HYPOGLYCEMIA

BACKGROUND

Glucose is very important for the normal functioning of our body organs, including our brain, even when we are sleeping. It is the main source of energy for the body. When the blood glucose level or blood sugar level drops from the normal level, which is between 70 to 140 mg / dl (milligrams of glucose per decilitre of blood) depending on the last consumed meal, the disorder is known as hypoglycemia.

Hypoglycemia is a common disorder in people diagnosed with diabetes. In such cases, this disorder may be triggered by:

• Consuming too much medication for controlling blood sugar levels
• A missed or delayed meal
• Giving the wrong type of insulin at the wrong time
• Strenuous exercising over a long time period
• Any emotional stress
• Diarrhoea or vomiting
• Any other disorder associated with type 1 diabetes, such as an adrenal problem or celiac disease

Hypoglycemia may also occur in people who do not have diabetes. It may occur only as a single incidence of hypoglycemia, caused by any illness that prevents you from eating properly, such as stomach flu, or prolonged periods of fasting, or exercising vigorously over a long period without food.

In other cases, you may experience repeated episodes of hypoglycemia, even if you are not diabetic. This may occur because of a medication you may be taking which affects your blood sugar levels, or a disorder affecting metabolism that you may be suffering from.

DISEASE OCCURRENCE IN POPULATION:

Hypoglycemia is common in type 1 diabetes, especially in patients receiving intensive insulin therapy, in whom the risk of severe hypoglycemia is increased more than threefold in the Diabetes Control and Complications Trial (DCCT). Patients with type 1 diabetes may suffer an average of two episodes of symptomatic hypoglycemia per week, thousands of such episodes over a lifetime of diabetes, and one episode of severe, at least temporarily disabling hypoglycemia per year.

Hypoglycemia is less frequent in type 2 diabetes than it is in type 1. Population-based data indicate that the overall event rate for severe hypoglycemia (requiring the assistance of another individual) in insulin-treated type 2 diabetes is approximately 30 percent of that in type 1 diabetes and that event rates for hypoglycemia requiring professional emergency medical treatment range from 40 to 100 percent of those in type 1 diabetes.

In contrast to patients with diabetes, hypoglycemia is uncommon in individuals who do not have drug-treated diabetes mellitus.

RISK FACTORS:

Risk factors for nondiabetic patients include:

• Certain medicines
• Diseases of theliver, kidneys, or pancreas
• Metabolic problems
• Alcohol use
• Stomachsurgery
• Low economic status
• Low health literacy

Risk factors for diabetic patients include:

• Incorrect dosing of glucose-lowering medications such as sulfonylureas and insulin
• Skipping meals, eating smaller meals, and having irregular eating patterns
• Increased physical activity may increase hypoglycemia by increasing insulin sensitivity.
• Drug or alcohol consumption
• Older age
• Longer duration of diabetes
• Intensive insulin therapy
• Peripheral neuropathy
• Obesity
• Stress
• Hypoglycemia unawareness
• Cognitive dysfunction
• Medicines such as beta blockers, and ACE inhibitors.
• Prior episode of severe hypoglycemia
• Liver diseases such as hepatitis and cirrhosis as well as kidney diseases
• Low economic status
• Low health literacy

SIGN AND SYMPTOMS:

The symptoms of low blood sugar vary from person to person, and can change over time. During the early stages of low blood sugar, you may experience:

• Cold sweat
• Tremble
• Feel hungry
• Feel anxious
• Dizziness
• Headaches
• Irritability
• Paleness

If untreated, your symptoms can become more severe, and can include:

• Clumsiness
• Tingling sensation around the mouth
• Rapid heart rate
• Difficulty walking
• Weakness
• Difficulty seeing clearly
• Bizarre behavior or personality changes
• Confusion
• Unconsciousness or seizure

When possible, you should confirm that you have low blood sugar by measuring your blood sugar. Low blood sugar is generally defined as a blood sugar of 60 mg / dL (3.3 mmol / L) or less.

Some people with diabetes develop symptoms of low blood sugar at slightly higher levels. If your blood sugar levels are high for long periods of time, you may have symptoms and feel poorly when your blood sugar is closer to 100 mg / dL (5.6 mmol / L). Getting your blood sugar under better control can help to lower the blood sugar level when you begin to feel symptoms.

DIAGNOSTIC TEST:

Doctor will take your medical history to find out the specific characteristics of symptoms and whether you have been diagnosed with diabetes in the past. The doctor will also request blood test to check the level of glucose.

In general, the following are the criteria for evaluating if you may be suffering from hypoglycemia, also known as the ‘whipple triad’:

• Characteristic signs and symptoms of hypoglycemia
• Low blood glucose level
• Relief in symptoms when the your’s blood glucose level is raised to normal

In some cases, the doctor may also request additional tests to assess your insulin level. In yet other cases, you may have to undergo a fasting study to collect blood samples and check blood glucose levels over a period of several hours.

TREATMENT OPTIONS:

When you are low, you should check your blood sugar level as soon as possible. However, go ahead and treat yourself for low blood sugar if your monitoring equipment (blood glucose meter, test strips, lancet) is not readily available. Treat yourself quickly, especially if your blood sugar is less than 40 mg/dL (2.2 mmol/L).

• If your blood sugar is 51 to 70 mg / dL (2.8 to 3.9 mmol / L), eat 10 to 15 grams of fast-acting carbohydrate (e.g. 1/2 cup fruit juice, 6 to 8 hard candies, 3 to 4 glucose tablets).
• If you are less than 50 mg / dL (2.8 mmol / L), eat 20 to 30 grams of fast-acting carbohydrates.

This amount of food is usually enough to raise the blood sugar into a safe range without causing high blood sugar levels (called hyperglycemia). Avoid foods that contain fat (like candy bars) or protein (cheese) initially, since they slow down your body's ability to absorb glucose.

Retest after 15 minutes and repeat treatment if needed. If your next meal is more than an hour away, eat an additional 15 grams of carbohydrate and 1 ounce of protein. Examples of this include crackers with cheese or one-half of a sandwich with peanut butter. It is important not to eat too much because this can raise your blood sugar above the target level and lead to weight gain over the long-term.

GLUCAGON: If your low blood sugar is severe, you may pass out or become too disoriented to eat. A close friend or relative should be trained to recognize severe low blood sugar and treat it quickly. Dealing with a loved one who is pale, sweaty, acting bizarrely, or is passed out and convulsing can be scary. An injection of glucagon stops these symptoms quickly.

Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits, which can be bought with a prescription in a pharmacy. Directions are included in each kit; a roommate, spouse, or parent should learn how to use the injection before an emergency occurs.

PROCEDURE: Glucagon should be injected in the thigh or abdomen. The injection sites and technique are similar to an insulin injection.

• Remove the needle protector and inject the entire content of the syringe (a clear solution) into the glucagon powder. Do not remove the plastic clip on the syringe. Remove the needle from the bottle.
• Swirl the mixture gently until the powder is dissolved. The solution should be clear. Do not use the solution if it is discolored.
• Hold the bottle upside down and withdraw the contents into the syringe (1 mg mark on syringe for adults and children over 44 pounds [20 kilograms]). Children under 44 pounds need one-half the dose, and only 1/2 the solution should be withdrawn (0.5 mg mark on syringe).
• Choose an injection site in the abdomen or thigh
• Insert the needle into the skin
• Press the plunger to inject the glucagon.
• Withdraw the needle, and replace the syringe in the storage case (do not attempt to re-cap the needle). Press lightly at the injection site.
• Turn the person to his or her side. This prevents choking if he/she vomits.

Symptoms should resolve within 10 to 15 minutes, although nausea and vomiting may follow 60 to 90 minutes later. As soon as the person is awake and able to swallow, offer a fast-acting carbohydrate such as glucose tablets or juice. After the person begins to feel better, he or she should eat a snack with protein, such as crackers and cheese or a peanut butter sandwich.

If the patient is not conscious within 10 minutes, another glucagon injection should be given, if a second kit is available. Emergency help should be called immediately.

If your hypoglycemia is caused by certain medications used for diabetes (people with either type 1 or type 2 diabetes can become hypoglycemic), your healthcare professional may suggest several things to help you treat hypoglycemia when it happens. He or she may also suggest adjustments in your diabetes treatment plan to help you prevent hypoglycemia. The doctor may suggest:

• Medication (e.g. insulin certain oral medications) dose adjustment: This may also include changing when you take your medication.
• Working with a dietitian to develop or adjust your meal plan: A dietitian can help you figure out a good meal plan for example, one that maintains consistency in carbohydrates at meals. A dietitian can also help you learn how to count grams of carbohydrates so that you can better plan your medication and / or insulin.
• Increase (or more closely follow) self-monitoring of blood glucose levels: Knowing your blood glucose level throughout the day, when you get up, before meals, after meals, etc. can help you avoid going low.

PRECAUTIONS:

The best way to prevent low blood sugar is to monitor your blood sugar levels frequently and be prepared to treat it promptly at all times. You and a close friend or relative need to learn the symptoms and should always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate. If you are diabetic, you can also follow below mentioned instruction to prevent hypoglycemia:

• Don't skip or delay meals or snacks: If you take insulin or oral diabetes medication, be consistent about the amount you eat and the timing of your meals and snacks.
• Monitor your blood sugar:Depending on your treatment plan, you may check and record your blood sugar level several times a week or several times a day. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range.
• Measure medication carefully, and take it on time: Take your medication as recommended by your doctor.
• Adjust your medication or eat additional snacks if you increase your physical activity: The adjustment depends on the blood sugar test results and on the type and length of the activity.

Eat a meal or snack with alcohol, if you choose to drink: Drinking alcohol on an empty stomach can cause hypoglycemia.