(1) insulin. Among diabetic patients treated with insulin, hypoglycemia related to insulin application is mainly seen in: ① excessive insulin dose. It is common in the early stage of diabetes treatment and during the intensive treatment of diabetes, and occasionally you can see the calculation errors of patients or medical staff. For example, 100u/ml human insulin is mistaken for 40u/ml animal or human insulin, resulting in excessive insulin dosage; Occasionally, some patients with impaired vision will lead to incorrect dose extraction. ② Exercise. In non-diabetic individuals, exercise can obviously increase the intake of glucose in muscle tissue (20 ~ 30 times higher than the basic value), but the increase of glucose utilization can be compensated by the increase of glucose production in liver and kidney, accompanied by the inhibition of insulin secretion in B cells (mostly secondary to the increase of catecholamine secretion caused by exercise), so hypoglycemia generally does not occur, but this situation does not exist in diabetic patients treated with insulin. If you do too much exercise and don't adjust insulin in time, it will often lead to hypoglycemia after exercise, especially injecting insulin near exercise-related muscles, which can obviously promote insulin absorption. Therefore, it is better to inject insulin into the abdomen before exercise. ③ Improper food intake. One of the most common reasons for hypoglycemia in diabetic patients treated with insulin is that patients do not eat on time or eat less after insulin injection, which will happen when patients go out to eat or travel. Patients can take some dry food with them to prevent hypoglycemia. If you have poor appetite when you are sick, you should reduce the dosage of insulin appropriately. If you can't eat, you should give rehydration, intravenous injection of glucose and insulin. 4 others. A local environmental changes at the injection site: hot water bath can promote insulin absorption after insulin injection, and insulin injection enters the muscle tissue too deeply to accelerate insulin absorption. B complicated with renal insufficiency: when the renal function deteriorates, the inactivation and clearance of insulin are reduced, and the renal glycogen dysplasia is reduced, which may be accompanied by a decrease in food intake. Therefore, the dosage of insulin should be reduced in time. C diabetic gastroparesis: due to diabetic autonomic neuropathy, delayed gastric emptying often causes postprandial hypoglycemia in patients treated with insulin. Pressure:
Various stress states, such as infection, surgery, trauma or mental stress, often lead to an increase in insulin demand for controlling hyperglycemia. Once the stress state is relieved or eliminated, the insulin dose should be restored to the pre-stress dose in time, otherwise it will easily lead to hypoglycemia. E Complicated with hypocortisolemia: 1 type diabetic patients may occasionally be complicated with primary adrenal insufficiency or pituitary hypofunction, which leads to the decrease of blood cortisol level, increased sensitivity to insulin and easy hypoglycemia, so the demand for insulin should be reduced.
(2) oral hypoglycemic agents. All oral hypoglycemic agents (including sulfonylureas and non-sulfonylureas insulin secretagogues) that promote insulin secretion can cause hypoglycemia, among which glibenclamide and chlorosulfonylurea (half-life as long as 35 years, which have been discontinued in China) are the most dangerous, serious and last the longest. Special attention should be paid when using, especially for elderly patients. Relatively speaking, the incidence of hypoglycemia of D860, mepiride, gliquidone, glibenclamide (such as Amory) and some non-sulfonylurea insulin secretagogues such as repaglinide and nateglinide is low and mild. The clinical application of biguanides, α -glucosidase inhibitors, thiazolidinedione derivatives (insulin sensitizers) and pure Chinese medicine preparations alone will generally not lead to hypoglycemia in the clinical sense, but if combined with insulin or sulfonylureas, it may increase the chance of hypoglycemia. Some Chinese patent medicines (such as Xiaoke pills) may be mixed with sulfonylureas, so attention should be paid to avoid hypoglycemia when using them.
(3) Combined application of some drugs. Many other drugs combined with insulin or sulfonylurea drugs may enhance the hypoglycemic effect of insulin or sulfonylurea drugs and induce hypoglycemia.
Common drugs include:
Ethanol: it can inhibit the dysplasia of liver glycogen, and the maintenance of fasting blood glucose mainly depends on the dysplasia of liver glycogen; In addition, drinking alcohol can mask the warning symptoms of hypoglycemia, so diabetic patients should try to avoid drinking alcohol, especially on an empty stomach.
Salicylic acids: Salicylic acids have certain hypoglycemic effects, and were once used as hypoglycemic drugs, but they were stopped as hypoglycemic drugs because of their large dosage (such as aspirin 4-6g/d) and adverse reactions related to large dosage. The hypoglycemic mechanism of these drugs is not very clear, which may be related to its high dose of stimulating insulin secretion and inhibiting renal excretion. In addition, they can be used in combination with protein instead of sulfonylureas, which increases the chances of hypoglycemia in diabetic patients treated with sulfonylureas.
Diabetic patients need to use salicylic acid drugs such as aspirin to relieve fever and pain at the same time, starting with a small dose, and pay attention to monitoring blood sugar.
Beta blockers: Diabetic patients treated with beta blockers, especially non-selective beta blockers, may have an increased chance of hypoglycemia, and some patients may cause severe hypoglycemia. The mechanism of hypoglycemia caused by beta blockers is to inhibit the stimulation of sympathetic nerve or the output of adrenaline, thus inhibiting the output of liver sugar. The recovery of hypoglycemia is often delayed because beta blockers block the anti-regulation of adrenaline during hypoglycemia. Another important problem is that beta blockers inhibit important signs and symptoms, such as adrenaline-mediated tachycardia and palpitations during hypoglycemia, thus reducing patients' vigilance against hypoglycemia. Therefore, proper attention should be paid to diabetic patients treated with beta blockers. Reports from UKPDS and JNC-ⅵ believe that although β -blockers have some adverse reactions, such as reducing peripheral blood flow, prolonging the recovery time of hypoglycemia, and covering up the symptoms of hypoglycemia, the application of β -blockers in diabetic patients can achieve similar or greater cardiovascular reduction than that in non-diabetic patients.
Others: Some drugs such as angiotensin converting enzyme inhibitors, monoamine oxidase inhibitors, phenytoin sodium, tricyclic antidepressants, sulfonamides, tetracyclines, etc. combined with hypoglycemic drugs may also increase the chances of hypoglycemia in diabetic patients.
(4) Excessive use of insulin or sulfonylureas. Few patients with diabetes (especially some patients with mental disorders or in order to attract the attention of people around them or for other reasons) may overuse insulin or sulfonylureas, resulting in artificial hypoglycemia. If it is caused by exogenous insulin, patients often show hyperinsulinemia, and the immune activity of plasma C peptide is obviously inhibited.
⑤ Type 2 diabetes. In the early stage of patients with type 2 diabetes mellitus, the perception defect of B cells to glucose stimulation and early insulin release disorder lead to early postprandial hyperglycemia, delayed insulin release peak time, intensified insulin release reaction, and reactive hypoglycemia often occurs 3-5 hours after meals, also known as delayed postprandial hypoglycemia.