Diabetes hypoglycaemia

Pre-approval safety and efficacy clinical studies involved product administration to 2500 adults with either type-1 or -2 diabetes. The primary efficacy parameter measured was glycaemic control (as measured by the reduction from baseline in haemoglobin Ale). Hypoglycaemia was the most commonly reported adverse effect. Trials also showed a greater decline in pulmonary function in the Exubera group, and product should not be administered to patients with underlying lung disease, or to smokers. Exubera was developed by Nektar Inc. and is marketed under licence by Pfizer. 

Hypoglycaemia remains the most frequent complication of insulin administration to diabetics. It usually occurs due to (a) administration of an excessive amount of insulin (b) administration of insulin prior to a mealtime, but with subsequent omission of the meal or (c) due to increased physical activity. In severe cases this can lead to loss of consciousness, and even death. Although it may be treated by oral or i.v. administration of glucose, insulin-induced hypoglycaemia is sometimes treated by administration of glucagon. 

Q76 Lantus may be considered in type II diabetic patients whose lifestyle is severely restricted by recurrent symptomatic hypoglycaemia. Lantus should not be used in combination with metformin. 

The commonest cause of hypoglycaemia is administration of therapeutic doses of insulin or sulphonylureas in patients treated for diabetes. Nondiabetic people may also take or be given hypogly-caemic agents. Hypoglycaemia can occur spontaneously in insulinomas, hypoadrenalism, and other uncommon circumstances. 

Acute complications of diabetes include diabetic ketoacidosis, hyperglycaemic non-ketotic hyperosmolar coma, lactic acidosis and hypoglycaemia. 

Exercise is an essential yet neglected aspect of treatment for type 2 diabetes especially in its early stages where insulin resistance may predominate. Accumulation of at least 30 0 minutes of moderate physical activity on most days of the week is recommended. For type 1 diabetes the emphasis must be on adjusting the therapeutic regimen to allow safe sports participation to prevent precipitation of ketoacidosis or hypoglycaemia. Extra care is required in cases with known complications like proliferative retinopathy, nephropathy, foot ulcers and cardiac or peripheral vascular disease. 

Newey PJ, Abousleiman Y, Jamieson A. Pituitary failure, metformin and hypoglycaemia in type 2 diabetes. Br J Diabetes Vase Dis 2004 4 128-30. 

Vilsboll T, Krarup T, Madsbad S, Holst JJ. No reactive hypoglycaemia in Type 2 diabetic patients after subcutaneous administration of GLP-1 and intravenous glucose. Diabet Med 2001 18(2) 144-9. 

Henderson JN, Allen KV, Deary IJ, Frier BM. Hypoglycaemia in insulin-treated type 2 diabetes frequency, symptoms and impaired awareness. Diabetic Med 2003 20 1016-21. 

Hvidberg A, Christensen NJ, Hilsted J. Counterregulatory hormones in insulin-treated diabetic patients admitted to an accident and emergency department with hypoglycaemia. Diabet Med 1998 15(3) 199-204. 

Kaneto H, Ikeda M, Kishimoto M, Iida M, Hoshi A, Watarai T, Kubota M, Kajimoto Y, Yamasaki Y, Hori M. Dramatic recovery of counter-regulatory hormone response to hypoglycaemia after intensive insulin therapy in poorly controlled type I diabetes mellitus. Diabetologia 1998 41(8) 982-3. 

Oskarsson P, Adamson U, Sjobom NC, Lins PE. Longterm follow-up of insulin-dependent diabetes mellitus patients with recurrent episodes of severe hypoglycaemia. Diabetes Res Clin Pract 1999 44(3) 165-74. 

Amiel SA. R.D. Lawrence Lecture 1994. Limits of normality the mechanisms of hypoglycaemia unawareness Diabet Med 1994 ll(10) 918-24. 

Teuscher A, Berger WG. Hypoglycaemia unawareness in diabetics transferred from beef/porcine insulin to human insulin. Lancet 1987 2(8555) 382—5. 

George E, Bedford C, Peacey SR, Hardisty CA, Heller SR. Further evidence for a high incidence of nocturnal hypoglycaemia in IDDM no effect of dose for dose transfer between human and porcine insulins. Diabet Med 1997 14(6) 442—8. 

Bradley KJ, Paton RC. Silent hypoglycaemia at the diabetic clinic. Diabet Med 2001 18(5) 425-6. 

Cryer PE. Hypoglycaemia the limiting factor in the gly-caemic management of Type I and Type II diabetes. Diabetologia 2002 45(7) 937-48. 

Matyka KA, Wigg L, Pramming S, Stores G, Dunger DB. Cognitive function and mood after profound nocturnal hypoglycaemia in prepubertal children with conventional insulin treatment for diabetes. Arch Dis Child 1999 81(2) 138-42. 

Amiel SA. Studies in hypoglycaemia in children with insulin-dependent diabetes mellitus. Horm Res... 

Barkai L, Vamosi I, Lukacs K. Prospective assessment of severe hypoglycaemia in diabetic children and adolescents with impaired and normal awareness of hypoglycaemia. Diabetologia 1998 41(8) 898-903. 

Airey CM, Williams DR, Martin PG, Bennett CM, Spoor PA. Hypoglycaemia induced by exogenous insulin— human and animal insulin compared. Diabet Med 2000 17(6) 416-32. 

Bragd J, Adamson U, Lins PE, Wredling R, Oskarsson P. A repeated cross-sectional survey of severe hypoglycaemia in 178 Type 1 diabetes mellitus patients performed in 1984 and 1998. Diabet Med 2003 20(3) 216-9. 

Clarke B, Ward JD, Enoch BA. Hypoglycaemia in insulin-dependent diabetic drivers. BMJ 1980 281(6240) 586. 

Tupola S, Sipila I, Huttunen NP, Salo S, Nuuja A, Akerblom HK. Management of asymptomatic hypoglycaemia in children and adolescents with Type 1 diabetes mellitus. Diabet Med 2000 17(10) 752-3. 

Parmar MS. Recurrent hypoglycaemia in a diabetic patient as a result of unexpected renal failure. BMJ 2004 328 883 1. 

Linkeschova R, Raoul M, Bott U, Berger M, Spraul M. Less severe hypoglycaemia, better metabolic control, and improved quality of life in type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy an observational study of 100 consecutive patients followed for a mean of 2 years. Diabet Med 2002 19(9) 746-51. 

Mehmet S, Quan G, Thomas S, Goldsmith D. Important causes of hypoglycaemia in patients with diabetes on peritoneal dialysis. Diabet Med 2001 18(8) 679-82. 

Prakash PK, Banerjee M, Harlow J, Hanna FW. An unusual case of hypoglycaemia. Diabet Med 2001 18(9) 769-70. 

Ferguson SC, Strachan MW, Janes JM, Frier BM. Severe hypoglycaemia in patients with type 1 diabetes and impaired awareness of hypoglycaemia a comparative study of insulin lispro and regular human insulin. Diabetes Metab Res Rev 2001 17(4) 285-91. 

Ford-Adams ME, Murphy NP, Moore EJ, Edge JA, Ong KL, Watts AP, Acerini CL, Dunger DB. Insulin lispro a potential role in preventing nocturnal hypoglycaemia in young children with diabetes mellitus. Diabetic Med 2003 20 656-60. 

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