• Diabetes Leader Editions

• Philippine Clinical Practice
  Guidelines for Diabetes

• Article of the Month

ARTICLE OF THE MONTH

HYPOGLYCEMIA

By: Maria Jocelyn C. Isidro, MD

The management of diabetes becomes a challenge to patients and their relatives because most often than not, they need to do a balancing act in order to manage it properly. This is to maintain the balance between the highs and lows of blood sugars. Low blood sugar or hypoglycemia is one of the most common feared complications in diabetes management. In a patient with well controlled blood sugar, a level of 70 mg/dl and below is considered low. However, among patients whose blood sugars have not been well controlled for a long time and then suddenly are reaching target sugar levels may have the signs and symptoms of hypoglycemia with normal or at higher blood sugar levels. This is what is termed as relative hypoglycemia. Moreover, hypoglycemic patients may not have the warning signs and symptoms of hypoglycemia despite a very low blood sugar level. This is what is termed as hypoglycemia unawareness. The former, occurs because the brain and the body got used to high levels of blood sugar which considered them as the “new normal” levels. Hence, normal levels or levels that are relatively lower than their usual are sensed as low already. The latter occurs because the repeated bouts of hypoglycemia lead to changes on how the body reacts to low blood sugar levels. The body stops releasing stress hormones particularly “epinephrine” which brings about cold sweats, tremors and palpitations as warning signs and symptoms of low blood sugar level, hence; patients do not have the typical signs and symptoms of hypoglycemia when their blood sugar is low. Hypoglycemia unawareness and the occurrence of relative hypoglycemia are not permanent. For many patients, the symptoms of low blood sugar as warning signals return at appropriate blood sugar levels once they have stable blood sugar control. Below are some clues and tips on how to identify, manage and prevent the occurrence of hypoglycemic episodes.

  1. What are the signs and symptoms of low blood sugar?

  2. Hypoglycemia or low blood sugar means that our body particularly the brain do not get enough sugar supply. Hence, patients feel weak, lethargic, dizzy, complains of cold sweats, experiences palpitations and blurry vision. Mild hypoglycemia means that the patient can still take care of himself to increase his blood sugar. A very low blood sugar level can even lead to confusion, seizure, coma or even death, termed as severe hypoglycemia.

  3. What are the causes of hypoglycemia?

    1. Wrong dose of anti-diabetic medications: Patients with wrong dose or too high a dose of medications that lower blood sugar levels which include insulin or medications that release insulin from the pancreas like sulfonylureas (Glibenclamide, Glimepiride, Gliclazide) or Meglitinides (Repaglinide) or Nateglinide are prone to develop hypoglycemia.

    2. Patients who skip or eat delayed meals: Patients on anti-diabetic medications be it oral or thru injections are expected to eat their meals on time. Failure to do so will predispose them to hypoglycemia particularly if they are taking their medications even when they are not eating on time.

    3. Unplanned exercise or exercise without snacks or adjustment of medications: Exercises particularly vigorous ones consume a lot of energy hence, patients on medications are advised to eat small snacks prior to exercise or adjust the dose and timing of their medications if exercise is anticipated. The adjustment of medication dose or its timing has to be prescribed by the doctor.

    4. Alcoholism: Alcohol acts on the pancreas by prolonging the late phase insulin secretion which predisposes to hypoglycemia. Patients who also have co existing liver diseases are more prone to develop hypoglycemia since the liver can no longer store sugars that can be released during initial lowering of blood sugar levels during alcohol binge. .

  4. How to prevent hypoglycemia?

  5. Hypoglycemia can be prevented by regular monitoring of blood sugars especially when the patient is sick or is not eating his meals on time. It can also be prevented by taking the prescribed medications on time and with the correct dose. In times of sickness or when the patient has vomiting, diarrhea or with poor appetite, anti-diabetic medications particularly insulin must be withheld. Similarly, adequate patient and family education and counselling on the signs and symptoms of hypoglycemia plays an important role in preventing its occurrence. Alcohol intake has to be limited or stopped as this can also increase the risk for hypoglycemia.

    On the other hand, in order to rapidly correct hypoglycemia, patients are advised to keep some sugars or sweets handy so that hypoglycemia can be properly addressed right away when it is still mild. Patients are also advised to always wear their medical alert identification bracelets at all times.

  6. How to manage hypoglycemia?

  7. When patients experience mild hypoglycemic symptoms, the immediate treatment is to check blood sugar with glucose meter. However, in the absence of a glucometer, patients who are symptomatic must be advised to act as if they are hypoglycemic. They can be given ½ glass of juice or regular soda or approximately 15-20 grams of glucose. Blood sugar maybe checked after 15 minutes and every 30-60 minutes until blood sugars are stable. If blood sugar is severely low and the patient is not conscious, emergency hotline must be accessed for prompt response then the patient must be brought to a hospital right away.

    Hypoglycemia is indeed part and parcel of diabetes management. It is worthwhile to recognize it and manage it appropriately in order to prevent its severe complications. Management of hypoglycemia requires a team effort which include the physicians, diabetes educators, patients and their families in order to recognize its symptoms, prevent its occurrence and manage it accurately to prevent its long term or immediate complications.