1. Hypoglycemia & Hyperglycemia Dave Joffe, BSPharm, CDE, FACA

2. Objectives: Define & assess blood sugar values Causes of hypoglycemia & hyperglycemia including normal causes and medically induced causes. Recognition of hypoglycemia & hyperglycemia Treatment of both hypoglycemia & hyperglycemia depending on the severity of the presentation. The bodies response to changes in blood sugar

3. We Have an Epidemic of Diabetes !! 2010 26mil 2008 24mil

4. Source: 2007–2009 National Health Interview Survey estimates projected to the year 2010.

5. Genes Environment Insulin Resistance + Beta-cell Failure Relative Deficiency in Insulin Type 2 Diabetes Adapted from Kahn CR. Diabetes. 1994;43:1066–1084. Pathogenesis of Type 2 Diabetes Beta Cell Failure and Insulin Resistance

6. Adapted from Kendall D, Bergenstal R. © International Diabetes Center. Glucose (mg/dL) Relative Function (%) 0 100 200 300 -10-5051015202530 50 150 250 350 Years of diabetes Insulin resistance Insulin level Fasting glucose Beta-cell failure Postmeal glucose At risk for diabetes Natural History of Type 2 Diabetes Progression: Beta Cell Failure and Insulin Resistance Pre Diabetes IFG IGT

7. Type 2 Diabetes Increased Hepatic Glucose Production Increased Glucagon Secretion Impaired Incretin Effect 1.Decreased secretion of GLP-1 2.Impaired response to GIP Increased Gastric Emptying Rate Other Aspects of Type 2 Diabetes Pathophysiology Decreased Amylin Secretion

8. Glycemic Goals for all Patients EuglycemicADAAACE/ACEIDF A1C4.4-5.9%< 7%<= 6.5%<6.5% FBG (mg/dl)<10070 – 130< 110 1-2hppBG (mg/dl) <140< 180 (bedtime: < 140) <140<145

9. BP and Lipid Goals ADAAACE/ACEIDF BP (mmHg)<130/80 LDL ( mg/dL)< 100 or <70 < 95 HDL ( mg/dL)> 40 (M) or >50 (F) > 39 TG ( mg/dL)< 150 < 200

10. Relationship Between A1C and Average Blood Glucose A1C (%) Average BG (mg/dL) High Risk for Complications Increasing Risk for Complications Good Control Less Risk for Complications Normal Range Low Risk for Complications 345 320 295 255 225 195 165 135 106 75 13 12 11 10 9 8 7 6 5 4 Data from Diabetes Control and Complications Trial (DCCT). QUALITY OF PATIENT CARE US Average 9.3 US Average 245mg/dl ACE Goal 6.5