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Major Metabolic Defects in Type 2 Diabetes Peripheral insulin resistance in muscle and fat Peripheral insulin resistance in muscle and fat Decreased pancreatic insulin secretion Decreased pancreatic insulin secretion Increased hepatic glucose output Increased hepatic glucose output Haffner SM, et al.
Development and Progression of Type 2 Diabetes* Relative Activity Glucose Years from Diabetes Diagnosis –10–5051015202530 -10-5051015202530 *Conceptual representation. 0 UKPDS: Progressive Deterioration in Glycemic Control Over Time Intensive Conventional Time from randomization (y) 6391215 Median A1C (%) A1C Years from diagnosis -cell function (%) 100 80 60 40 20 0 UKPDS Group. Potential Causes for Declining Insulin Secretion Glucotoxicity Lipotoxicity -cell Apoptosis Insulin Secretion Prentki M et al. Abnormalities of ? -Cell Function in Type 2 Diabetes Elevated glucagon levels Elevated glucagon levels Loss of insulin-induced suppression Loss of insulin-induced suppression Loss of glucose-induced suppression Loss of glucose-induced suppression Increased stimulatory effect of arginine Increased stimulatory effect of arginine Dunning BE et al. Perioperative Beta Blockers In what clinical settings would you prescribe a perioperative beta-blocker? Case # 5 A 70 year old man with diabetes, hypertension, CAD, and COPD is admitted with right upper quadrant pain. Case #5 Which of the following is most likely to reduce the risk of perioperative pulmonary complications?
Hypoglycemia is a common side effect of using insulin, and it can also occur in people who take pills that cause the pancreas to release more insulin. Often, however, the most education a person receives on the signs and symptoms of hypoglycemia is a handout listing its 10 most common symptoms. Low blood glucose, or hypoglycemia, is a condition in which the brain does not have enough glucose to carry out its many functions. When a person’s blood glucose level begins to drop, his body starts a series of reactions intended to raise its blood glucose level. Given the potential consequences of severe hypoglycemia, it’s worth doing your best to avert it by treating mild hypoglycemia as quickly as possible. For some people who take beta-blockers, a type of blood pressure medicine, sweating may be the only early symptom of hypoglycemia, because beta-blockers can prevent the body from shaking or having other hypoglycemia symptoms such as a fast heartbeat. Enlarged pupils can also be a symptom of hypoglycemia, but you are unlikely to notice them unless you’re looking in a mirror or someone else takes a close look at your eyes. It may help to talk over the possibility of this happening with your friends, coworkers, and family members before it happens and to brief them on what to do if it does.
Typically, a person passes from an agitated stage to a more docile stage, when it may be easier to get him to drink juice or to eat something. For obvious reasons, it is important for people with diabetes to recognize symptoms of hypoglycemia while driving and to pull over to treat it. One way to lower your chances of experiencing low blood glucose while driving is to establish a minimum safe blood glucose level for driving with the help of your health-care provider and to always check your blood glucose level before driving. Because of the increased responsibility that comes with driving, you should confirm that your blood glucose has returned to a safe level after consuming some carbohydrate before resuming driving. Wearing or carrying medical identification specifying that you have diabetes is always a good idea, and it’s especially true while driving.
However, the police are required to look at a person’s wrist, neck, and wallet for medical identification. Because others could mistake hypoglycemia for something else, many parents of teenagers with diabetes require that their teens get in the habit of wearing identification before they are allowed to take driver’s education. After an episode of nighttime hypoglycemia, it’s important to think about how to prevent future episodes. When you were first informed about hypoglycemia by your doctor or diabetes educator, you may not have paid a lot of attention or felt too concerned about it.
You can reduce your chances of developing hypoglycemia by learning to make adjustments in your diabetes control regimen to accommodate different activities and circumstances. Your goal is to find a healthy balance to keep your blood glucose level in target range most of the time. Celia Kirkman is the Diabetes Coordinator at the Anne Arundel Medical Center’s Diabetes Center in Annapolis, Maryland.
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Pills that have this effect include glimepiride (brand name Amaryl), glipizide (Glucotrol, Glucotrol XL, and the combination pill Metaglip), glyburide (DiaBeta, Glynase, Glycron, Micronase, and the combination pill Glucovance), nateglinide (Starlix), and repaglinide (Prandin). Once you (and your friends, coworkers, and family members) are better equipped to recognize hypoglycemia, you will be able treat low blood glucose faster and avert more severe hypoglycemia and its sometimes serious consequences. In a person with diabetes, it most often results when there is an imbalance in food, insulin, and exercise. If others have to assist you in obtaining and consuming a source of carbohydrate, you would generally be considered to have moderate hypoglycemia. In addition, the earlier you treat mild hypoglycemia, the faster your symptoms will go away. A common early symptom of hypoglycemia, shaking does not refer to the full-body shakes of someone having a seizure but instead to a more subtle trembling that may initially be sensed by the person experiencing it without being visible to an observer. Many things in addition to hypoglycemia can cause a fast heartbeat, including excitement, stress, exercise, or ketones associated with high blood glucose.

Hunger is a useful symptom of hypoglycemia since it usually leads a person to eat and consequently raise his blood glucose level. These symptoms are directly related to your body not having enough energy (glucose) for both physical and mental needs. Having a headache often signals that you had hypoglycemia earlier in the day or have had it for some time. Double vision and tunnel vision are two types of visual disturbances that may occur with hypoglycemia. If you are becoming hypoglycemic while reading, you may notice that you cannot find the correct line or that you see fewer words with each glance. Dizziness is another symptom that occurs after a person has been hypoglycemic for some time. Anxious, giddy, confused, and irritable behaviors are important symptoms for friends, coworkers, and family members to learn about. You might ask your potential helpers to remain calm, to refrain from raising their voices (which can feel threatening), and to place a container of juice or some glucose tablets in your hand or on the table or desk in front of you. However, two common early symptoms of hypoglycemia, shaking and sweating, are often not noticed while driving.
If you’re taking a long trip, plan to pull over and check your blood glucose level every two hours, eat all snacks and meals on schedule, and share the driving with someone else. Even if you’re in a hurry, you need to change your priorities, especially before resuming a long trip, to ensure your safety and the safety of others.
If you pass out at the wheel or are driving erratically because of hypoglycemia, other drivers and the police may assume that you’re drunk. Parents are also demanding that teens check their blood glucose level before driving and delay driving until their blood glucose is in a safe range. If you awaken to cold, wet sheets or pajamas, you may be tempted to just change clothes or get a dry sheet and go back to sleep as quickly as possible. For this symptom to be useful, you have to learn to recognize that a fast heartbeat is a symptom of something very wrong and take action. If it will be many hours before you wake up for breakfast, you should also have a substantial snack containing carbohydrate so that your blood glucose doesn’t go low again during the night. Review your exercise, food intake, and medicine intake from the previous evening or day to look for clues to the cause of your hypoglycemia. It is often not until the first mild or moderate hypoglycemia episode that you or your family members learn the value of avoiding low blood glucose.
For example, if you find you tend to develop hypoglycemia after a certain type of exercise, you can learn (with the help of your doctor or diabetes educator) how to adjust your food or medicine on the days you perform that exercise. You should not have low blood glucose frequently, but you also should not maintain high blood glucose to avoid hypoglycemia, because having chronically high blood glucose has consequences, too. It is therefore important that anyone who uses one of these drugs know what causes hypoglycemia, how to prevent it, how to recognize it, and how to treat it. But, as any longtime user of insulin will tell you, such a list does not go far enough in describing how those common symptoms can feel, and it misses some important, albeit not-so-common, symptoms of hypoglycemia. These hormones also produce some of the symptoms typically associated with hypoglycemia, such as trembling. Some experts also recommend checking blood glucose levels again an hour after the last treatment to see whether additional food is necessary.
In moderate hypoglycemia, your ability to communicate, pick an appropriate food, or realize that you should do something to raise your blood glucose level may be impaired. It may progress to fine tremors of the fingers so that if you are trying to perform fine motor tasks with your hands, such as writing or threading a needle, you may notice that the task is more difficult. This can make it harder to notice fast heartbeat as a potential sign of hypoglycemia, but if you are having a fast heartbeat when there is no apparent reason for this to occur, you should check your blood glucose level.
However, you may be in the habit of ignoring the initial symptoms of hunger at work or school if you’re in a meeting, engrossed in studying, or attending a lecture. It may be tempting to take a nap when you feel weak and tired, but it’s important to monitor your blood glucose level if you feel this way at a time of day when you are not usually tired. For example, if you wake up with a headache or leave a movie theater with a headache, you may have been hypoglycemic for some time.
Like headache, impaired vision also often signals that your blood glucose has been low for quite some time. If you find yourself reading the same paragraph over and over or listening to someone speak then realizing you missed what was said, perhaps because you were daydreaming, you may have hypoglycemia. Sometimes the numbness is first noticed in one spot, such as the upper lip, then it spreads across the face. Even though dealing with an agitated person is difficult, it is better to at least try to get him to eat or drink than to simply wait until his blood glucose level drops even lower. Two typical characteristics of a driver with hypoglycemia are that he develops a sort of one-track mind, in which continuing to drive becomes the sole goal, and that he loses the ability to remember where he is or how to get to his final destination.
If you don’t have it, you may be placed in a holding room at a jail and not receive any help. These same rules should be followed by drivers of any age who are at risk for hypoglycemia.

In addition, you may not realize that you have double vision or notice weakness or fatigue. But you need to consume some carbohydrate and do a thorough job of treating your low blood sugar to avoid more problems later. Usually, treatment for severe hypoglycemia during the day is to either call an ambulance or give glucagon. If you cannot readily determine the cause or correct the problem on your own, contact your health-care provider for help.
Keeping a blood glucose monitoring log and regularly reviewing it with your health-care provider can help to determine where problems may be occurring and how to fix them. By learning about the many symptoms of hypoglycemia and paying attention to the symptoms you experience, you have empowered yourself to seek treatment faster.
Consult appropriate health-care professionals before taking action based on this information. In addition to preoperative cardiac risk stratification, you consider the risk of pulmonary complications. If the body cannot reverse the low blood glucose on its own (which can happen if the liver’s supply of stored glucose has been depleted by, say, vigorous exercise) and the person does not recognize the symptoms of low blood glucose and does not consume some carbohydrate, the blood glucose level will drop further. Severe hypoglycemia occurs when you have lost consciousness, are having a seizure, or cannot be awakened. This is a dangerous habit to have, because the longer you ignore hunger, the hungrier you get and the more likely you are to overeat when you finally eat. If hypoglycemia is causing your feeling of fatigue, your blood glucose level may go even lower during your nap, and you are unlikely to be able to detect other symptoms of hypoglycemia while asleep.
Your brain routinely takes two pictures from two eyes and formulates the pictures into a single image. Your blood glucose may be so low that you no longer recognize family members or authority figures such as the police. Keep in mind that it will take a while for a person’s blood glucose level to rise and that anyone who has needed assistance treating hypoglycemia should not be left alone until his blood glucose is in a safe range and he shows signs of good judgment. If you are gripping the steering wheel, you may not notice fine tremors in your fingers, and if you are driving in hot weather, you may assume that sweating is due to the weather.
A driver may, for example, miss the exit to a familiar destination, drive steadily in one direction with no change in driving speed, or drive for many miles beyond his destination.
In contrast, for severe nighttime hypoglycemia, many health-care providers recommend doing both: giving glucagon and calling an ambulance, because the person may have been severely low for some time before anyone realized there was a problem. You should not have to give up the things that are important to you such as exercise, playing with your children, or driving just because you could develop hypoglycemia. Exercise usually lowers blood glucose level (unless there is not enough insulin circulating in the bloodstream, in which case it may raise it).
To revive you, someone must give you an injection of glucagon, a hormone that stimulates the release of glycogen, a form of stored glucose, from the liver, or emergency services must be called to give you glucose intravenously. You may have your own, unique indicators of hypoglycemia that don’t appear on this list. While in some situations you may be keenly aware that your sweating is unusual, there are others in which you may not realize you’re sweating because of hypoglycemia. In addition, if you wait until you have moderate hypoglycemia, your judgment may be affected such that you eat the first thing you find, whether or not it will quickly raise your blood glucose level.
You should treat yourself with carbohydrate and plan to monitor more frequently for the rest of the day.
When your brain does not have enough glucose, the brain loses the ability to coordinate vision. If strangers or the police find you swerving while walking, medical identification in the form of a bracelet, necklace, or wallet card may save you from a misunderstanding and get you the treatment needed to stave off severe hypoglycemia.
Other peculiar driving behavior reported by family members of people driving with hypoglycemia include stopping at all traffic lights no matter what the color of the light.
If so, glucagon may not be effective because the liver’s supply of glycogen may be depleted.
Hypoglycemia results if not enough food is eaten for the amount of insulin present and exercise done. In addition, your experience of a common symptom may be somewhat different from someone else’s, or it may be different from what you might have expected. If the hypoglycemia has lasted a long time, the body’s stored sugar may have been used up, and you are more prone to repeat episodes of hypoglycemia that day.
You may see fine with one eye closed, but quick action is needed to prevent the confused state that will follow if you don’t raise your blood glucose level. If sweating occurred while swimming, taking a shower, or sleeping, you might not even realize you were sweating.

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