Page 72 - Retail Pharmacy November/Decemeber 2020

Protocol for the management of non-severe hypoglycaemia in children and adolescents3 The Therapeutic Guidelines advise that for children and adolescents who have a blood glucose reading of less than 4mmol/lt and are conscious and cooperative, short acting carbohydrate is to be given. If 15 minutes later, the blood glucose is still below 4mmol/ lt, the short acting carbohydrate should be repeated, or if above 4mmol/lt, a long acting carbohydrate should be given. Note that Therapeutic Guidelines advise that short acting carbohydrate should be 5g for children aged five years or younger (or who weigh up to 25kg) and 10g for children six years old and older (or who weigh more than 25kg).3 The patient must seek medical advice if more than three short acting carbohydrate portions are needed to restore blood glucose concentration. It’s important to note that guidelines vary in their portion requirements of short acting carbohydrate for children in the acute treatment of hypoglycaemia. The Australian Diabetes Society’s ‘National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults’ advises the amount of short acting carbohydrate required for children and adolescents for hypoglycaemia acute treatment is 10g to 20g.21 UpToDate, however, recommends 0.3mg/kg of short acting carbohydrate.28 Given the variation in available guidelines, the dose of rapid acting carbohydrate required for children and adolescents for a hypoglycaemic event should be proactively discussed with a diabetes educator and/or endocrinologist on an ongoing basis to ensure treatment is effective. A glucagon mini dose may be required in non-severe hypoglycaemia or if hypoglycaemia is imminent (blood glucose less than 4.4mmol/lt) in children and adolescents if administering oral short acting carbohydrate is impractical (eg, vomiting, child refusing to swallow).3 For children aged two years and younger, 20mcg of glucagon can be administered intramuscularly or subcutaneously, and for children three years to 15 years, 10mcg per year of age (up to 150mcg of glucagon) can be administered, while adolescents aged over 15 years can be given 150mcg of glucagon.38 Glucagon can be measured using a 100-unit insulin syringe where one unit of the insulin syringe equals 10mcg of glucagon when drawing up 1mg/ml reconstituted glucagon.3 If the child has been administered with a glucagon mini dose, the blood Figure 1. GlucaGen Hypokit (glucagon) preparation Source: GlucaGen Consumer Medicine Information. 2015. Available: ebs.tga.gov.au/ebs/picmi/picmirepository. nsf/pdf?OpenAgent&id=CP-2010-CMI-02766-3 \[Accessed: 20 October 2020\] glucose should be checked 30 minutes after the dose and if blood glucose has not increased to more than 5.5 mmol/lt, doubling the previous glucagon mini dose should be considered.38 If the blood glucose has increased to more than 5.5mmol/lt, hourly monitoring of blood glucose should occur and a reduction of the next insulin dose by 10 per cent is advised.38 If oral intake has not resumed, glucagon can be repeated in two to three hours.3 If the non-severe hypoglycaemia is ongoing and regular oral intake hasn’t resumed, the child should be given an intravenous glucose infusion in hospital.3 The goal of mini-dose glucagon is to allow the child to recover sufficiently to tolerate small amounts (sips) of sugar-containing fluids and reduce likelihood of an emergency department admission.38 Adverse effects from large doses of glucagon are nausea and vomiting, which is why mini doses are favourably used in a non-severe setting where oral intake is not practical.38 Protocol for the management of severe hypoglycaemia in adults, adolescents and children3 Severe hypoglycaemia in someone who is unconscious is a medical emergency.3 In the case of severe hypoglycaemia, the patient should be put onto their side to ensure clear airways, glucagon should be administered, and an ambulance called.36 Severe hypoglycaemia can be confirmed with a blood glucose test. However, if testing is likely to delay treatment then treatment should be commenced.3 Treatment is either via glucagon injection, intravenous glucose infusion or both.3 In a community setting glucagon will be administered in the first instance as this is what is readily available. In Australia, glucagon is available over the counter as a Schedule 3 product and is also available on the PBS on prescription.39,40 Glucagon causes nausea and vomiting as an adverse effect, once patients regain consciousness.20 The process of reconstituting GlucaGen Hypokit is represented in Figure 1. Adult patients can respond to glucagon in eight minutes.3 If a patient is not responding, it could mean insufficient glucose is stored in the liver and intravenous glucose therapy will have to be commenced.3 If a patient has not responded to the first dose of glucagon and an ambulance has not arrived yet, a second dose of glucagon can be administered 20 minutes after the first dose.3 Once consciousness has been regained, oral glucose can be given to the patient.3 Glucagon is to be administered 1mg intramuscularly or subcutaneously in adults, children and adolescents over 25kg. For children less than 25kg, the dose is 0.5mg.3 Families, friends, carers and colleagues of patients with type 1 diabetes and those with type 2 diabetes at high risk of hypoglycaemia should be educated on how to administer glucagon.3 After an episode of severe hypoglycaemia, close follow-up is required, including increased blood glucose monitoring, identifying the cause of hypoglycaemia and adjusting medication doses if needed.3 The patient is at high risk of another episode of hypoglycaemia in the 48 hours following a severe episode.3 Driving may not be resumed until the patient has been assessed by a diabetes specialist, and there is often a minimum period of six weeks before a patient may return to driving.41 Driving and hypoglycaemia Hypoglycaemia can be a serious risk to safety when driving.42 The National Diabetes Services Scheme promotes awareness with the notion ‘Don’t drive under five’.42 Patients should check blood glucose before driving, to ensure it’s over 5mmol/lt. If their blood glucose is less than 5mmol/lt, the patient should be treated as though they have hypoglycaemia and should not drive until the blood glucose has consistently been above 5mmol/lt for 30 minutes. This is to allow time for the brain to recover from the hypoglycaemia.42 If a patient feels the symptoms of hypoglycaemia when driving, they should pull the car over safely, turn off the engine and remove the key from the ignition, check blood glucose and treat for hypoglycaemia if necessary.42 It’s recommended that patients with diabetes bring both fast and long acting carbohydrate foods or drinks with them TO PAGE 72 RETAIL PHARMACY • NOV/DEC 2020 CPD ACTIVITY 71