MMPAD Munich Meeting Report

MEETING REPORT 9 European Roadshow - Friday 25 th May, 2018 Munich, Germany When should we suspect hypoglycaemia? Reinhard Holl explained that clinical alert for hypoglycaemia should be raised if blood sugar values (symptomatic or asymptomatic) are 70 mg/dL or below (grade 1). Moderate hypoglycaemia (grade 2) occurs if blood sugar concentrations fall below 54 mg/ dL and severe hypoglycaemia (grade 3) is present if there is a loss of brain function, Holl said. Cognitive deficits require external help in the form of carbohydrate intake . 2, 9 Perspiration, headaches, concentration difficulties, convulsion, coma, behavioural changes, irritability and temper tantrums are all signs of hypoglycaemia. As an example, Holl suggested first measuring blood sugar levels during outbursts of anger. Suspected hypoglycaemia should be treated immediately, followed by a check of blood sugar levels. Holl also pointed out that there is a time lag between interstitial glucose concentrations and levels measured in the peripheral blood. The challenges of young children According to analyses in patients younger than 18 years old in Germany and Austria, mild hypoglycaemia with cravings occurs 2.8 times per patient–month and severe hypoglycaemia with patients being totally dependent on others occurs once every 5 years. Unconsciousness, convulsions and coma were observed once every other decade. 10,11 Younger children have a slightly higher risk of severe hypoglycaemia and coma; 2–3-year olds are particularly affected during sustained and/or intense physical activity if carbohydrate intake is too low. Holl reminded the audience that a 3-year-old still needs help when trying to open a bottle of apple juice; such banalities aggravate self- control even more during hypoglycaemia in the very young. Children rarely fail to notice symptoms of low blood sugar levels and when it does occur, it is a transient problem. Children with diabetes who have previously experienced hypoglycaemic episodes are at an increased risk for new episodes. Comorbidities, such as Addison's disease, may also be risk factors. These should be considered in patients presenting with a high incidence of new hypoglycaemic episodes, Holl warned. Autoimmune renal insufficiency occurs in 1–2% of children with type 1 diabetes. According to Holl, simultaneous occurrence of undiagnosed coeliac disease and untreated hypothyroidism should be monitored. Migrant background may hamper patient education because of language barriers and therefore severe hypoglycaemic episodes may occur more frequently. Holl questioned whether intensified insulin treatment is still associated with frequent severe hypoglycaemia in 2018. A study from Karges and colleagues demonstrated that this is not the case, and that stricter metabolic control since 2004 with lower glycated haemoglobin (HbA1c) values has not been associated with increased severe hypoglycaemic episodes . 10 Three recent registries in the USA, Australia and Germany did not find this correlation (Figure 2) . 10, 11 Driving Holl briefly covered the topic of "driving a motorised vehicle and diabetes". He quoted the S2 guidelines "Diabetes and traffic regulations of the DDG [German Diabetes Association]" which were implemented in May, 2014, and state that "road safety is primarily endangered by diabetes mellitus when a hypoglycaemic event occurs which may cause a loss of control, behavioural changes or the impairment of consciousness". Therefore, self-awareness of hypoglycaemia is a prerequisite for young drivers. ACUTE COMPLICATIONS – HYPOGLYCAEMIA Presented by Professor Reinhard Holl - University of Ulm