Ulmer H V and Pisarz S Nightly hypoglycaemia

Ulmer, H. -V. and Pisarz, S. Nightly hypoglycaemia, an often not sufficiently known special risk for diabetics (type 1) after intensive physical activities Inst. Sport science Univ. Mainz, ulmer@uni-mainz. de 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia; Ulmer 1

i Introduction, state of knowledge, aim, methods, results, diskussion, i Introduction Exercise/sports is good for diabetics, an often used recommendation. Exercise is a complication for diabetics, however, because carbohydrate supply, insuline dosage and metabolism are to be balanced. This requires experience for the individual case 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 2

i Introduction, state of knowledge, aim, methods, results, diskussion, i Mountaineering/hiking is performed with high physical intensities, often used only few days/year (problem of experience). Consequence: Depletion of glycogen stores, filled up during sleep with the special risk of unnoticed dangerous hypoglycaemia. Informal remarks led to the assumption, that this fill-up effect, especially after intensive physical activities in the afternoon or later, is not sufficiently known. 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 3

i Introduction, state of knowledge, aim, methods, results, diskussion, i Numerous measures are desribed in literature and guidelines against exercise-resulted hypoglycaemia • Frequent prophylactic measures of bloodglucose • Measures in actual case 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 4

i Introduction, state of knowledge, aim, methods, results, diskussion, i Depletion of glycogen stores after muscular activities is a well known effect, e. g. in 2 German guidlines 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 5

i Introduction, state of knowledge, aim, methods, results, diskussion, i German guidelines for diabetics and exersise: 1) Körperliche Aktivität und Diabetes mellitus = physical activity and diabetes mellitus, Evidence-based guideline of the German Diabetes Association DDG (10/2008), planned update: 10/2010 http: //www. deutsche-diabetesgesellschaft. de/fileadmin/Redakteur/Leitlinien/Evidenzbasierte_Leitlinien/EBL_Bewegung_2008. pdf 2) Praxis-oriented guideline Diabetes, Sport und Bewegung = Diabetes, Sports and Movement (Esefeld, K. et al. , last update 2017) from the DDGHomepage https: //www. deutsche-diabetesgesellschaft. de/fileadmin/Redakteur/Leitlinien/Praxisempfehlungen/2017/dus_2017_S 2_Praxisempfehlu ngen_3974253_Halle_Diabetes__Sport_und_Bewegung__13__Online-PDF. PDF 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 6

i Introduction, state of knowledge, aim, methods, results, diskussion, i In both German guidelines for diabetics and exercise the special risk of nightly hypoglycaemia after intensive physical activities at afternoon or evening is not mentioned, however. But recommendation: Sports and games should be promoted as part of quality of life for diabetics (2017) 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 7

i Introduction, state of knowledge, aim, methods, results, diskussion, i Dead-in-bed syndrome Tattersdall, R. B. & Gill, G. V. (1991): Unexplained deaths of type 1 diabetic patients: „There are major difficulties in diagnosing hypoglycaemia post mortem“ but the random conditions suggest, „that hypoglycaemia or a hypoglycaemia-associated event was responsible“ for the 22/50 cases of dead in bed, age 12 -43 years. „Most of whom had gone to bed in apperently good health and 20/22 were found in the morning in an undisturbed bed“. https: //www. ncbi. nlm. nih. gov/pubmed/1826245 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 8

i Introduction, state of knowledge, aim, methods, results, diskussion, i Dead-in-bed syndrome Conclusion of Medtronic to this paper: Schlussfolgerung: „Hypoglykämien bzw. Hypoglykämie-assoziierte Ereignisse zeichnen sich als signifikante Risikofaktoren für das „Tod in Bett“-Syndrom aus“. https: //www. medtronic-community. de/wp-content/uploads/3 -Tattersall-und-Gill_Tod-in-Bett-Syndrom. pdf = Final conclusion: Hypoglycaemia and hypoglycaemia-associated occasions are significant risk factors for the „dead-in-bed syndrome“. But what are: Hypoglycaemia-associated occasions? 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 9

i Introduction, state of knowledge, aim, methods, results, diskussion, i Dead-in-bed syndrome A comment from 2014 focussed to cardiac aspects, too, but mentioned: „Hence, some deaths may have been due to other conditions such as cardiomyopathy or diabetic precoma“ 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 10

i Introduction, state of knowledge, aim, methods, results, diskussion, i • Ischaemic heart deseases are a typical long-term consequence of diabetes type 1 and cardiac attacs can be provocated by hypoglycaemia. • And hypoglycaemia per se as a reason for dead-in-bed cases? 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 11

i Introduction, state of knowledge, aim, methods, results, diskussion, i Aim To clear up these aspects, wether the special risk of nightly hypoglycaemia after intensive physical activities at afternoon or evening is sufficiently known 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 12

i Introduction, state of knowledge, aim, methods, results, diskussion, i To clarify this question, we made literature survey, concerning diabetes type 1: 39 books, 35 additional sources (journals, homepages, information papers), 7 training materials for patients Interviews with 14 diabetes advisers 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 13

i Introduction, state of knowledge, aim, methods, results, diskussion, i Results (state 2013): Scientific literature (books) at 31% (of n=39), additional sources (journals, homepages, information papers, at 23% (of n=35) described this effect. In training materials at 29 % (n=7) explicitly the risk of nightly hypoglycaemia after intensive sports was explained. 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 14

i Introduction, state of knowledge, aim, methods, results, diskussion, i Nightly check of bloodglucose was commended in books: 23% of 39 in additional sources: 3% of 35 in training materials: 22% of 9. 69% oft the 14 diabetes-advisers informed explicitly about the special risk of nightly hypoglycaemia after intensive metabolic/sports activities and 67% recommended a nightly bloodglucose check. Some of them made their own training materials, refering to the risks of nightly hypoglycaemia after sports at afternoon 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 15

i Introduction, state of knowledge, aim, methods, results, diskussion, i Discussion The presented study was done in 2013, but the last update of the German guideline of 2017 shows the similar result: Obviously there is a relevant lack about informations concerning the nightly hypoglycaemia after glucose-consuming activities at afternoon or evening (percentages only about 30 %). Nightly bloodglucose measurements were recommended < 25 %. 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 16

i Introduction, state of knowledge, aim, methods, results, diskussion, i Only the diabetes advisers (ca. 70 %) informed about this special risk including the recommendation: Nightly bloodglucose measurements. And this in contrast to the typical recommendations: – Generally: Propagating aerob activities as „healthy sports“ – For diabetics: Recommendations e. g. in the German guidelines refering to physical activities. 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 17

i Introduction, state of knowledge, aim, methods, results, diskussion, i Considerations about dead-in-bed syndrome: The nightly hypoglycaemia after previous physical activities at afternoon or evening is so insufficient known, that we are not surprized, that we found no comment about a possible interaction with the dead-in-bed syndrome. We assume, that there could be a causal interaction, whitch should regarded in future, not only looking after heart diseases 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 18

in particular i Introduction, state of knowledge, aim, methods, results, diskussion, i Final conclusion and recommendation Hikers and mountaineers as diabetics are endagered in particular, if – they are beginners or – activ only in holidays (less experience in handling bloodglucose in unusal situations). As one prophylactic mean we recommend to use an alarm mobile/clock for checking bloodglucose at about 3 a. m. 9 th Europ. Hypoxia-Symposium, 14 -17 June 2018, Kühroint: Nightly hypoglycaemia, Ulmer 19

Literature • https: //www. medtronic-community. de/wpcontent/uploads/3 -Tattersall-und-Gill_Tod • https: //www. medtronic-community. de/wp-content/uploads/3 -Tattersallund-Gill_Tod-in-Bett-Syndrom. pdf • e 20