Insulin therapy hypoglycemia with

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. 

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. 

Metformin. Metformin [657-24-9] (1,1-dimethylbiguanide), mol wt 129.17, forms crystals from propanol, mp 218—220°C, and is soluble in water and 95% ethanol, but practically insoluble in ether and chloroform. Metformin, an investigational dmg in the United States, does not increase basal or meal-stimulated insulin secretion. It lowers blood glucose levels in hyperglycemic patients with Type II diabetes but has no effect on blood glucose levels in normal subjects. It does not cause hypoglycemia. Successful metformin therapy usually is associated with no or some weight loss. 

Occasionally, conversion to tolbutamide in the hospital may be advisable in candidates who require more than 40 units of insulin daily. During this conversion period when insulin and tolbutamide are being used, hypoglycemia rarely may occur. During insulin withdrawal, have patients test urine for glucose and acetone at least 3 times/day and report results to their physician. The appearance of persistent acetonuria with glycosuria indicates that the patient is a type 1 diabetes patient who requires insulin therapy. 

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. 

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. 

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. 

In 3805 children and adolescents with type 1 diabetes in 21 pediatric centers in 17 countries, feedback was given on the overall mean HbAlc concentration in all the centers (176). After 3 years insulin therapy was more intensive, but glycemic control improved in only three centers. The relative risk of severe hypoglycemia was lowest in the center with the best glycemic control. 

In 426 patients with type 2 diabetes poorly controlled with oral therapy, randomized to protamine zinc insulin or insulin glargine, glucose concentrations after dinner were lower with insulin glargine and there were significantly fewer attacks of hypoglycemia (27). HbAic was 8.2 and 8.1% with insulin glargine and protamine zinc insulin respectively. 

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