
Duration of action (4-5 hours) than human regular insulin (6-10 hours) when given subcutaneously, causing less hypoglycemia and better postprandial glucose control with lower postprandial glycemic excursions. These analog insulins are ideal add-ons for regimens that include long-acting and intermediate-acting insulins or for patients maximized on oral therapy who need coverage for intermediate postprandial hyperglycemia caused by stress, variations in diet, or medication adjustments (23). 2. Increased risk of hypoglycemia if the patient finds the meal unpalatable or is unable to eat for any reason.
The management of individuals with diabetes relies heavily on dietary control along with hypoglycemic agents and insulin. The goals of therapy are the optimization of blood glucose control and minimization of the risk of hypoglycemia in individuals treated with insulin, and the prevention or delay of the onset of chronic complications for all diabetics. Clinical trials have demonstrated the benefit of aggressive treatment to achieve glycemic control in delaying complications.89 Although the evidence is not strong, vegetarians may have lower rates of type 2 diabetes.96 There have been a number of large cohort studies that show an inverse association between incidence of diabetes and intakes of cereal grains and dietary fiber.97-99 High risk of diabetes was associated with a large glycemic index of foods consumed by participants.97 The glycemic index is an indicator of carbohydrates' ability to raise blood glucose levels. These relationships are physiologically substantiated by the...
Type II Diabetes Mellitus (Maturity-Onset Diabetes). Maturity-onset diabetes mellitus results from an individual's reduced sensitivity to the effects produced by insulin. Maturity-onset diabetes is characterized by the slow onset of symptoms and signs associated with diabetes. Maturity-onset diabetes can often be controlled by requiring the patient to follow a strict diet plan. Oral hypoglycemic agents are also used in the treatment of this condition.
Shoot, leaf Has hypoglycemic activity Farnsworth, 1995) Aerial parts Five glycans, trichosans A, B, C, D, and E show hypoglycemic activity (Hikino et al., 1989) Root, stem, Extracts have hypoglycemic bark, leaf activity (Marles and Farnsworth, 1995) Seed Extracts have hypoglycemic
Patients with shigellosis should be fed to the extent they are willing to eat (breast milk or solid foods, depending on age) to prevent acute hypoglycemia as well to militate against the development or aggravation of malnutrition. Feeding may be limited because of diminished appetite, at least until the infection is controlled with antimicrobial therapy.73
The answer is a. (Tierney, 39 e, pp 1152-1157.) Hyperosmolar hyperglycemic nonketotic state (HHNKS) is seen in patients with NIDDM and is usually precipitated by an illness. The patient's residual insulin prevents lipolysis and ketogenesis. Diabetic ketoacidosis (DKA) is due to an absolute deficiency of insulin relative to the counter-regulatory hormones. The result is gluconeogenesis, ketogenesis, lipolysis, and decreased glucose uptake causing hyperglycemia and a metabolic acidosis. Kussmaul respiration is a respiration pattern of increased tidal volume seen in patients with metabolic acidosis (i.e., DKA). Gestational diabetes occurs in 3 of pregnancies all women should be screened between the 24th and 28th wk of pregnancy. Complications of undiagnosed gestational diabetes include macrosomia and neonatal hypoglycemia. Impaired glucose tolerance is defined as a 2-h plasma glucose of 140-200 mg dL after a glucose load of 75 g in a patient whose fasting blood glucose is normal....
A child presents with low blood glucose (hypoglycemia), enlarged liver (hepatomegaly), and excess fat deposition in the cheeks (cherubic facies). A liver biopsy reveals excess glycogen in hepatocytes. Deficiency of which of the following enzymes might explain this phenotype
Monitoring of blood glucose levels by the patient and the healthcare provider is a cornerstone of diabetes care. With the development of home blood glucose meters, the management of diabetes has changed dramatically. Based on findings from the DCCT, SMBG is recommended for individuals with diabetes to facilitate reaching goals for blood glucose levels.28 The optimal frequency of blood glucose monitoring in type 2 diabetes is not known, and the role of monitoring in diet-controlled type 2 diabetes is not known. SMBG is recommended for all insulin-treated patients with diabetes, and the frequency of monitoring should be increased when adding or modifying any diabetes therapy, with insulin or oral hypoglycemic agents. Patients need instruction in SMBG, including Initiation of sulfonylurea therapy should be considered if a patient has failed to achieve adequate blood glucose control with diet and exercise. Recommended doses and frequency of dosing vary by specific drug, but for many of...
Insulin, associated with well-fed, absorptive metabolism, and glucagon, associated with fasting and post absorptive metabolism, usually oppose each other with respect to pathways of energy metabolism. Glucagon works through the cAMP system to activate protein kinase A favoring phosphorylation of rate-limiting enzymes, whereas insulin often activates protein phosphatases that dephosphorylate many of the same enzymes. An example of this opposition in glycogen metabolism is shown in Figure 1-9-5. Glucagon promotes phosphorylation of both rate-limiting enzymes (glycogen phosphorylase for glycogenosis and glycogen synthase for glycogen synthesis). The result is twofold in that synthesis slows and degradation increases, but both effects contribute to the same physiologic outcome, release of glucose from the liver during hypoglycemia. Insulin reverses this pattern, promoting glucose storage after a meal.
Reduces blood glucose (Ivorra et al., 1989) Used to treat diabetes (Lust, 1986) Reduces blood glucose level in blood of alloxan-treated rats (Lemus et al., 1999) Contains triterpenes with hypoglycemic activity (Reher et al., 1991) Contains triterpenes with hypoglycemic activity (Reher et al., 1991) Reduces blood glucose (Handa et al., 1989) Extracts reduce blood glucose, cholesterol and triglycerides in patients with type 2 diabetes that did not respond to conventional treatments (Herrera-Arellano et al., 2004) Used to treat diabetes (Winkelman, Extracts inhibit a-glucosidase (Onal et al., 2005) Extracts have hypoglycemic activity (Marles and Farnsworth, 1995) Precatorine shown to have hypoglycemic activity (Marles and Farnsworth, 1995) Reduces glucose levels (Handa et al., 1989) Used to treat diabetes (Marles and Farnsworth, 1995) Extracts reported to have hypoglycemic activity (Singh et al., 1976) Used to treat diabetes (Marles and Farnsworth, 1995) Reduces glucose levels (Handa et...
The key thing to remember here is that acetyl-CoA carboxylase catalyzes the first and rate-limiting step of fatty acid synthesis. If you got that far, you could have figured out which of die choices would inhibit the synthesis of fatty acids. Certainly glucagon, a catabolic hormone released in response to low blood glucose, would be a likely candidate to inhibit the synthesis of fatty acids. In fact, glucagon inhibits fatty acid synthesis by a cAMP-dependent phosphorylation of acetyl-CoA carboxylase. Conversely, glucagon stimulates fatty acid oxidation. 15. The correct answer is D. Galactosemia occurs in two very different clinical forms. Deficiency of galactokinase produces very mild disease the only significant complication is cataract formation. In contrast, homozygous deficiency of galactose-l-phosphate uridyitransferase produces severe disease, culminating in death in infancy. In addition to galactosemia and galactosuria, these patients have impaired...
The cause of death was thought to be shock secondary to severe hypoxia and clonic seizures. Intraperitoneal injection in rats of 5 ml kg of neem seed oil produced a similar result, with the additional findings of reduced blood glucose, raised AST and ALT (alanine transaminase) levels, fatty infiltration of the liver, and mitochondrial degeneration on electron microscopy (Sinniah et al., 1985). Orally administered neem seed oil also produces hypoglycemia in rats and rabbits (Dixit et al., 1986 Pillai and Santhakumari, 1981). Interestingly, a similar clinical picture has been observed in human infants treated with neem seed oil. Sinniah and Baskaran (1981) report a series of 13 babies ages 21 days to 2 years who had been given 5 to 30 ml of neem seed oil by their parents as a treatment for minor illnesses, such as vomiting, fever, or upper respiratory tract infections. Within V2 to 4V2 hours, the children developed drowsiness, tachypnea, and metabolic acidosis,...
As stated, Toxoplasma free-GPIs elucidate strong and early immunogenic responses during host infection. Data from other protozoa suggest that other functions of GPIs in host immune response are possible. In Plasmodium falciparum, the GPI moiety, free or associated with protein, induces tumor necrosis factor and interleukin-1 production by macrophages, and regulates metabolism in adipocytes (Schofield and Hackett, 1993). Deacylation with specific phospholipases abolishes cytokine induction. When administered to mice in vivo the malaria parasite GPI induces cytokine release, a transient pyrexia and hypo-glycemia, and profound and lethal cachexia, in the presence of sensitizing agents. The data suggest that the GPI of Plasmodium is a potent glycolipid toxin that may be responsible for a novel pathogenic process. It has been further demonstrated that Plasmodium GPI directly and specifically increases cell adhesion molecule expression in HUVECs, and parasite cytoadherence (Schofield et...
Infants of diabetic mothers look a lot alike. Most have a ruddy, plethoric complexion and tend to be large for gestational age, which can lead to birth trauma. Jitters, tremors, and excitability result from hypoglycemia. Associated hypocalcemia and Hypomagnesemia also occur. Because insulin can block surfactant production, IDM are more prone to respiratory distress syndrome. Hypertrophic cardiomyopathy is also common, as are hyperbilirubinemia and polycythemia. IDM are also at higher risk for congenital anomalies, including cardiac defects (ventricular septal defects, atrial septal defects, transposition), lumbosacral agenesis, and small (lazy) left colon. Treatment. Therapy begins in utero, by controlling the mother's blood glucose and close follow-up. After birth, infant blood sugars are monitored closely, and hypoglycemia is treated aggressively.
According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (47), P-1 selective agents are beneficial as part of multidrug therapy in diabetic patients, being especially helpful in hypertensive diabetic patients with ischemic heart disease with recurrent myocardial infarction being significantly reduced in the P-blocker-treated population. In the Metoprolol CR Randomised Intervention Trial in Congestive Heart Failure (48) diabetic patient subpopulation, death plus hospitalization as a result of heart failure was reduced by 29 in the first year, with less hypoglycemia than the nonselective P-blockers.
Glucose in cerebrospinal fluid is decreased in the presence of bacteria, fungi, protozoa, or tubercle bacilli. Specific diseases associated with the presence of these microorganisms are acute bacterial meningitis and tuberculous, fungal, and amebic meningitis. Other diseases found with decreased CSF glucose levels are neoplasms, hypoglycemia, and meningeal metastasis of lymphomas, and leukemias. Spinal cord tumors and insulin shock are also associated with decreased cerebrospinal fluid glucose. Glucose levels are elevated in diabetic coma.
Hypoglycemic conditions caused by fasting, caffeine, and body movements can modify brain wave patterns. Oil, dirt, and hair preparations such as hairspray can interfere with electrode placement and contact, and thereby interfere with the recording process. Sedatives, anticonvulsants, and alcohol affect test results.
The glucose tolerance test is a timed test of the glucose concentration in both the blood and urine. This test is used to confirm or rule out diabetes and is a definitive test for diagnosing hypoglycemia. After fasting overnight, the client is given a concentrated amount of glucose dissolved in a flavored, water-based drink. Blood and urine samples are collected over a three- to four-hour period. Variations from Normal. Individuals who are diabetic or hypoglycemic will not be able to tolerate the glucose load administered during the glucose tolerance test. Diabetic clients will exhibit increased glucose levels that exceed 190 mg dl at one hour 165 mg dl at two hours or 145 mg dl at three hours. Different types of diabetes can be identified by the glucose elevation at specific time intervals. The hypoglycemic individual will also have trouble handling the glucose load administered during the glucose tolerance test. The glucose load will trigger high insulin levels, which will in turn...
Glucose, a simple sugar, is the main blood carbohydrate and a major source of energy for all cells. The fasting blood sugar (FBS), postprandial blood sugar (PPBS), and the glucose tolerance test (GTT), or standard oral glucose tolerance test (SOGTT), are three of the most frequently performed blood sugar tests and are used to determine the level of glucose in the blood. Variations in blood glucose levels are broadly categorized as hyperglycemia, or increased blood sugar levels, and hypoglycemia, or decreased blood sugar levels. Glucose tolerance test (GTT) Rule out diabetes confirm hypoglycemia Hypoglycemia, a decrease in blood glucose, is often caused by an overdose of insulin or skipping meals. Other causes of hypoglycemia include pancreatic islet cell malignancy, severe liver damage, hypothyroidism, Cortisol deficiency, and pituitary hormone deficiency.
Overproduction or increased levels of growth hormone can lead to gigantism in children or acromegaly in adults. Gigantism, characterized by abnormally large body proportions and abnormal sexual development, is usually attributed to hypersecretion of growth hormone during childhood. Acromegaly, characterized by enlargement, thickening, and elongation of facial and extremity bones, is the result of hypersecretion of growth hormone in adults. Increased growth hormone levels are also associated with hypoglycemia and anorexia nervosa. Interfering Circumstances. Stress, exercise, and low blood glucose levels may cause increased growth hormone levels. Many drugs such as amphetamines, estrogens, glucagon, histamine, and insulin may also increase GH levels. Decreased levels are seen in obese patients and individuals who use corticosteroid medications.
Coronary artery disease, myeloma, hypoglycemia Increases in coagulation factors rarely occur. Elevated Factor VIII (antihemophilic factor) plasma levels are associated with coronary artery disease, hyperthyroidism, hypoglycemia, and Cushing's syndrome. In addition to these disease processes, an increase in Factor VIII is seen in normal pregnancies and postoperative period. In all of these situations, there is a tendency toward clot formation.
Breakdown of fat and muscle build up in the blood and lead to the production of substances called ketones. If nothing is done to stop this, the level will rise until eventually it causes the person to go into what's known as a ketoacidotic coma. This is much less common these days as diabetes is usually diagnosed long before coma develops. However, when it occurs patients need urgent hospital treatment with insulin and fluids into a vein. This is not the same thing as a coma induced by low blood sugar (or hypoglycaemia) - see page 12.
Treatment of hypoglycemia is best accomplished with oral glucose or glucose-containing food. The addition of fat retards the absorption of the glucose and should be avoided. Adding protein to the treatment does not affect the glycemic response, nor does it prevent subsequent hypoglycemia. Ten grams of oral glucose will raise blood sugar levels by about 40 mg dl over 30 minutes, and 20 g will raise blood sugar levels by about 60 mg dl over 45 minutes.15
A major vascular procedure will normally last between 2 and 3 h, but can be prolonged if complications occur. This can result in metabolic disturbances (low sodium and low blood sugar) and hypothermia. Patients may require a period of ventilation in CCU for these abnormalities to be corrected. Pressure
Continuous subcutaneous insulin infusion via the external insulin infusion pump is an alternative to multiple daily injections for patients with labile glucose levels and frequent episodes of hypoglycemia. These pumps attach to the body through flexible plastic tubing with a needle inserted subcutaneously in the abdominal area. 2. Marked variability in glucose levels with a history of hypoglycemic unawareness or hypoglycemic events requiring assistance. Use of the analog insulins has resulted in less overall insulin use in a 24-hour period, with even fewer episodes of less hypoglycemia. In the DCCT trial (11) with patients with type 1 diabetes, the incidence of severe hypoglycemia was three times greater in the group receiving intensive therapy than in the group receiving conventional therapy, but less than in the group receiving multiple-dose injections. The reduction in insulin requirements, better pharmacological delivery of insulin, and the minimal weight gain with insulin pumps...
Although undergoing some major improvements over the past several years, human insulin still has some limitations. The human insulins have variable and inconsistent absorption rates that cause erratic and unpredictable blood-glucose-lowering effects, resulting from the varying onset of actions, peak, and duration of action of these products. This is because when regular insulin is administered subcutaneously, its absorption into the circulation is slow, with a subsequent slow onset of action. Therefore, regular insulin should be administered 30-40 minutes before a meal to avoid a potential physiological mismatch, with subsequent hypoglycemia. This advance administration can become inconvenient or somewhat hazardous at times, particularly if the patient is unable to eat and has taken insulin (e.g., if the meal becomes surprisingly delayed or is not palatable to the patient). Additionally, when larger doses of regular insulin are given subcutaneously, the duration of action is...
A 26-year-old gravida 3 woman has a history of gestational diabetes and a delivery of two previous infants at term that were greater than 4000 g, each of whom had severe hypoglycemia. Which of the following maneuvers is least likely to reduce the chance of the next child's having hyperglycemia
Recent studies have found that the most important factor is getting the blood pressure controlled, and this is more important than the means. 10 Similarly, most patients will need more than one medication. Several commissions have suggested that the first-line drugs should be low-dose thiazide diuretics or beta-blockers, in the absence of other factors. Beta-blockers, especially the cardioselective types, are good medications for many individuals. Data suggest that use of beta-blockers may reduce the incidence of strokes but not total mortality.11 They are especially good choices in patients with tachycardia, anxiety, migraine headaches, and angina. They should be avoided in asthmatics, patients with bradycardia or atrioventricular blocks, and diabetic patients using insulin who may become hypoglycemic. Beta-blockers can make the individual feel slow, tired, or depressed. Their effects on women's sexual function are not known.
LESSON 10 Insulin and Oral Hypoglycemic Agents. hypoglycemia or hyperglycemia and a group of statements, select the statement that describes the cause, signs and or symptoms, or treatment for the given condition. statement that describes the mechanism of action of the oral hypoglycemics. substances, select the substance(s) likely to interact with oral hypoglycemics. 10-16. Given the trade and or generic name of an oral hypoglycemic agent and a group of uses, side effects, and cautions and warnings, select the use(s), side effect(s), or caution(s) and warning(s) associated with the given agent. 10-17. Given the trade, generic, or commonly used name of an insulin product or hypoglycemic agent and a group of trade, generic, or commonly used names of drugs, select the trade, generic, or commonly used name that corresponds to the given drug name.
Hypoglycemia and hyperglycemia are two of these potential difficulties. a. Hypoglycemia ( Low Blood Sugar ). Hypoglycemia (also known as low blood sugar or insulin reaction ) results from an overdose of insulin or an oral hypoglycemic agent, from the too frequently administered insulin, from unaccustomed exercise, or from a delayed or skimpy meal. In other words, there is insufficient glucose present in the patient's blood. In this condition the diabetic speech becomes slurred and the patient appears to be intoxicated. It is critical that this condition be properly diagnosed by medical personnel. Hypoglycemia can be quickly treated. One, the diabetic can be given a source of energy (e.g., a teaspoonful of sugar or a candy bar) by mouth. Two, medical treatment personnel can administer glucagon injection, a product that acts on liver glycogen in order to convert the glycogen to glucose.
The answer is b. (Fauci, 14 e, p 2083.) The surreptitious injection of insulin is just as common as insulinoma. Patients have low C-peptide levels with high insulin levels. Factitious disease should be suspected when hypoglycemic symptoms appear in health professionals or in relatives of patients with diabetes mellitus. Patients with insulinoma have high levels of both C-peptide and insulin. Finding high levels of circulating insulin antibodies may help to make the diagnosis of factitious hypoglycemia. 282. The answer is d. (Fauci, 14 e, p 1953. Tierney, 39 e, pp 1177-1182, 1193.) Diabetics with peripheral neuropathy are susceptible to developing a Charcot joint. The insensitivity of the feet predisposes the patient to multiple silent fractures causing a deformed joint. The Somogyi effect is nocturnal hypoglycemia, which stimulates a surge of counterregulatory hormones to produce a high fasting blood sugar in the morning. The Dawn phenomenon is morning hyperglycemia from reduced...
With aggressive glucose lowering to meet HbA1c targets and prevent vascular complications, increasing frequency and severity of hypoglycemia occur and should also be considered a diabetes complication. One option to help achieve target HbA1c with less hypoglycemia is to monitor two-hour postprandial glucose levels, with target glucose less than 180 mg dl (10.0 mmol l).
Glycogen stored in the liver is a source of glucose mobilized during hypoglycemia. Muscle glycogen is stored as an energy reserve for muscle contraction. In white (fast-twitch) muscle fibers, the glucose is converted primarily to lactate, whereas in red (slow-twitch) muscle fibers, the glucose is completely oxidized.
As we stated earlier, humans with mutations of the IR gene are profoundly growth-retarded, while mice are hardly affected. A potential explanation of this finding is that humans and mice do not follow the same developmental timing. For example, if we compare the development of eyelids in mice and humans, it is evident that mice are born at a gestational stage corresponding to about 26 wk in human fetuses (58). Likewise, if we examine body composition in newborn mice, we will find that lipid content is significantly lower in mice compared to humans (2 vs 16 , respectively) (59). There are no data on the time course of growth retardation in humans with leprechaunism, but there are some data suggesting that, in patients with pancreatic agenesis, intra-uterine growth retardation is not apparent at gestational ages of 18-20 wk (60,61). On the other hand, there is an abundant literature on excessive fetal growth caused by maternal hypergly-cemia associated with secondary fetal...
Patients with type 2 diabetes may be managed by dietary change, exercise prescription, oral drug therapy, or insulin therapy. Despite treatment, the natural history of most subjects with type 2 diabetes is that increasing amounts of oral drugs are required to produce adequate glucose concentrations. Many patients need to transfer to treatment with insulin with the inconvenience of self-injection, requirement to monitor blood glucose levels, and increased risk of hypoglycemia (e.g., 38 of patients in the intensive glucose control group of the UKPDS study eventually received insulin).46
The answer is d. (Greenfield, 2 e, pp 204-205.) Clinical manifestations of adrenocortical insufficiency include hyperkalemia, hyponatremia, hypoglycemia, fever, weight loss, and dehydration. There is excessive sodium loss in the urine, contraction of the plasma volume, and perhaps hypotension or shock. Classic hyperpigmentation is present in chronic Addison's disease only. Addison's disease may present in newborns as a congenital atrophy, as an insidious chronic state often due to tuberculosis, as an acute dysfunction secondary to trauma or adrenal hemorrhage, or as a semiacute adrenal insufficiency seen during stress or surgery. In this last instance, signs and symptoms include nausea, lassitude, vomiting, fever, progressive salt wasting, hyperkalemia, and hypoglycemia. It may be confirmed by measurements of urinary Na+ loss and absence of response to ACTH.
Therefore, isotonic fluid is usually given to these patients to establish perfusion. Dextrose-containing solutions should be given to children who are hypoglycemic. 32-agonist therapy may help children with bronchospasm. Prophylactic antibiotics are not recommended unless the child has been exposed to contaminated water. It is imperative to establish an airway and deliver oxygen to prevent further hypoxia.
They each possess fast absorption patterns, which reduce their tendency to dissociate into hexamers or dimers and they exhibit increased absorption rates. The increased absorption rates allow the insulin analogs to be given closer to mealtime and even, on occasion, shortly after eating. This makes these insulins very popular and desirable from the patient's point of view because of the relative proximity of meal consumption to use. Indeed, in head-to-head studies with human insulin, the insulin analogs produced less hypoglycemia, had better postprandial glucose levels with comparable hemoglobin A1-C control (17). A surprising benefit of glargine is an attenuation of postprandial glycemic excursions, despite its not being a bolus insulin. Patients taking glargine tend to have tighter glyce-mic control with less hypoglycemia than patients who are given NPH. Thus, glargine seems to be the ideal replacement basal insulin for regulating glucose fluctuations during...
The major difference between the premixed human insulins and the premixed analog insulins is that there is less of an incidence of hypoglycemia with the analogs, because progressively higher doses of the bolus human insulin results in prolonged duration of action of the shorter-acting insulin, which increases the risk for hypoglycemia. insulin plus two or three injections of a short-acting insulin with meals. When this regimen is used, the second dose of NPH is usually given at bedtime rather than dinner time in an attempt to decrease nocturnal hypoglycemia and to control basal hepatic gluconeogenesis and the dawn phenomenon characterized by an early morning glycemic surge (19). Less insulin is necessary to attenuate hepatic gluconeogenesis compared with the amount needed to drive insulin intracellularly.
Another interesting aspect of amylin's physiological effects is its neuroendocrine mode of action. Bilateral vagotomies have been shown to abolish the effects of amylin. Amylin has been shown to be efficacious in decreasing gastric emptying, but this effect seems to be dependent on serum glucose levels. Thus, in situations associated with hyperglycemia, amylin slows gastric emptying, whereas this effect is minimized in hypoglycemic states. Various alternatives to injectable insulin are currently being explored, including transdermal, buckle, oral, pulmonary, and nasal inhalation systems. Of these, orally inhaled forms of insulin seem to be the most promising and closest to being released for use. This is because the lungs have certain advantages for insulin delivery. The epithelium is very thin and the surface area is very large (making it attractive for drug uptake), and the inhaled insulins have comparable efficacy in type 1 and type 2 diabetes to fast-acting injectable insulin with...
The meglitinides are more properly referred to as the glinides because repaglinide and nateglinide are not members of the same chemical class. Repaglinide is a benzoic acid derivative and nateglinide is a phenylalanine derivative. The glinides specifically target postprandial hyperglycemia, and, compared with sulfonylureas, have less risk of hypoglycemia and less continuous stimulation of the P-cells. Nateglinide has the shortest duration of action of all of the insulin secretagogues and the least specific inhibition of the cardiac potassium channel. Nateglinide possesses the least risk for hypoglycemia of any of the secretagogues, along with lower insulin levels and more physiological insulin release at mealtime. When used alone, repaglinide can be as effective as the sulfonylureas in reducing hemoglobin A1-C and seems to be slightly more potent in that effect than nateglinide. Occasionally, patients can be switched from sulfonylureas to repaglinide and achieve better control. This...
A 14-year-old boy has been experiencing progressive onset of muscle fatigue and cramping. His physician finds no evidence for hypoglycemia, and fatty acids are released appropriately in response to a glucagon challenge. A muscle biopsy reveals unusual lipid-filled vacuoles in the cytoplasm of his myocytes. On analysis the vacuoles are found to contain triglyceride. The most likely cause of these symptoms is a deficiency of
Which of the following statements regarding hypo-glycemia is FALSE (A) Counterregulatory hormones are released in a hypoglycemic state (B) Hypoglycemia causes both autonomic and neu-roglycopenic symptoms (C) Hypoglycemic patients commonly present with altered levels of consciousness, lethargy, confusion, or agitation (D) Hypoglycemia is diagnosed when the blood glucose is less than 60 mg dL (E) Glucagon is ineffective in the treatment of alcohol-induced hypoglycemia 308. All of the following are important in quickly mediating and correcting states of hypoglycemia EXCEPT 309. What is the MOST common cause of hypoglycemia in patients presenting to the ED (C) Oral hypoglycemics
Of the 656 species of flowering plants identified in this study, a high proportion of the 437 genera, representing 111 families, come from the rosids and asteroids (Table 2.1 Figure 2.1). However, there are representatives with potent activity in the magnoliids and monocots (Table 2.1). Within the Ranunculales, alkaloids with potential antidiabetic activity have been isolated from the Berberidaceae, Menispermaceae, Papaveraceae, and Ranunculaceae. The best studied example is berberine from rhizomes of Coptis chinensis (Ranunculaceae). It is reported to be hypoglycemic in normal and in diabetic mice (Chen and Xie, 1986). Treating impaired glucose tolerance rats with berberine resulted in a reduction in levels of fasting blood glucose, triglycerides, and total cholesterol (Leng et al., 2004). Berberine also aided insulin secretion of HIT-TI5 cells and murine pancreatic islets in a dose-dependent manner in vitro (Leng et al., 2004). It has been shown that oral administration of berberine...
The patient carries a history of hypertension and diabetes. She is taking Lopressor 50 mg bid, and an oral hypoglycemic. There is no history of tobacco use. She has no knowledge of what her cholesterol level might be. Her father died of a stroke in his 70s, and her mother died of heart failure, also in her 70s, but she can think of no one in the family who ever had a heart attack.
Oral hypoglycemics Parathyroid agents Thyroid agents 419, A 75-year-old diabetic female on an oral hypoglycemic agent becomes light-headed and has profuse sweating. A blood glucose is below normal. Which of the following agents is responsible for these findings 424, Concern is raised in an 86-year-old male with non-insulin-dependent diabetes mellitus (N1DDM), or type II diabetes, about the possibility of hypoglycemia when considering the use of an oral hypoglycemic agent. Which of the following antidiabetic drugs is least likely to cause hypoglycemia 434, A 60-year-old diabetic male on an oral hypoglycemic agent develops abnormal liver function tests. Which of the following agents can cause this finding c. Hypoglycemia 442, A 60-year-old male alcoholic treated for type II diabetes me Hi tu s develops lactic acidosis. Which of the following oral hypoglycemic agents might cause this adverse effect
A 3-year-old girl who is small for her age has had multiple hypoglycemic episodes associated with moderate fasting during periods of illness. In her most recent episode associated with influenza, her parents slept late, and at 10 am were unable to rouse the child from sleep. Blood and urine samples collected at the emergency department reveal marked hypoglycemia, ketonuria, and ketonemia along with an appropriately low insulin level. The blood alanine level is abnormally low however, infusion of alanine produces a rapid rise in blood glucose. The defect most likely responsible for these symptoms is found in which of the following pathways
HPI The patient is educated, articulate, and assertive and seems to be extremely knowledgeable about her disease. She claims that she controls her diabetes rigorously. After some phone inquiries, it is discovered that she has been admitted for hypoglycemia 01 DKA at various local hospitals 23 times over the past 18 months. When confronted with this finding, the patient becomes angry and defensive and leaves the hospital.
Studies by LePore in 2000 (28) confirm glargine's close comparison with continuous subcutaneous insulin infusion. In head-to-head comparisons with NPH insulin, glargine insulin had a lower incidence of nocturnal hypoglycemia in both type 2 and type 1 diabetic patients than NPH (31 vs 40 in type 2 diabetic patients, and 18 vs 27 in type 1 diabetic patients), whereas fasting plasma glucoses were reduced from baseline to a greater extent in patients with type 2 diabetes than with type 1 diabetes with insulin glargine (from 32 to 22 for type 2 diabetic patients and from 31 to 6 for patients with type 1 diabetes) (28). In the LePore studies, final hemoglobin A1-C levels were comparable A1-C levels achieved were 7.9 with NPH insulin and 8.2 with glargine in patients with type 1 diabetes, and in patients with type 2 diabetes A1-C levels were 7.49 with NPH and 7.54 with glargine. Studies published in Diabetes Care in 2001 by Hinella Yki-Jarvinen et al. showed less nocturnal hypoglycemia and...
The incidence of CP is approximately 1.5-5 per 1000 live births. The specific etiology is unknown but the incidence is high among infants who are small for gestational age. Some other known causes are intrauterine bleeding, infections, congenital malformations, intracranial hemorrhage, neonatal hypoglycemia, and kernicterus. Studies have demonstrated that birth asphyxia is an uncommon cause.
Beckwith-Wiedemann syndrome occurs in about 1 14,000 births. It is characterized by macro-somia and accelerated osseous maturation. Mild to moderate mental deficiency may be present patients may have normal intelligence. Physical examination is remarkable for macroglos-sia, a large fontanel, a linear fissure in the external ear, and indentations along the posterior rim of the helix. Organomegaly of the pancreas and kidney also occur, as well as omphalocele. Hypoglycemia occurs in one third to one half of patients, presenting in early infancy. In the neonate, apnea cyanosis and feeding problems may be related to the macroglossia. Neonates also have seizures and hypoglycemia. Patients are at higher risk for neonatal polycythemia and Wilms and other tumors (gonads, hepatoblastoma). Routine ultrasound and a-fetoprotein should be performed every 6 months until 6 years of age. Survivors of infancy tend to do well,
Seizures usually present within 12-24 h after birth. Intraventricular hemorrhage is more common in preterm infants. It is rarely present at birth but occurs at 1-3 days of age. A bulging fontanel or bloody cerebrospinal fluid on lumbar puncture is seen. Metabolic causes of seizures include hypoglycemia and hypocalcemia. Infections are also responsible for seizures.
A child with ketodc hypoglycemia following a period of fasting most likely has a defect in gluconeogenesis or in a pathway providing substrates for gluconeogenesis. Under fasting conditions, the primary substrate for gluconeogenesis is alanine derived from muscle protein. As muscle proteins are catabobzed, the amino acid skeletons are used as fuel in the muscle, while the amino groups are transam-inated to pyruvate, forming alanine, which is then transported to the liver and kidney cortex to be used in gluconeogenesis (Cahill cycle). In this child, alanine levels are abnormally low and infusion of alanine rapidly increases blood glucose. These findings rule out a defect in gluconeogenesis and are most consistent with a defect in protein catabolism in muscle. Glycogenolysis (choice B) is not involved, since liver glycogen stores would have been exhausted by this time. Moreover, defects in glycogenolysis should not produce such a severe hypoglycemia because they...
Over 10 million persons in the United States have diabetes mellitus. Diabetes mellitus affects both young and old alike. Insulin and oral hypoglycemic agents have helped prolong the life of persons who have diabetes mellitus. However, persons who have diabetes mellitus, even though it is successfully treated, sometimes have complications. Remember, diabetes mellitus can be treated, but it cannot be cured with the administration of either insulin or oral hypoglycemics. The complications most often associated with diabetes mellitus include blindness. Such blindness can result from several causes. Diabetic retinopathy, one of those causes of blindness, occurs because of the deterioration of the blood vessels in the eye. d. Clinical Tests for Discovering and Monitoring Diabetes. Suppose you think you have diabetes mellitus. Perhaps you have been drinking more fluids than usual. Perhaps you have more urine output than in the past. How can a person determine if he she has...
The analog mixes provide better postprandial control and less hypoglycemia in head-to-head comparisons with the NPH-based mixes. One of the criticisms of fixed-dose combinations is that inconsistent blood glucose readings increase the risk of hypoglycemia and hyperglycemia compared with regimens that segregate and vary the intermediate-acting and short-acting insulin doses based on dietary needs and irregularities. The fixed-dose combinations are not as easy to titrate as doses of only the shorter-acting analog insulins adjusted according to daily needs.
Although metformin has not been shown to increase adiponectin levels (as seen with the TZDs), it has been shown to reduce free fatty acid secretion, decrease intestinal absorption of glucose, and enhance peripheral glucose-uptake use (13). Unlike the sulfonylureas, metformin will not produce hypoglycemia in patients with type 2 diabetes. Food can decrease the extent of, and delay the absorption of, metformin, with 40 lower mean peak plasma levels after administration with food compared with taking the same medication on a fasting basis. Clinical relevance of this, however, has not been determined.
Lytes hyponatremia hyperkalemia. CBC PBS thrombocytopenia neutrophilic leukocytosis. LP CSF cloudy and under increased pressure increased proteins low sugar. Gram-negative diplococci (Neisseria meningitidis) seen within and outside WBCs on Gram stain negative India ink and ZN stain growth of meningococci later revealed on blood culture.
Salicylates are the most common cause of drug poisoning in the United States. Salicylates uncouple oxidative phosphorylation and increase the metabolic rate, resulting in tachypnea, tachycardia, fever, and hypoglycemia. The Krebs cycle is also inhibited, causing a metabolic acidosis. In addition, damage to hepatocytes occurs, causing liver toxicity, prolonged prothrombin time, platelet inhibition, and prolonged bleeding time. Diagnostic Tests. The white blood cell count, hematocrit, and platelets will be increased. The blood urea nitrogen and creatinine are also increased. Patients may have hypernatremia, or hyper- or hypokalemia. The patient may have hyper- or hypoglycemia. The arterial blood gas will show a metabolic acidosis with respiratory compensation in children and a respiratory alkalosis alone in adolescents.
An 8-year-old is seen in the emergency department with persistent vomiting and mental status changes. On examination he is combative and has a seizure, becomes apneic, and requires intubation. Laboratory tests are remarkable for hypoglycemia and elevated ammonia. The patient had recently recovered from a viral upper respiratory infection. Diagnostic Tests. Reye syndrome can be staged by symptoms. A table is shown below. Laboratory tests are remarkable for normal cerebrospinal fluid. Ammonia, transaminases, creatine kinase, and lactic dehydrogenase are markedly elevated. Hypoglycemia may be present. Treatment. Treatment of Reye syndrome is supportive. Intracranial pressure elevations need to be treated, and hypoglycemia should be avoided.
Glucagon is frequently called the hyperglycemic factor. Glucagon causes glycogenolysis (the conversion of glycogen into glucose) and tends to prevent hypoglycemia. Glucagon is released when blood glucose levels drop, thus, glucagon tends to raise the level of sugar in the blood. b. Insulin. Insulin's principal effect is to increase the cells' permeability to glucose. When the glucose enters the cells, it is metabolized to produce energy. Insulin also increases glycogenesis in the liver, thus, it increases glycogen stored there. A hyposecretion of insulin is known as diabetes mellitus. There are essentially two types of diabetes, juvenile diabetes and maturity-onset diabetes. Juvenile diabetes develops early in life, usually about the time of puberty, and is frequently associated with ketoacidosis. This form of diabetes is treated with insulin therapy. Maturity-onset diabetes frequently does not appear until middle age. Maturity-onset diabetes is usually milder than...
The effects of alcohol depend on the level. The alcohol level depends on the quantity of alcohol ingested, the size of the patient, and whether food was ingested. A person in most states is medico-legally intoxicated at 100 mg dl. At 50-150 mg dl the patient is uncoordinated and has blurred vision and a slow reaction time. At 150-300 mg dl the patient has visual impairment, staggering, and slurred speech. Levels of 300-500 mg dl produce stupor, hypoglycemia, and coma. A level of 500 mg dl is fatal if the patient has no tolerance. Treatment. The treatment is supportive. Hypoglycemia and acidosis should be treated. Artificial ventilation may be needed for respiratory failure. Alcohol is rapidly absorbed from the gut and is not adsorbed by activated charcoal, therefore GI decontamination of patients presenting 2 h after ingestion is rarely performed. Gastric lavage should be used in earlier presentations. However, activated charcoal should be...
Severe hypoglycemia from inadequate gluconeogenesis and exhaustion of glycogen stores is an uncommon complication seen in pediatric patients who manifest acute convulsions and even coma if serum glucose concentrations fall below 1 mmol L.43 In patients with severe dehydration and a marked decrease in renal perfusion, acute renal failure can occur. Very rarely, pulmonary edema can occur if large volumes of intravenous fluids without bicarbonate are rapidly infused in a patient with severe acidosis. In fact, this is a very rare complication and the opposite clinical situation where there is a failure to administer intravenous fluids in volumes adequate to correct the extreme deficits encountered in the severe dehydration associated with cholera gravis is much more frequent.
Many studies have demonstrated that the administration of tryptophan causes an enhancement in the activity of a variety of liver enzymes. Table 4.1 summarizes a number of hepatic enzymes that have reportedly increased in activity due to tryptophan. Tryptophan has been demonstrated to have specific effects on the activities of hormonally and nutritionally sensitive enzymes, many of which are not necessarily related to tryptophan metabolism itself.1317 The mechanisms by which tryptophan acts to affect these enzyme levels are not clear. In some instances, there is evidence that the specific regulation by tryptophan involves enzyme degradation rather than synthesis.15 Deguchi and Barchas18 suggested that a metabolite, rather than tryptophan itself, may be the actual active component. Such is indeed the case for tryptophan-induced hypoglycemia in vivo.19 In searching for a unifying mechanism, Smith et al.20 conducted a systematic study involving the activities of a number of...
Hypoglycemia may occur when a mismatch occurs between carbohydrate intake and circulating insulin concentrations. Insulin-treated patients have the highest risk of severe hypoglycemia and the risk increases when lower glucose levels are pursued. Fear of hypoglycemia and dislike of injections are major obstacles to uptake of insulin therapy. Insulin analogues with different pharmacokinetic profiles that are less likely to cause hypoglycemia when used appropriately have been developed however, cost currently restricts their use in developing countries.68 At the present time, insulin replacement by pancreatic transplantation or islet cell transplantation are treatment options for only a minority of patients with type 1 diabetes in developed countries.6970
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