Hypoglycemia with insulin

In 518 patients with type 2 diabetes using protamine zinc insulin, with or without short-acting insulin, randomized to insulin glargine or protamine zinc insulin, there was less nocturnal hypoglycemia with insulin glargine (26). HbAic and mild symptomatic hypoglycemia was the same in both groups. 

Ratner RE, Hirsch IB, Neifing JL, Garg SK, Mecca TE, Wilson CAU.S. Study Group of Insulin Glargine in Type 1 Diabetes. Less hypoglycemia with insulin glargine in intensive insulin therapy for type 1 diabetes. Diabetes Care 2000 23(5) 639 13. 

To achieve hypoglycemia with insulin, the traditional route of administration has been via subcutaneous... 

Hypoglycemia Pramlintide alone does not cause hypoglycemia. However, pramlintide is indicated to be coadministered with insulin therapy, and, in this setting, pramlintide increases the risk of insulin-induced severe hypoglycemia, particularly in patients with type 1 diabetes. Severe hypoglycemia associated with pramlintide occurs within the first 3 hours following a pramlintide injection. 

Insulin For patients stabilized on insulin, continue the insulin dose upon initiation of rosiglitazone therapy. Dose rosiglitazone at 4 mg daily. Doses greater than 4 mg daily in combination with insulin are not currently indicated. It is recommended that the insulin dose be decreased 10% to 25% if the patient reports hypoglycemia or if fasting plasma glucose concentrations decrease to less than 100 mg/dL. 

Hypoglycemia Patients receiving pioglitazone or rosiglitazone in combination with insulin or oral hypoglycemics (eg, sulfonylureas) may be at risk for hypoglycemia reduction in the dose of insulin or sulfonylureas may be necessary. 

Biood giucose abnormaiities Disturbances of blood glucose, including symptomatic hyper- and hypoglycemia, have been reported, usually in diabetic patients receiving concomitant treatment with an oral hypoglycemic agent or with insulin. 

Severe hypoglycemia caused by hyperinsulinism may occur with insulin overdose, decrease or delay of food intake, or excessive exercise and in those with brittle diabetes. 

Diabetes mellitus, combination therapy PO With insulin Initially, 15-30 mg once a day. Initially, continue current insulin dosage then decrease insulin dosage by 10% to 25% if hypoglycemia occurs or plasma glucose level decreases to less than 100 mg/dl. Maximum 45 mg/day. With sulfonylureas Initially, 15-30 mg/day. Decrease sulfonylurea dosage if hypoglycemia occurs. With metformin Initially, 15-30 mg/day. As monotherapy Monotherapy is not to be used if patient is well controlled with diet and exercise alone. Initially, 15-30 mg/day. May increase dosage in increments until 45 mg/day is reached. 

Exenatide is approved for use in individuals who fail to achieve desired glycemic control on biguanides, or biguanides plus sulfonylureas. Hypoglycemia is a risk when exenatide is used with an insulin secretagogue or with insulin. The doses of the latter drugs have to be reduced at the initiation of exenatide therapy and subsequently titrated. 

Pramlintide is approved for concurrent mealtime administration in individuals with type 2 diabetes treated with insulin, metformin, or a sulfonylurea who are unable to achieve their postprandial glucose targets. Combination therapy results in a significant reduction in early postprandial glucose excursions mealtime insulin or sulfonylurea doses usually have to be reduced to prevent hypoglycemia. 

Special Precautions Hypoglycemia in combination with insulin or oral hypoglycemic agents Pregnancy Category C Ovulation Decreases in hemoglobulin and hematocrit Idiosyncratic hepatoxicity Edema Plasma volume expansion and pre-load-induced cardiac... 

Taira M, Takasu N, Komiya I, Taira T, Tanaka H. Voglibose administration before the evening meal improves nocturnal hypoglycemia in insulin-dependent diabetic patients with intensive insulin therapy. Metabolism... 

The most frequent complication of insulin therapy is inadvertent hypoglycemia (21-23). Over 5% of deaths in diabetes can be attributed to hypoglycemia. The frequency increases with rigorous maintenance of normogly-cemia (24,25). In the Diabetes Control and Complications Trial (DCCT) (26) the frequency of serious hypoglycemia was more than three times increased in the intensively treated group, and the frequency of the attacks was related to the concentration of HbAlc (27). The UK Prospective Diabetes Study in patients with type 2 diabetes also showed an increased risk of hypoglycemia with more intensive treatment (28). 

Respiratory effects of hypoglycemia A 19-year-old woman with diabetes developed hypoglycemia with pulmonary edema (59). This has previously been seen as a complication of insulin shock therapy for psychiatric illnesses. 

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