Hypoglycemia is the most common side
effect of insulin use and of some of the oral medicines used to treat
Type 2 diabetes. How likely a drug is to cause hypoglycemia and the
appropriate treatment for hypoglycemia depends on the type of drug.
Secretagogues. Oral medicines
that stimulate the pancreas to release more insulin, which include
sulfonylureas and the drugs nateglinide (brand name Starlix) and
repaglinide (Prandin), have the potential side effect of
hypoglycemia. Sulfonylureas include glimepiride (Amaryl), glipizide
(Glucotrol and Glucotrol XL), and glyburide (DiaBeta, Micronase, and
Glynase).
Sulfonylureas are taken once or twice a
day, in the morning and the evening, and their blood-glucose-lowering
effects last all day. If you miss a meal or snack, the medicine
continues to work, and your blood glucose level may drop too low.
So-called sulfa antibiotics (those that contain the ingredient
sulfamethoxazole) can also increase the risk of hypoglycemia when
taken with a sulfonylurea. Anyone who takes a sulfonylurea,
therefore, should discuss this potential drug interaction with their
health-care provider should antibiotic therapy be necessary.
Nateglinide and repaglinide are taken
with meals and act for only a short time. The risk of hypoglycemia is
lower than for sulfonylureas, but it is still possible to develop
hypoglycemia if a dose of nateglinide or repaglinide is taken without
food.
Insulin. All people with Type 1
diabetes and many with Type 2 use insulin for blood glucose control.
Since insulin can cause hypoglycemia, it is important for those who
use it to understand how it works and when its activity is greatest,
so they can properly balance food and activity and take precautions
to avoid hypoglycemia. This is best discussed with a health-care
provider who is knowledgeable about you, your lifestyle, and the
particular insulin regimen you are using.
Biguanides and thiazolidinediones.
The biguanides, of which metformin is the only one approved in
the United States, decrease the amount of glucose manufactured by the
liver. The thiazolidinediones, pioglitazone (Actos) and
rosiglitazone (Avandia), help body cells become more sensitive to
insulin. The risk of hypoglycemia is very low with these medicines.
However, if you take metformin, pioglitazone, or rosiglitazone along
with either insulin or a secretagogue, hypoglycemia is a possibility.
Alpha-glucosidase inhibitors.
Drugs in this class, acarbose (Precose) and miglitol (Glyset),
interfere with the digestion of carbohydrates to glucose and help to
lower blood glucose levels after meals. When taken alone, these
medicines do not cause hypoglycemia, but if combined with either
insulin or a secretagogue, hypoglycemia is possible. Because
alpha-glucosidase inhibitors interfere with the digestion of some
types of carbohydrate, hypoglycemia can only be treated with pure
glucose (also called dextrose or d-glucose), which is sold in tablets
and tubes of gel. Other carbohydrates will not raise blood glucose
levels quickly enough to treat hypoglycemia.
Although hypoglycemia is called a side
effect of some of the drugs used to lower blood glucose levels, it
would be more accurate to call it a potential side effect of diabetes
treatment — which includes food and activity as well as drug
treatment. When there is a disruption in the balance of these
different components of diabetes treatment, hypoglycemia can result.
The following are some examples of how
that balance commonly is disrupted:
#1. Skipping or delaying a meal.
When you take insulin or a drug that increases the amount of insulin
in your system, not eating enough food at the times the insulin or
drug is working can cause hypoglycemia. Learning to balance food
with insulin or oral drugs is key to achieving optimal blood glucose
control while avoiding hypoglycemia.
#2. Too much diabetes medicine. If
you take more than your prescribed dose of insulin or a secretagogue,
there can be too much insulin circulating in your bloodstream, and
hypoglycemia can occur. Changes in the timing of insulin or oral
medicines can also cause hypoglycemia if your medicine and food plan
are no longer properly matched.
#3. Increase in physical activity.
Physical activity and exercise lower blood glucose level by
increasing insulin sensitivity. This is generally beneficial in
blood glucose control, but it can increase the risk of hypoglycemia
in people who use insulin or secretagogues if the exercise is very
vigorous, carbohydrate intake too low, or the activity takes place at
the time when the insulin or secretagogue has the greatest (peak)
action. Exercise-related hypoglycemia can occur as much as 24 hours
after the activity.
#4. Increase in rate of insulin
absorption. This may occur if the temperature of the skin
increases due to exposure to hot water or the sun. Also, if insulin
is injected into a muscle that is used in exercise soon after (such
as injecting your thigh area, then jogging), the rate of absorption
may increase.
#5. Alcohol. Consuming alcohol
can cause hypoglycemia in people who take insulin or a secretagogue.
When the liver is metabolizing alcohol, it is less able to break down
glycogen to make glucose when blood glucose levels drop. In addition
to causing hypoglycemia, this can increase the severity of
hypoglycemia. Alcohol can also contribute to hypoglycemia by
reducing appetite and impairing thinking and judgment.
End of part 2 of 4 parts.
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