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.
Being able to recognize hypoglycemia
promptly is very important because it allows you to take steps to
raise your blood glucose as quickly as possible. However, some people
with diabetes don’t sense or don’t experience the early warning
signs of hypoglycemia such as weakness, shakiness, clamminess,
hunger, and an increase in heart rate. This is called hypoglycemia
unawareness. Without these early warnings and prompt treatment,
hypoglycemia can progress to confusion, which can impair your
thinking and ability to treat the hypoglycemia.
If the goals you have set for your
personal blood glucose control are “tight” and you are having
frequent episodes of hypoglycemia, your brain may feel comfortable
with these low levels and not respond with the typical warning signs.
Frequent episodes of hypoglycemia can further blunt your body’s
response to low blood glucose. Some drugs, such as beta-blockers
(taken for high blood pressure), can also mask the symptoms of
hypoglycemia.
If you have hypoglycemia frequently,
you may need to raise your blood glucose targets, and you should
monitor your blood glucose level more frequently and avoid alcohol.
You may also need to adjust your diabetes medicines or insulin doses.
Talk to your diabetes care team if you experience several episodes
of hypoglycemia a week, have hypoglycemia during the night, have such
low blood glucose that you require help from someone else to treat
it, or find you are frequently eating snacks that you don’t want
simply to avoid low blood glucose.
Anyone at risk for hypoglycemia should
know how to treat it and be prepared to do so at any time. Here’s
what to do: If you recognize symptoms of hypoglycemia, check your
blood glucose level with your meter to make sure. While the symptoms
are useful, the numbers are facts, and other situations, such as
panic attacks or heart problems, can lead to similar symptoms. In
some cases, people who have had chronically high blood glucose levels
may experience symptoms of hypoglycemia when their blood glucose
level drops to a more normal range, called false low. The usual
recommendation is not to treat normal or goal-range blood glucose
levels, even if symptoms are present.
Treatment is usually recommended for
blood glucose levels of 70 mg/dl or less. However, this may vary
among individuals. For example, blood glucose goals are lower in
women with diabetes who are pregnant, so they may be advised to treat
for hypoglycemia at a level below 70 mg/dl. People who have
hypoglycemia unawareness, are elderly, or live alone may be advised
to treat at a blood glucose level somewhat higher than 70 mg/dl.
Young children are often given slightly higher targets for treating
hypoglycemia for safety reasons. Work with your diabetes care team
to devise a plan for treating hypoglycemia that is right for you.
To treat hypoglycemia, follow the “rule
of 15”: Check your blood glucose level with your meter, treat a
blood glucose level under 70 mg/dl by consuming 15 grams of
carbohydrate, wait about 15 minutes, then recheck your blood glucose
level with your meter. If your blood glucose is still low (below 80
mg/dl), consume another 15 grams of carbohydrate and recheck 15
minutes later. You may need a small snack if
your next planned meal is more than an hour away. Since blood
glucose levels may begin to drop again about 40–60 minutes after
treatment, it may be a good idea to recheck your blood glucose level
approximately an hour after treating a low to determine if additional
carbohydrate is needed.
The following items have about 15 grams
of carbohydrate:
- 3–4 glucose tablets
- 1 dose of glucose gel (in most cases, 1 small tube is 1 dose)
- 1/2 cup of orange juice or regular soda (not sugar-free)
- 1 tablespoon of honey or syrup
- 1 tablespoon of sugar or 5 small sugar cubes
- 6–8 LifeSavers
- 8 ounces of skim (nonfat) milk
If these choices are not available, use
any carbohydrate that is — for example, bread, crackers, grapes,
etc. The form of carbohydrate is not important; treating the low
blood glucose is. (However, many people find they are less likely to
overtreat low blood glucose if they consistently treat lows with a
more “medicinal” form of carbohydrate such as glucose tablets or
gel.)
If you take insulin or a secretagogue
and are also taking an alpha-glucosidase inhibitor (acarbose or
miglitol), carbohydrate digestion and absorption is decreased, and
the recommended treatment is glucose tablets or glucose gel.
Other nutrients in food such as fat or
resistant starch (which is present in some diabetes snack bars) can
delay glucose digestion and absorption, so foods containing these
ingredients are not good choices for treating hypoglycemia.
If hypoglycemia becomes severe and a
person is confused, convulsing, or unconscious, treatment options
include intravenous glucose administered by medical personnel or
glucagon by injection given by someone trained in its use and
familiar with the recipient’s diabetes history. Glucagon is a
hormone that is normally produced by the pancreas and that causes the
liver to release glucose into the bloodstream, raising the blood
glucose level. It comes in a kit that can be used in an emergency
situation (such as when a person is unable to swallow a source of
glucose by mouth). The hormone is injected much like an insulin
injection, usually in an area of fatty tissue, such as the stomach or
back of the arms. Special precautions are necessary to ensure that
the injection is given correctly and that the person receiving the
injection is positioned properly prior to receiving the drug. People
at higher risk of developing hypoglycemia should discuss the use of
glucagon with their diabetes educator, doctor, or pharmacist.
End of part 3 of 4 parts.
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