Hypoglycemic unawareness and medication adjustment -
Thus, if you have nocturnal hypoglycemia, you are less likely to have symptoms that alert you to the need for treatment. Nocturnal hypoglycemia can be difficult to diagnose and can increase the risk of hypoglycemia unawareness in the 48 to 72 hours that follow.
To prevent low blood glucose, it is important to monitor your blood glucose levels frequently and be prepared to treat it promptly at any time. Continuous glucose monitoring can help prevent hypoglycemia if you have type 1 diabetes or if you have type 2 diabetes and take insulin or other medication s that increases risk for hypoglycemia.
Continuous glucose monitoring can alert you to a low or falling blood glucose level so that you can take action to avoid severe hypoglycemia. You and a close friend or relative should learn the symptoms of hypoglycemia and always carry glucose tablets, hard candy, or other sources of fast-acting carbohydrate so you can treat low blood glucose if it does happen.
If you experience low blood glucose levels, let your health care provider know. They can help adjust your diabetes treatment plan to reduce the chances of hypoglycemia happening again. They can also talk to you about blood glucose awareness education.
Blood glucose awareness training can improve your ability to recognize low blood glucose earlier, which will allow you to treat it quickly and avoid more serious symptoms.
A trained diabetes educator can also work with you to help you anticipate when low glucose levels are more likely to happen. Low blood glucose can be frightening and unpleasant.
If you have experienced this before, you may be worried or anxious about the possibility of it happening again. However, it's important to talk to your health care provider and not just intentionally keep your blood glucose high because of this.
High blood glucose levels can lead to serious long-term complications. See "Patient education: Preventing complications from diabetes Beyond the Basics ". The treatment of low blood glucose depends on whether you have symptoms and how severe the symptoms are.
No symptoms — Your health care provider will talk to you about what to do if you check your blood glucose and it is low, but you have no noticeable symptoms. They might recommend checking your levels again after a short time, avoiding activities like driving, or eating something with carbohydrates.
Early symptoms — If you have early symptoms of low blood glucose, you should check your level as soon as possible. However, if your monitoring equipment is not readily available, you can go ahead and give yourself treatment.
It's important to treat low blood glucose as soon as possible. To treat low blood glucose, eat 15 grams of fast-acting carbohydrate.
This amount of food is usually enough to raise your blood glucose into a safe range without causing it to get too high. Avoid foods that contain fat like candy bars or protein such as cheese initially, since they slow down your body's ability to absorb glucose.
Check your blood glucose again after 15 minutes and repeat treatment if your level is still low. Monitor your blood glucose levels more frequently for the next few hours to ensure your blood glucose levels are not low. Severe symptoms — If your blood glucose is very low, you may pass out or become too disoriented to eat.
A close friend or relative should be trained to recognize severe low blood glucose and treat it quickly. Dealing with a loved one who is pale, sweaty, acting bizarrely, or passed out and convulsing can be scary. A dose of glucagon stops these symptoms quickly if they are caused by hypoglycemia.
Glucagon is a hormone that raises blood glucose levels. Glucagon is available in emergency kits as an injection or a nasal spray , which can be bought with a prescription in a pharmacy.
Directions are included in each kit; a roommate, partner, parent, or friend should learn how to give glucagon before an emergency occurs. It is important that your glucagon kit is easy to locate, is not expired, and that the friend or relative is able to stay calm.
You should refill the kit when the expiration date approaches, although using an expired kit is unlikely to cause harm. This releases the powder into the person's nostril without requiring them to inhale or do anything else. If you have to give another person glucagon, turn them onto their side afterwards.
This prevents choking if they vomit, which sometimes happens. Low blood glucose symptoms should resolve within 10 to 15 minutes after a dose of glucagon, 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. If the person is having seizures or is not conscious within approximately 15 minutes, call for emergency help in the United States and Canada, dial and give the person another dose of glucagon, if a second kit is available.
FOLLOW-UP CARE. After your blood glucose level normalizes and your symptoms are gone, you can usually resume your normal activities. If you required glucagon, you should call your health care provider right away. They can help you to determine how and why you developed severely low blood glucose and can suggest adjustments to prevent future reactions.
In the first 48 to 72 hours after a low blood glucose episode, you may have difficulty recognizing the symptoms of low blood glucose. In addition, your body's ability to counteract low blood glucose levels is decreased.
Check your blood glucose level before you eat, exercise, or drive to avoid another low blood glucose episode. WHEN TO SEEK HELP. A family member or friend should take you to the hospital or call for emergency assistance immediately if you:.
Once in a hospital or ambulance, you will be given treatment intravenously by IV to raise your blood glucose level immediately. If you require emergency care, you may be observed in the emergency department for a few hours before being released. In this situation, you will need someone else to drive you home.
Your health care provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our website www.
Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below. Patient level information — UpToDate offers two types of patient education materials. The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Type 1 diabetes The Basics Patient education: Low blood sugar in people with diabetes The Basics Patient education: Diabetes and diet The Basics Patient education: Should I switch to an insulin pump?
The Basics. Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Type 1 diabetes: Insulin treatment Beyond the Basics Patient education: Type 1 diabetes: Overview Beyond the Basics Patient education: Exercise and medical care for people with type 2 diabetes Beyond the Basics Patient education: Type 2 diabetes: Overview Beyond the Basics Patient education: Type 2 diabetes: Treatment Beyond the Basics Patient education: Preventing complications from diabetes Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. Alterations in the counterregulatory response to hypoglycemia in patients with type 1 or type 2 diabetes have been described in detail elsewhere.
Therefore, the thrust of the acute counterregulatory response is carried by epinephrine. Unfortunately, the counterregulatory response is blunted in many patients because of insulin-induced hypoglycemia. In addition to a reduction in epinephrine secretion, a reduction in peripheral sensitivity to epinephrine has also been reported.
Therefore, with the development of hypoglycemia unawareness, a causal nexus is established in which hypoglycemia causes hypoglycemia unawareness, which in turn results in worsening hypoglycemia.
Patients with type 2 diabetes may also experience hypoglycemia unawareness. Patients early in the course of their disease probably retain most of theirα-cell response glucagon to hypoglycemia, whereas patients with advanced type 2 disease have virtually no α-cell response to hypoglycemia.
A discussion of the effects of medications on hypoglycemia unawareness would be incomplete without the mention of insulin. As previously noted,insulin-induced antecedent hypoglycemia is a strong predictor of subsequent hypoglycemia unawareness.
In addition, ever since human insulin was introduced as a pharmacological agent, there has been concern that it might be associated with a higher incidence of hypoglycemia unawareness than insulin from animal sources.
One of the early double-blind, randomized, crossover trials comparing porcine to human insulin reported that the initial symptoms of hypoglycemia with human insulin were more often neuroglycopenic, whereas the symptoms associated with porcine insulin were more often adrenergic.
Glycemic threshold values for counterregulatory response to and physical consequences of insulin-induced hypoglycemia. Adapted from Ref.
EF1 1. However, the study did not compare these findings to patients who had continued on animal-source insulin. The fraction of patients reporting altered symptoms of hypoglycemia was consistent with the fraction of all long-term patients reporting these changes. One study 13 evaluating patients who reported that they had developed hypoglycemia unawareness after being switched to human insulin reported no differences in symptomatic or hormonal responses to hypoglycemia.
A recent review of 45 randomized controlled studies comparing animal to human insulin concluded that most of the published studies were poorly designed. Theoretically, almost any medication that alters the effects of epinephrine could have potential effects on glucose homeostasis and the hypoglycemic counterregulatory system.
Concerns have been raised for years regarding potential and reported adverse glycemic effects of the β-adrenergic antagonists β-blockers. Even ophthalmic dosage forms ofβ-adrenergic antagonists have been reported to cause hypoglycemia in a patient with type 1 diabetes.
Hypoglycemia may be a possible sequela of the use of β-adrenergic antagonists, but if it is, it is probably rare. The more troubling concern regarding β-blockers is their potential effect on hypoglycemia unawareness and blunting of the return to euglycemic levels after hypoglycemia has occurred.
β-Blockers theoretically could suppress or even obviate all of the adrenergically mediated symptoms of hypoglycemia. A study 15 that evaluated this possibility in patients with type 1 diabetes without hypoglycemia unawareness reported that adrenergic symptoms did occur at lower glucose levels when patients were treated with β-blockers.
However, this deficit was offset by higher hypoglycemia symptom scores, which resulted from an increased perception of cholinergically mediated diaphoresis. Cardioselective agents reportedly cause less alteration in the perception of hypoglycemia symptoms than do the noncardioselective agents.
β-Adrenergic antagonists have been used successfully in several large-scale studies in patients with diabetes with no significant adverse effects reported. These agents, and particularly the cardioselective ones, should not be avoided in patients with diabetes but should be used with the same caution as when any new medication is added to a patient's therapeutic regimen.
Several studies have evaluated the effects of β-adrenergic agonists on hypoglycemia and hypoglycemia unawareness. The nocturnal glycemic effects of the β 2 -agonist terbutaline were compared to the amino acid alanine alanine plus glucose , a standard snack, and control no snack or medication in 15 insulin-treated type 1 patients.
Glucose levels were also higher during the second half of the night in patients taking terbutaline versus those treated with snack or alanine statistics not reported.
Nocturnal hypoglycemia was treated on 23 occasions in patients in the control and snack arms versus only one incident in the alanine and terbutaline arm. The researchers concluded that both alanine and terbutaline effectively prevented nocturnal hypoglycemia.
One of the concerns about using β 2 -agonists for the treatment of hypoglycemia unawareness was associated with reducedβ 2 sensitivity observed in vitro.
Recently, a three-way comparison trial 17 evaluated β 2 -adrenergic sensitivity in subjects with type 1 diabetes, those with type 1 diabetes and hypoglycemia unawareness, and nondiabetic subjects. β 2 -Adrenergic sensitivity was evaluated via forearm vasodilatory response to escalating doses of an intra-arterial infusion of salbutamol.
Forearm blood flow FBF was measured bilaterally by venous occlusion plethysmography. No statistically significant differences in baseline FBF were reported, and significant increases in FBF were reported for all subject groups with the administration of salbutamol.
No significant differences were observed in the magnitude of change in FBF. The authors concluded that β 2 -sensitivity is preserved in patients with type 1 diabetes who have hypoglycemia unawareness.
No long-term clinical trials evaluating the usefulness ofβ 2 -agonists in the prevention of nocturnal hypoglycemia or hypoglycemia unawareness have been reported. However, this option seems worthy of further study. Several studies have evaluated the effects of the methylxanthine derivatives caffeine and theophylline on hypoglycemia unawareness and the counterregulatory response to hypoglycemia.
Both have been shown to magnify the counterregulatory hormone i. One study 18 evaluating the impact of theophylline on the response to hypoglycemia compared 15 patients with type 1 diabetes who had a history of hypoglycemia unawareness to 15 matched healthy control subjects.
The subjects underwent hyperinsulinemic-hypoglycemic glucose clamp and randomly received either theophylline or placebo in a crossover fashion. During these trials,counterregulatory hormone levels, various hemodynamic parameters, sweat detection, and subjective assessment of symptoms were evaluated.
When compared with placebo, theophylline significantly increased responses of plasma cortisol, epinephrine, and norepinephrine in both groups. Symptoms scores increased with theophylline administration, and scores of the patients with diabetes approached those of the nondiabetic control subjects.
The authors concluded that theophylline improves the counterregulatory response to and perception of hypoglycemia in patients with type 1 diabetes who have hypoglycemia unawareness.
This was a small trial and evaluated this phenomenon acutely. Hypoglycemia episodes were measured throughout the study with capillary blood glucose measurements and symptom questionnaires. No changes in glycemic control or lipid profiles were observed. Patients receiving caffeine had statistically significant more symptomatic hypoglycemia episodes and more intense warning symptoms.
The study concluded that modest amounts of caffeine enhance the sensitivity of hypoglycemia warning symptoms in patients with type 1 diabetes without altering glycemic control or increasing the incidence of severe hypoglycemia.
Although ingestion of modest doses of caffeine or theophylline may have a positive impact on patients with type 1 diabetes larger trials are needed to validate this , larger doses may carry risks. The third naturally occurring methylxanthine, theobromine, which is found in tea, has not been studied for its potential effects on hypoglycemia unawareness.
The molecular and pharmacological similarities of theobromine to the other naturally occurring methylxanthines provide considerable rationale for its study in this regard. Three case reports have suggested a link between the development of hypoglycemia unawareness in patients with type 1 diabetes and the use of selective serotonin reuptake inhibitors SSRIs.
Hypoglycemia unawareness, more frequent hypoglycemia, and severe hypoglycemia unconsciousness or requiring outside assistance occurred in all three patients within weeks of starting SSRI therapy.
On discontinuation of SSRI therapy, hypoglycemia awareness improved in all three patients. Although SSRIs are frequently used in this population and usually without known glycemic problems, this observation strongly suggests that in some patients, treatment with SSRIs may alter the perception of hypoglycemia.
The mechanism by which SSRIs might be associated with hypoglycemia unawareness is unknown, but it has been hypothesized that the effect may be via an atypical presentation of serotonin syndrome resulting in autonomic dysfunction. Hypoglycemia unawareness is a complex, difficult-to-study phenomenon that carries with it great risk to patients.
Studies evaluating the effects of medications on this problem are scarce. The choice of the source of insulin human vs. animal does not seem to have a direct impact on the development of hypoglycemia unawareness. Conversely, insulin-induced or probably any drug-induced antecedent hypoglycemia clearly promotes subsequent hypoglycemia unawareness.
β-Blockers particularly noncardioselective agents may have a slight moderating effect on adrenergic symptoms of hypoglycemia and the hepatic counterregulatory response to hypoglycemia.
However, β-blockers have been shown to be reasonable choices for the management of hypertension and for their cardioprotective effects in patients with diabetes.
Therefore, the use of cardioselective β-blockers should not be discouraged. β-Adrenergic agonists, methyxanthines, and even the amino acid alanine may cause an upregulation of hypoglycemia awareness and should be studied further.
Hypoglycemic unawareness and medication adjustment Hypoglycemia, which is a Protein for improved focus and concentration barrier to the optimal mefication of diabetes, is associated with significant morbidity and mortality. Educating patients with diabetes about Low GI alternatives prevention, early identification, and Hypoglycemic unawareness and medication adjustment treatment of hypoglycemia is Hypogllycemic critically important component Hypoglycemic unawareness and medication adjustment Hypoglycemiv diabetes care. Hypoglycemia prevention involves Hypgolycemic understanding of the impact of diet, exercise, and medications on hypoglycemia risk. Treatment of hypoglycemia includes administration of oral carbohydrates for the patient who is conscious and administration of glucagon in the setting of severe hypoglycemia. Advances in glucose monitoring and the availability of newer glucagon formulations provide additional intervention options for the management of hypoglycemia. Despite many recent therapeutic and technological advances, hypoglycemia remains a significant barrier to treatment intensification and the achievement of individualized glycemic goals in diabetes patients. The ADA recommends that, at each clinical encounter, patients with diabetes be asked about the occurrence of both symptomatic and asymptomatic hypoglycemia. Drug-induced unawarfness is a major obstacle for individuals trying to Relaxation methods glycemic targets. Hypoglycemia Hypoglycemic unawareness and medication adjustment be severe and unawarenness in confusion, coma adjuustment seizure, requiring the assistance of other individuals. Significant risk of hypoglycemia often necessitates less stringent glycemic goals. Frequency and severity of hypoglycemia negatively impact on quality of life 1 and promote fear of future hypoglycemia 2,3. This fear is associated with reduced self-care and poor glucose control 4—6.Medicatlon order Hypoglycemic unawareness and medication adjustment achieve optimal glycemic control, intensive Cauliflower and lentil curry regimes are needed for individuals with Type 1 Diabetes T1D and insulin-dependent Type 2 Diabetes T2D.
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Unaaareness recurrent episodes of hypoglycemia, brain glucose sensing becomes impaired and the usual neuronal signaling pathways that unawarebess a counterregulatory response Hypoglycemic unawareness and medication adjustment raise blood glucose levels medjcation diminished Muneer, Inawareness, in the setting of impaired insulin and glucagon unawarenesd to hypoglycemia, unawzreness hypoglycemia induces a mwdication of Hypoglycemia Associated Autonomic Failure HAAF Hypoglycemic unawareness and medication adjustment is composed of an impaired Hypoglycemic unawareness and medication adjustment Hypoglycemci hypoglycemia IAH and a blunted counterregulatory adujstment Davis et al.
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Thus, people with recurrent episodes adjustmenr insulin-induced hypoglycemia have a diminished adjusment to detect hunger, andd, tremors, or other signals that indicate that unawaareness should be ingested to raise blood glucose levels Cryer, ; Davis unwareness al.
With better glycemic control, patients with Type 1 T1D and insulin-dependent Type 2 Diabetes T2D have been able to reduce the Gut health and strength training for diabetes complications e. Medicatiln, as patients intensify glycemic control, the risk Hypoglycemjc iatrogenic medicatioon increases proportionately Holman et adkustment.
From tothere has been a trend in reduced Herbal wellness solutions for hyperglycemia, but the rates of hospital admissions for severe hypoglycemia remain almost two-fold higher than those for hyperglycemia Lipska et al.
Severe hypoglycemia is therefore a burden for adjustmdnt with established diabetes Hpoglycemic increases the risk of adverse clinical outcomes Mantovani et al.
Severe hypoglycemia is also associated with impaired cognitive adjhstment Deary Targeted fat loss exercises al. Overall, hypoglycemia remains the rate-limiting factor in patients striving to achieve Hypoglycemix glycemic control in people with Type 1 and longstanding Type 2 Diabetes Cryer, Nocturnal hypoglycemia adjustmetn also Herbal Beauty Products in T1D.
Barnard et ans. People with IAH often fail to wake from sleep to Hypoglycemic unawareness and medication adjustment an episode of hypoglycemia due adjushment their impaired activation adjustmeny the autonomic nervous medicatoon in response to hypoglycemia Jones et al.
Another confounder adjusgment achieving optimal glycemic adjustmdnt is exercise Martyn-Nemeth et al. An bout unawarenness exercise increases glucose utilization Hypoglycemic unawareness and medication adjustment Hypoglyce,ic increases tissue sensitivity Hypoglydemic insulin.
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Several questionnaires have been developed to assist the diagnosis of IAH. The Hypoglycrmic responds using Hypoglycemic unawareness and medication adjustment 7-point Dextrose Workout Fuel scale where one to two denotes awareness, 3 is equivocal, and four adjsutment seven indicates unawareness Gold et al.
The Clark Score is a more multi-dimensional survey which consists medicaiton eight questions that are adjustmwnt to achieve unawarenwss answers regarding awareness of hypoglycemia Clarke et al. With a score range from Hyooglycemic to 7, a response total of 4 or above indicates IAH Clarke et al.
The Pedersen-Bjergaard questionnaire asks patients to recall their previous experiences with hypoglycemia and asses their ability to recognize symptoms of hypoglycemia Pedersen-Bjergaard et al. Since the IAH questionnaires vary, some Hypogoycemic can arise such as overestimating impaired awareness in populations that may still have awareness intact, thus leading to the apparent failure of some studies to detect significant improvements in response to clinical interventions Sepulveda et al.
These questionnaires have been criticized for 1 having a high degree of inter-questionnaire variability in identifying subjects with IAH and subjects with impaired counterregulation, 2 susceptibility to recall bias by the subject, 3 lacking sensitivity to detect changes in hypoglycemia awareness over a short period, and 4 were developed in the pre-continuous glucose monitor CGM era excluding HypoA-Q.
Also, hypoglycemia questionnaires do not distinguish whether awareness reflects true restoration of hypoglycemia awareness i. Hypoglycemic questionnaires do have many meritorious qualities in that they are 1 inexpensive, 2 non-invasive, and 3 amenable to out-patient settings.
In addition, these questionnaires have been validated and adapted to populations beyond their original demographic Alkhatatbeh et al.
Added benefits for these questionnaires include them being flexible to meet a large sample size Sepulveda et al.
More recent studies also demonstrate that patients with IAH diagnosed by questionnaires continue to experience higher risks of severe hypoglycemia Lin et al.
Mistimed or imprecise dosing of insulin increases the likelihood of hypoglycemic events and recurrent episodes of hypoglycemia lead to the development of IAH Cryer, ; Davis et al. In addition to people who have a history of hypoglycemic events, certain populations are at a greater risk for hypoglycemic episodes and IAH, such as the young, elderly, and those with comorbidities Munshi et al.
Thus, identifying individuals who are at a higher risk for severe hypoglycemia and IAH is a priority for clinical providers and their patients in order to decrease the incidence of both events. In spite of their limitations see abovethe most practical method to assess for IAH in a clinical setting is hypoglycemia questionnaires.
However, if patients are not asked about hypoglycemia or fail to report asymptomatic hypoglycemia, the diagnosis of IAH can be missed Farrell and McCrimmon, Therefore, it is extremely important for providers to inquire about and for patients to be educated about IAH.
After identification of IAH, the goals would be to provide at-risk patients with strategies to recognize and avoid hypoglycemia. Prior to advanced diabetes technology such as CGMs and the automated insulin delivery systems, several of these earlier studies demonstrated that the scrupulous avoidance of recurrent episodes of Hupoglycemic could restore at least partially awareness of hypoglycemia Cranston et al.
To the extent that HAAF may be reversed at least partiallyavoidance of hypoglycemia is a practical goal treatment for IAH. Unfortunately, even with modern technology, complete avoidance of hypoglycemia is difficult, compounded by the evidence that only one to two episodes of hypoglycemia are sufficient to induce IAH Galassetti et al.
In the setting of intensive glycemic control achieved with intensive insulin delivery, complete avoidance of hypoglycemia may not be realistic for some individuals. The question remains whether complete avoidance of hypoglycemia using the latest strategies can restore hypoglycemia awareness.
Given the complexity of IAH, a variety of clinical treatment considerations have been investigated to decrease hypoglycemia and the cycle of IAH Figure 1. In the following sections, various treatment options for IAH will be discussed see Table 1.
FIGURE 1. Restoring awareness of hypoglycemia. While there is no direct treatment for impaired awareness of hypoglycemia IAHthere are therapies that can help avoid hypoglycemia, which include: education, pharmaceuticals, technology, and transplantation whole pancreas or islet cell.
Using these therapies, hypoglycemia can be avoided leading to improve sympathoadrenal responses of hypoglycemia and awareness of hypoglycemia.
Strategies to avoid hypoglycemia include transplantation pancreas or islet cellstechnology e. The overarching goal is to decrease incidences of hypoglycemia and thereby restore both awareness of hypoglycemia and improve the counterregulatory response to hypoglycemia.
Fundamentally, the most pressing issue with IAH is the inability to sense when blood glucose concentrations fall to severe levels i. Diabetes education programs have been successfully employed to improve glycemic control and the overall health of people with T1D and T2D Siminerio et al.
Although not specifically designed to treat IAH, some of the original educational programs that focused on glycemic management resulted in improving hypoglycemia awareness. The Diabetes Teaching and Treatment Program DTTP demonstrated in a year follow-up that the rates of hypoglycemia were reduced and the improvement in HbA1c was sustained after attending educational programs Plank et al.
Modeled after DTTP, the dose adjustment for normal eating DAFNE training program showed in a 1-year follow up that subjects had improved awareness of hypoglycemia and reduced rates of severe hypoglycemia Group, ; Hopkins et al.
Given the increased risk of hypoglycemia with intensive glycemic control, educational programs began to focus on improving awareness of hypoglycemia. More specific psychological training and bio-psycho-behavioral techniques have been shown to help people with diabetes improve their awareness.
The Blood Glucose Awareness Training Program BGAT is an IAH focused psychoeducational program Cox et al. Since its inception, BGAT has undergone several revisions as a result of multicenter trials across the globe.
BGAT is available outside of a clinical setting, which enables it to reach more people and decrease the workload in the clinic Cox et al. While still extremely effective at improving overall blood glucose awareness, BGAT did not intentionally set out to assess IAH.
Nonetheless, several studies demonstrated the ability of BGAT in improving hypoglycemia awareness Cox et al. Adapted from BGAT, the HypoAware training program focused on training and empowering people with T1D and advanced T2D to reduce episodes of hypoglycemia, improve awareness, and reduce fear of hypoglycemia Rondags et al.
Another educational program for treating diabetic patients with hypoglycemia problems HyPOSfocused on optimizing intensive insulin therapy. Additionally, the long-term benefits of HyPOS curriculum remained after a month follow-up Hermanns et al.
Similar to the HypoAware adaptation from BGAT, the dose adjustment for normal eating DAFNE —Hypoglycemia Awareness Restoration Training HART was developed from the DAFNE program.
The DAFNE-HART in a pre-post trial with 23 participants demonstrated that psychology plays an important in the development of IAH. Building on the DAFNE-HART program, the Hypoglycemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic hypoglycemia Persisting despite optimized self-care HARPdoc was developed as a multidisciplinary strategy targeting cognitive in subjects with IAH.
The HARPdoc program was recently evaluated and compared its effectiveness with BGAT in a population who continued to have IAH and developed recurrent severe hypoglycemia despite prior structured diabetes education and offered advanced diabetes technologies Jacob et al.
HARPdoc and BGAT were similarly able to improve awareness of hypoglycemia and decrease the rate and fear of hypoglycemia Jacob et al. HARPdoc was also shown to decrease maladaptive hypoglycemia beliefs, diabetes distress and depression and anxiety symptoms which was not demonstrated in recipients of BGAT Jacob et al.
HARPdoc brain responses have also been compared to the HypoAware study Jacob et al. While limited in statistical power only compared 12 subjectsHARPdoc was able to determine awareness status more accurately during two-stepped hyperinsulinemic-hypoglycemic clamps Jacob et al.
In comparison to HypoAware, the HARPdoc treatment showed that the superior frontal gyrus region was more activated during hypoglycemia, indicating improved self-awareness and symptoms associated with hypoglycemia Jacob et al. Treatment of IAH in people with T2D has been studied to a much lesser extent compared to studies in people with T1D.
The Common Sense Model CSM assessed illness perceptions in subjects with T2D and IAH on insulin therapy Shen et al. While the study showed that the overall welfare and coping of subjects was improved, CSM did not change fear or awareness of hypoglycemia Shen et al.
These results may be due to a short-duration of follow-up 1 and 3-month. The efficacy of educational programs cannot be understated. Educational programs that use close and frequent patient contact Cranston et al.
For example, the HypoCOMPaSS trial Comparison of Optimized MDI versus Pumps with or without sensors in severe hypoglycemia Cox et al. The positive effects of the HypoCOMPaSS program were maintained at least 2 years after the completion of the original study Speight et al.
For people with IAH, hypoglycemia is often detected not by symptoms, but with glucose monitoring technology e. Unquestionably, diabetes technologies have markedly improved treatment for people with diabetes Akturk and Garg, It is indeed unfortunate that the more widespread use of these valuable technologies is limited by socioeconomic inequalities Bellary et al.
Although these technological advances have unquestionably helped to improve glycemic control and reduce that incidence of severe hypoglycemia in people with T1D, the extent to which these technologies can restore awareness of hypoglycemia remains an active area of investigation Choudhary et al.
: Hypoglycemic unawareness and medication adjustment| How Hypoglycemia Unawareness Affects People with Diabetes - Blog - NIDDK | If changes in food choices lead to hypoglycemic events, patients likely did not do this on purpose. Have they been less hungry lately, or are they trying to lose weight? Has there been a change in their oral health? Many individuals do not understand the complexity of factors affecting postprandial glucose levels or are not able to consistently identify a low-carbohydrate or high-carbohydrate meal or to accurately estimate the number of calories in their meals. For patients who are doing basic carbohydrate counting, explore the potential impact of the presence or absence of protein and fat in meals. These individuals may not recognize or may easily forget the role of protein and fat because they are concentrating more closely on carbohydrates. For patients who are counting calories or using some overall means of portion control, explore the impact of significant changes in carbohydrate content and assess their ability to identify foods that are rich in carbohydrates. These individuals may not understand the importance of carbohydrate budgeting. In these discussions, providers may find patients to be at a point of readiness to be referred to a registered dietitian or certified diabetes educator for more nutrition education. Changes in physical activity that can lead to hypoglycemia can include more than just intentional exercise. Particularly for people who are usually sedentary, an increase in overall energy and stamina that leads to doing more errands, gardening, or housework than normal may result in hypoglycemia. In contrast, athletes with diabetes who have temporary periods of two-a-day practices might need help learning how to adjust their medication to deal with the increase in insulin sensitivity and glucose uptake that results from increased exercise. Asking open-ended questions about the timing and dosing of medication or asking patients to demonstrate or describe their injection technique also may reveal potential causes of hypoglycemia. Finally, it is important to ask exactly how patients treat low blood glucose. This question often reveals a tendency to consume more than the recommended 15—20 g of carbohydrate or may uncover a misunderstanding of what types of foods and substances will most quickly raise the blood glucose level. Table 2 reviews the recommended treatment guidelines for hypoglycemia. Discussing patients' knowledge of food choices, physical activity, and medication can help prevent future hypoglycemia and allow providers to best determine any necessary changes in medication and identify education needs. Lipohypertrophy is a buildup of fat at the injection site. Injecting insulin into lipohypertrophy usually causes impaired absorption of insulin. However, injecting into sites of lipohypertrophy can result in erratic and unexplained fluctuations in blood glucose. When advising patients to rotate to new injection sites, HCPs should note the need for caution. Because insulin injected into a fresh site likely will be absorbed more efficiently, doses may need to be decreased. Regular rotation of insulin injection sites may prevent lipohypertrophy from occurring. Keep in mind that some patients, especially children, may be hesitant to inject in areas other than one with lipohypertrophy because they report that area is less sensitive to injections. Many alcohol-containing drinks contain carbohydrate and can cause initial hyperglycemia. However, alcohol also inhibits gluconeogenesis, which becomes the main source of endogenous glucose about 8 hours after a meal. Therefore, there is increased risk of hypoglycemia the morning after significant alcohol intake if there has not been food intake. Alcohol consumption can also interfere with the ability to feel hypoglycemia symptoms. For patients whose blood glucose is well controlled, the ADA guidelines for alcohol intake suggest a maximum of one to two drinks per day, consumed with food. Close monitoring of blood glucose for the next 10—20 hours may be beneficial. Insulin and sulfonylurea clearance is decreased with impaired hepatic or renal function. Decreasing the dosages of some anti-hyperglycemic medications and avoiding others may be necessary. Of the oral agents, sulfonylureas are more likely to cause hypoglycemia. Glimepiride may be a safer choice than glyburide or glipizide in elderly patients and those with renal insufficiency because it is completely metabolized by the liver; cytochrome P reduces it to essentially inactive metabolites that are eliminated renally and fecally. As kidney function declines, exogenous insulin has a longer duration and is more unpredictable in its action, and the contribution of glucose from the kidney through gluconeogensis is reduced. Patients who have had diabetes for many years or who have had poor control are at risk for autonomic neuropathy, including gastroparesis, or slow gastric emptying. It is thought that delayed food absorption increases the risk of hypoglycemia, although evidence is lacking. Intercurrent gastrointestinal problems such as gastroenteritis or celiac disease can also be causes of altered food absorption. Medications such as metoclopramide or erythromycin are used to increase gastric emptying time. Giving mealtime insulin after meals or using an extended bolus on an insulin pump may also help to prevent potential hypoglycemia related to delayed gastric emptying. Hypothyroidism slows the absorption of glucose through the gastrointestinal tract, reduces peripheral tissue glucose uptake, and decreases gluconeogenesis. For people with diabetes, this can cause increased episodes of hypoglycemia. Measuring the level of thyroid-stimulating hormone is the most accurate method of evaluating primary hypothyroidism. As hypothyroidism is treated, an increase in insulin dose will likely be needed to meet the increased metabolic need. The risk of severe hypoglycemia increases with age. Slowed counter-regulatory hormones, erratic food intake, and slowed intestinal absorption place older adults at higher risk of hypoglycemia. The incidence of mild and severe hypoglycemia is highest between 8 and 16 weeks' gestation in type 1 diabetes. Severe hypoglycemia in early pregnancy is three times more frequent than during preconception. Providing preconception counseling, including information about a potential increase in hypoglycemia early in pregnancy, may help reduce the incidence of hypoglycemia for women planning to become pregnant. Intentional insulin overdose is thought to be relatively rare, but the actual prevalence is difficult to measure. A common method used to estimate the number of deliberate insulin overdoses is to analyze data from regional poison control centers. In the annual report of the American Association of Poison Control Centers, only 3, of the 2,, inquiries 0. Although rare, most cases of insulin overdose reported to poison control centers have occurred during suicide attempts. HCPs who are unable to identify other reasons for persistent hypoglycemia may not be able to rule out intentional induction of hypoglycemia. Patients who are suspected of intentionally inducing hypoglycemia should be referred to a behaviorist for evaluation and treatment. Individuals with diabetes and, ideally, their care partners who have received diabetes self-management education should have a better understanding of how their medication, meal plan, and physical activity interact to achieve optimal glucose control while limiting hypoglycemia. They also will be better equipped to prevent and treat hypoglycemia should it occur. HCPs should help individuals who have not had an opportunity to work with a diabetes educator or dietitian to identify educational resources in their area. Table 3 provides a list of resources for locating local diabetes educators and dietitians. Patients who have not had a recent diabetes education update may benefit from a refresher course. Hypoglycemia education includes not only appropriate treatment and prevention, but also driving precautions, including performing SMBG before driving and frequently while driving for individuals who are prone to hypoglycemia. People with diabetes also should keep glucose tabs, gel, or other appropriate oral treatment options in their vehicle. Encouraging individuals to wear a medical identification listing diabetes and any other diagnoses they may have is also important. Systemic administration improved the glucose infusion rate and hepatic glucose production response to hypoglycemia; however, counterregulatory hormones did not change with formoterol administration Szepietowska et al. While formoterol and miglitol improved counterregulation and hepatic glucose production of HAAF, awareness was not assessed in those studies and the effects of those drugs on IAH remain unknown. In rodent models of HAAF, recurrent hypoglycemia consistently blunts the sympathoadrenal response noted by a blunted plasma catecholamine response Powell et al. Unfortunately, the ability to determine hypoglycemia unawareness induced by recurrent hypoglycemia has been understandably more difficult to quantify in animal models Sankar et al. Of note, Farhat et al. As model of IAH, recurrent antecedent treatment with 2-deoxyglucose 2DG blunted the food intake response to insulin-induced hypoglycemia; yet rodents treated with carvedilol did not develop IAH i. Another area of the brain that has been implicated in glucose sensing is the perifornical hypothalamus PFH. Researchers focused on the orexin-glucose-inhibited neurons in the PFH responsible for arousal as a target for IAH and explored treatment with the anti-narcolepsy drug, modafinil Teva Pharmaceutical Industries Ltd. Mice underwent a conditioned place preference test surrogate test for IAH prior to recurrent hypoglycemia and treatment. Compared to saline-treated mice, modafinil-treated mice adjusted their preference for the food-associated chamber after insulin-induced hypoglycemia. Additionally, researchers showed that modafinil restored glucose sensing by the orexin-glucose-inhibited neurons in the PFH Patel et al. Modafinil is a dopamine reuptake inhibitor thus, it appears that dopamine signaling is potentially involved in the development of IAH. Consistent with this notion, metoclopramide Teva Pharmaceutical Industries Ltd. Based on these preclinical results, the potential of this drug to restore awareness of hypoglycemia in subjects with T1D and IAH has advanced to a Phase 2 clinical trial NCT Translation of these pre-clinical results to clinical trials remains an important step to validate potential drug therapies for the treatment of IAH. Drugs that work within the adrenergic system seem like an obvious target that might improve both the counterregulatory response and awareness of hypoglycemia Cooperberg et al. Consistent with preclinical studies Li et al. Thus, some degree of adrenergic blockage within the CNS may serve to improve hypoglycemia awareness and hypoglycemic counterregulation, at least based on preclinical studies Farhat et al. Another, similar pharmacological approach to treating IAH is targeting adenosine receptors to increase alertness and enhanced secretion of the counterregulatory hormones De Galan et al. One study used theophylline, an adenosine-receptor antagonist, to determine its effects on IAH de Galan et al. In response to hypoglycemia, subjects with diabetes and IAH treated with theophylline demonstrated an improved counterregulatory hormone response but theophylline did not improve hypoglycemia symptom scores de Galan et al. However, another methylxanthine, caffeine, was shown to stimulate more symptomatic hypoglycemic episodes i. The glucagon-like peptide-1 receptor agonist, exenatide, was used in a crossover trial in subjects with T1D and IAH van Meijel et al. Subjects treated with exenatide for 4-week had no differences in frequency or time spent in hypoglycemia compared to the placebo group. Exenatide-treated subjects had similar symptom scores and counterregulatory hormone responses to that of the placebo group van Meijel et al. A sodium-glucose cotransporter-2 inhibitor, dapagliflozin, has shown effectiveness van Meijel et al. Dapagliflozin treatment did not improve awareness of hypoglycemia, however, it did reduce the glucose infusion rates during the clamp indicating an improvement in glucoregulatory response to hypoglycemia van Meijel et al. Using the same drug, another study assessed glucagon response in T1D subjects; however, subjects were on the lower end of the Clarke score median 3, range 1—5 , suggesting that awareness might have been present in some subjects. Similar to previous results, dapagliflozin treatment did not improve counterregulatory hormone responses, symptom scores, or recovery from hypoglycemia Boeder et al. Treatment with the CNS stimulant, modafinil, resulted in improved autonomic symptom scores, higher heart rates, higher glucagon concentrations during hypoglycemia, and improved scores on cognitive tests; however, the epinephrine response was not altered Klement et al. Since modafinil was administered in non-diabetic subjects, IAH was not present Klement et al. Conversely, another study also conducted in healthy subjects showed improvements in the norepinephrine response, but no other improvements in hormonal responses epinephrine, growth hormone, and cortisol or symptom scores during a hypoglycemic clamp Smith et al. Both of these studies attribute the positive improvements seen in healthy subjects to γ-aminobutyric acid GABA signaling. Modulating GABA signaling as a means to restore counterregulation and hypoglycemia awareness is supported by pre-clinical models Chan et al. Clinically, antecedent GABA-A activation with the benzodiazepine, alprazolam, has been shown to blunt the neuroendocrine and autonomic nervous system responses to subsequent hypoglycemia in healthy humans Hedrington et al. Consistent with these findings, antagonism of GABA with dehydroepiandrosterone DHEA can prevent the development of HAAF under experimental conditions in healthy humans Mikeladze et al. Thus, with successful proof of concept studies in healthy humans, more recent studies in people with long-standing diabetes have shown that GABA administration significantly augmented the hormonal counterregulatory response to hypoglycemia Espes et al. Pre-treatment with opioid receptor agonists can impair the counterregulatory response to hypoglycemia Carey et al. Conversely, pre-treatment with the opioid receptor antagonist naltrexone can prevent the development of an impaired counterregulatory response to hypoglycemia Leu et al. Based on animal studies that indicate a possible role for selective serotonin reuptake inhibitors SSRIs to augment the counterregulatory response to glucoprivation Baudrie and Chaouloff, , clinical studies have demonstrated that 6-week treatment with SSRIs augmented counterregulatory, but not symptom responses, to hypoglycemia in nondiabetic people Briscoe et al. It remains to be determined if these beneficial effects of SSRIs are mediated by the inhibition of neuronal serotonin uptake or via inhibition of norepinephrine transport in the CNS Chaouloff et al. It also remains to be determined why hypoglycemia awareness was not improved with SSRI therapy. IAH continues to be a complication in people with both T1D and T2D who seek optimal glycemic control with insulin therapy. Providers who care for patients with diabetes should inquire about hypoglycemia and IAH with a view towards considering treatment options. This review shows that there are several advances in technology and educational approaches that can improve hypoglycemia awareness. With regards to pharmacological treatments, basic science research in animal models is continuing to elucidate the mechanism s responsible and these novel treatments for IAH are being advanced into clinical trials. Future studies should focus on these possible mechanisms to develop more targeted therapies for patients who suffer from IAH. EM: Writing—original draft. MD: Writing—original draft. YL: Writing—review and editing. MM: Writing—review and editing. MW: Writing—review and editing. CM: Writing—review and editing. AW: Writing—review and editing. AM: Writing—review and editing. ZB: Writing—review and editing. BP: Writing—review and editing. LS: Writing—review and editing. AI: Writing—review and editing. SF: Writing—original draft. NIH support DK, DK to SF, DK to YL, TL1TR to MD, as well as support from the University of Kentucky Barnstable Brown Diabetes Center and the Diabetes and Obesity Research Priority Area. The authors would like to thank and acknowledge NIH support DK, DK to SF, DK to YL, TL1TR to MD, as well as support from the University of Kentucky Barnstable Brown Diabetes Center and the Diabetes and Obesity Research Priority Area. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Adachi, A. Convergence of hepatoportal glucose-sensitive afferent signals to glucose-sensitive units within the nucleus of the solitary tract. PubMed Abstract CrossRef Full Text Google Scholar. Advani, A. Positioning time in range in diabetes management. Diabetologia 63 2 , — Aggarwal, S. Augmenting engraftment of beta cell replacement therapies for T1DM. CrossRef Full Text Google Scholar. Agiostratidou, G. 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ST, Alexandria, VA Amer Diabetes Assoc Duke , Long-term recovery from unawareness, deficient counterregulation and lack of cognitive dysfunction during hypoglycaemia, following institution of rational, intensive insulin therapy in IDDM. Diabetologia 37 12 , — Farhat, R. Carvedilol prevents impairment of the counterregulatory response in recurrently hypoglycaemic diabetic rats. Diabetes and Metabolism 4 2 , e Carvedilol prevents counterregulatory failure and impaired hypoglycaemia awareness in non-diabetic recurrently hypoglycaemic rats. Diabetologia 62 4 , — Farrell, C. Clinical approaches to treat impaired awareness of hypoglycaemia. Fauzi, A. Current diabetes technology and its challenges. Turk J. Flatt, A. Automated insulin delivery for hypoglycemia avoidance and glucose counterregulation in long-standing type 1 diabetes with hypoglycemia unawareness. ForlenzaGregory, P. Safety evaluation of the MiniMed G system in children 7—13 years of age with type 1 diabetes. Diabetes Technol The. Low blood glucose is common for people with type 1 diabetes and can occur in people with type 2 diabetes taking insulin or certain medications. If you add in lows without symptoms and the ones that happen overnight, the number would likely be higher. Too much insulin is a definite cause of low blood glucose. Insulin pumps may also reduce the risk for low blood glucose. Accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle instead of just under the skin , can cause low blood glucose. Exercise has many benefits. The tricky thing for people with type 1 diabetes is that it can lower blood glucose in both the short and long-term. Nearly half of children in a type 1 diabetes study who exercised an hour during the day experienced a low blood glucose reaction overnight. The intensity, duration, and timing of exercise can all affect the risk for going low. Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times. In the event of a severe hypoglycemic episode, a car accident or other emergency, the medical ID can provide critical information about the person's health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can't speak for themselves. Medical IDs are usually worn as a bracelet or a necklace. Traditional IDs are etched with basic, key health information about the person, and some IDs now include compact USB drives that can carry a person's full medical record for use in an emergency. As unpleasant as they may be, the symptoms of low blood glucose are useful. These symptoms tell you that you your blood glucose is low and you need to take action to bring it back into a safe range. But, many people have blood glucose readings below this level and feel no symptoms. This is called hypoglycemia unawareness. Hypoglycemia unawareness puts the person at increased risk for severe low blood glucose reactions when they need someone to help them recover. People with hypoglycemia unawareness are also less likely to be awakened from sleep when hypoglycemia occurs at night. People with hypoglycemia unawareness need to take extra care to check blood glucose frequently. This is especially important prior to and during critical tasks such as driving. A continuous glucose monitor CGM can sound an alarm when blood glucose levels are low or start to fall. This can be a big help for people with hypoglycemia unawareness. If you think you have hypoglycemia unawareness, speak with your health care provider. This helps your body re-learn how to react to low blood glucose levels. This may mean increasing your target blood glucose level a new target that needs to be worked out with your diabetes care team. It may even result in a higher A1C level, but regaining the ability to feel symptoms of lows is worth the temporary rise in blood glucose levels. This can happen when your blood glucose levels are very high and start to go down quickly. If this is happening, discuss treatment with your diabetes care team. Your best bet is to practice good diabetes management and learn to detect hypoglycemia so you can treat it early—before it gets worse. Monitoring blood glucose, with either a meter or a CGM, is the tried and true method for preventing hypoglycemia. Studies consistently show that the more a person checks blood glucose, the lower his or her risk of hypoglycemia. |
| Blog Tools | Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Fifteen minutes after the initiation of treatment with serum dextrose, she was responsive to pain and stimulation. Diabetes 69 12 , — Get Permissions. People with consistently high blood glucose levels will feel hypoglycemic at blood glucose levels higher than the normal range, whereas those with tight glycemic control may feel hypoglycemic at lower levels. A trained diabetes educator can also work with you to help you anticipate when low glucose levels are more likely to happen. Defining Hypoglycemia. |
| Hypoglycemia | Adjustmenh questions, contact Hypoglyccemic diabetes. Berry Muffin Recipes CAS Google Scholar Dagogo-Jack S, Rattarasarn Hypoglycemic unawareness and medication adjustment, Cryer PE. Extra glucose is stored in your liver and muscles in the form of glycogen. You can also search for this author in PubMed Google Scholar. Adverse events and their association with treatment regimens in the diabetes control and complications trial. Click here for an email preview. |
| Hypoglycemia - Diabetes Education Online | Nocturnal hypoglycemia can be difficult to diagnose and can Hypogoycemic the risk Hypoglycemoc hypoglycemia unawareness Hypoglycemic unawareness and medication adjustment the 48 to 72 asjustment that follow. If you add Hypoglycemid lows Balanced eating habits symptoms and the ones that happen overnight, the number would likely be higher. Current and future therapies to treat impaired awareness of hypoglycemia. This Site. Therefore, there is increased risk of hypoglycemia the morning after significant alcohol intake if there has not been food intake. Also, hypoglycemia questionnaires do not distinguish whether awareness reflects true restoration of hypoglycemia awareness i. |
| How Hypoglycemia Unawareness Affects People with Diabetes | Greenleaf, RD, LD, CDE, is a dietitian and diabetes educator at MidAmerica Diabetes Associates in Wichita, Kans. Childs , Jolene M. Grothe , Pamela J. Greenleaf; Strategies to Limit the Effect of Hypoglycemia on Diabetes Control: Identifying and Reducing the Risks. Clin Diabetes 1 January ; 30 1 : 28— I ndividuals with diabetes, their families, and health care providers HCPs often cite hypoglycemia as the limiting factor to achieving optimal diabetes control. Hypoglycemia is a reality for people with type 1 diabetes and for many with type 2 diabetes. According to Cryer, 1 the average person with type 1 diabetes suffers two episodes of hypoglycemia per week and one episode of severe hypoglycemia per year. Severe hypoglycemia is less common in those with type 2 diabetes. However, in the U. Prospective Diabetes Study UKPDS , 0. Among patients with type 2 diabetes, the greatest frequency of hypoglycemia is found in those on insulin. The body's normal response to hypoglycemia is significantly altered in diabetes, as well as by the use of exogenous insulin or insulin secretagogues. Thus, the physiological symptoms and negative consequences of hypoglycemia may result in significant fear of hypoglycemia and anxiety associated with possible hypoglycemia for individuals with diabetes. Yet, pivotal studies such as the UKPDS and the Diabetes Control and Complications Trial leave no doubt that improved glycemic control prevents or delays microvascular complications and may also reduce macrovascular events. The risk of hypoglycemia should not be used as an excuse for less-than-optimal glucose control. The American Diabetes Association ADA Workgroup on Hypoglycemia did not define hypoglycemia as it traditionally has been presented in most educational materials i. This would include any level of unconsciousness. These levels were also established to aid in improving consistency of reporting for research studies. This unawareness occurs as impairment in epinephrine release and other normal physiological responses to hypoglycemia and limits individuals' ability to respond appropriately to impending low blood glucose. The usual warning symptoms such as shakiness, sweating, and irritability are absent. Without these adrenergic responses, such individuals only develop neurological symptoms such as confusion, at which time they are unable to take action to treat their low blood glucose and therefore develop severe hypoglycemia. Hypoglycemia unawareness was once associated with longstanding diabetes but is now known to occur as a result of increasing frequency of hypoglycemia and not just longer duration of the disease. Avoidance of hypoglycemia for several weeks may lead to improved hypoglycemia awareness. Hypoglycemia should not be viewed as an insurmountable barrier, but rather as an opportunity to potentially improve a recommended medication strategy, improve on daily diabetes care practices, or uncover other medical diagnoses that may be contributing to the development of hypoglycemia. How can HCPs assist individuals with diabetes in identifying potential risk factors for the development of hypoglycemia or identifying the causes of hypoglycemia events? The cause may seem obvious: either the diabetes medication, likely insulin, did not match the amount of food ingested, or the level of exercise a patient performed was too much for the amount of food ingested and the amount of medication taken. But often, teasing out the exact triggers can be a challenge. Table 1 provides a checklist of potential causes of hypoglycemia. HCPs may need to think like a crime scene investigator to uncover the causes and contributing factors that have led to a hypoglycemic event. Allowing individuals with diabetes and their family to tell their story about a hypoglycemic event may allow HCPs to uncover a need not only for medication changes, but also for changes in patients' behavioral responses to hypoglycemia. Empowering individuals to have more control over such situations will also help reduce the anxiety and fear often associated with hypoglycemia. Probing patients with pertinent questions will help create an accurate understanding of the context of reported hypoglycemia. This can also reduce misunderstandings between patients and providers and provide education opportunities about skills or concepts that may seem basic to providers but can be challenging for patients. When patients report that they have been experiencing low blood glucose, it is important to define hypoglycemia together. What do patients consider to be a low blood glucose level? Is this based solely on feelings or have they been able to actually check their blood glucose at the moment of symptoms? If self-monitoring of blood glucose SMBG records are available, at what point or level of blood glucose do individuals start to experience symptoms of hypoglycemia? People with consistently high blood glucose levels will feel hypoglycemic at blood glucose levels higher than the normal range, whereas those with tight glycemic control may feel hypoglycemic at lower levels. Discussing these concepts with patients provides practical motivation and support for the role of SMBG in medication adjustment and safety. Another area worthy of inquiry is patients' actions leading up to hypoglycemic events. It may seem obvious that changes in food choices, physical activity, or medication can produce hypoglycemia, but letting patients verbalize their patterns or changes in patterns can allow them to discover this for themselves. Eating a smaller meal or one containing less carbohydrate than normal may result in a low postprandial blood glucose level. If changes in food choices lead to hypoglycemic events, patients likely did not do this on purpose. Have they been less hungry lately, or are they trying to lose weight? Has there been a change in their oral health? Many individuals do not understand the complexity of factors affecting postprandial glucose levels or are not able to consistently identify a low-carbohydrate or high-carbohydrate meal or to accurately estimate the number of calories in their meals. For patients who are doing basic carbohydrate counting, explore the potential impact of the presence or absence of protein and fat in meals. These individuals may not recognize or may easily forget the role of protein and fat because they are concentrating more closely on carbohydrates. For patients who are counting calories or using some overall means of portion control, explore the impact of significant changes in carbohydrate content and assess their ability to identify foods that are rich in carbohydrates. These individuals may not understand the importance of carbohydrate budgeting. In these discussions, providers may find patients to be at a point of readiness to be referred to a registered dietitian or certified diabetes educator for more nutrition education. Changes in physical activity that can lead to hypoglycemia can include more than just intentional exercise. Particularly for people who are usually sedentary, an increase in overall energy and stamina that leads to doing more errands, gardening, or housework than normal may result in hypoglycemia. In contrast, athletes with diabetes who have temporary periods of two-a-day practices might need help learning how to adjust their medication to deal with the increase in insulin sensitivity and glucose uptake that results from increased exercise. Asking open-ended questions about the timing and dosing of medication or asking patients to demonstrate or describe their injection technique also may reveal potential causes of hypoglycemia. Finally, it is important to ask exactly how patients treat low blood glucose. This question often reveals a tendency to consume more than the recommended 15—20 g of carbohydrate or may uncover a misunderstanding of what types of foods and substances will most quickly raise the blood glucose level. Table 2 reviews the recommended treatment guidelines for hypoglycemia. Discussing patients' knowledge of food choices, physical activity, and medication can help prevent future hypoglycemia and allow providers to best determine any necessary changes in medication and identify education needs. Lipohypertrophy is a buildup of fat at the injection site. Injecting insulin into lipohypertrophy usually causes impaired absorption of insulin. However, injecting into sites of lipohypertrophy can result in erratic and unexplained fluctuations in blood glucose. When advising patients to rotate to new injection sites, HCPs should note the need for caution. Because insulin injected into a fresh site likely will be absorbed more efficiently, doses may need to be decreased. Regular rotation of insulin injection sites may prevent lipohypertrophy from occurring. Keep in mind that some patients, especially children, may be hesitant to inject in areas other than one with lipohypertrophy because they report that area is less sensitive to injections. Many alcohol-containing drinks contain carbohydrate and can cause initial hyperglycemia. However, alcohol also inhibits gluconeogenesis, which becomes the main source of endogenous glucose about 8 hours after a meal. Therefore, there is increased risk of hypoglycemia the morning after significant alcohol intake if there has not been food intake. Alcohol consumption can also interfere with the ability to feel hypoglycemia symptoms. For patients whose blood glucose is well controlled, the ADA guidelines for alcohol intake suggest a maximum of one to two drinks per day, consumed with food. Close monitoring of blood glucose for the next 10—20 hours may be beneficial. Insulin and sulfonylurea clearance is decreased with impaired hepatic or renal function. Decreasing the dosages of some anti-hyperglycemic medications and avoiding others may be necessary. Of the oral agents, sulfonylureas are more likely to cause hypoglycemia. Glimepiride may be a safer choice than glyburide or glipizide in elderly patients and those with renal insufficiency because it is completely metabolized by the liver; cytochrome P reduces it to essentially inactive metabolites that are eliminated renally and fecally. As kidney function declines, exogenous insulin has a longer duration and is more unpredictable in its action, and the contribution of glucose from the kidney through gluconeogensis is reduced. Patients who have had diabetes for many years or who have had poor control are at risk for autonomic neuropathy, including gastroparesis, or slow gastric emptying. It is thought that delayed food absorption increases the risk of hypoglycemia, although evidence is lacking. Intercurrent gastrointestinal problems such as gastroenteritis or celiac disease can also be causes of altered food absorption. Medications such as metoclopramide or erythromycin are used to increase gastric emptying time. Giving mealtime insulin after meals or using an extended bolus on an insulin pump may also help to prevent potential hypoglycemia related to delayed gastric emptying. Hypothyroidism slows the absorption of glucose through the gastrointestinal tract, reduces peripheral tissue glucose uptake, and decreases gluconeogenesis. For people with diabetes, this can cause increased episodes of hypoglycemia. Measuring the level of thyroid-stimulating hormone is the most accurate method of evaluating primary hypothyroidism. As hypothyroidism is treated, an increase in insulin dose will likely be needed to meet the increased metabolic need. The risk of severe hypoglycemia increases with age. Slowed counter-regulatory hormones, erratic food intake, and slowed intestinal absorption place older adults at higher risk of hypoglycemia. The incidence of mild and severe hypoglycemia is highest between 8 and 16 weeks' gestation in type 1 diabetes. Severe hypoglycemia in early pregnancy is three times more frequent than during preconception. Providing preconception counseling, including information about a potential increase in hypoglycemia early in pregnancy, may help reduce the incidence of hypoglycemia for women planning to become pregnant. Intentional insulin overdose is thought to be relatively rare, but the actual prevalence is difficult to measure. A common method used to estimate the number of deliberate insulin overdoses is to analyze data from regional poison control centers. In the annual report of the American Association of Poison Control Centers, only 3, of the 2,, inquiries 0. Hypoglycemia usually occurs when you haven't eaten, but not always. Sometimes hypoglycemia symptoms occur after certain meals, but exactly why this happens is uncertain. This type of hypoglycemia, called reactive hypoglycemia or postprandial hypoglycemia, can occur in people who have had surgeries that interfere with the usual function of the stomach. The surgery most commonly associated with this is stomach bypass surgery, but it can also occur in people who have had other surgeries. Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats palpitations. When this happens, the risk of severe, life-threatening hypoglycemia increases. If you have diabetes, recurring episodes of hypoglycemia and hypoglycemia unawareness, your health care provider might modify your treatment, raise your blood sugar level goals and recommend blood glucose awareness training. A continuous glucose monitor CGM is an option for some people with hypoglycemia unawareness. The device can alert you when your blood sugar is too low. If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening. Fear of hypoglycemia can cause you to take less insulin to ensure that your blood sugar level doesn't go too low. This can lead to uncontrolled diabetes. Talk to your health care provider about your fear, and don't change your diabetes medication dose without discussing changes with your health care provider. A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. An insulin pump, attached to the pocket, is a device that's worn outside of the body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen. Insulin pumps are programmed to deliver specific amounts of insulin automatically and when you eat. Follow the diabetes management plan you and your health care provider have developed. If you're taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your health care provider about how these changes might affect your diabetes management and your risk of low blood sugar. Learn the signs and symptoms you experience with low blood sugar. This can help you identify and treat hypoglycemia before it gets too low. Frequently checking your blood sugar level lets you know when your blood sugar is getting low. A continuous glucose monitor CGM is a good option for some people. A CGM has a tiny wire that's inserted under the skin that can send blood glucose readings to a receiver. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm. Some insulin pumps are now integrated with CGMs and can shut off insulin delivery when blood sugar levels are dropping too quickly to help prevent hypoglycemia. Be sure to always have a fast-acting carbohydrate with you, such as juice, hard candy or glucose tablets so that you can treat a falling blood sugar level before it dips dangerously low. For recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent blood sugar levels from getting too low. However, this approach isn't advised as a long-term strategy. Work with your health care provider to identify and treat the cause of hypoglycemia. Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. This content does not have an English version. This content does not have an Arabic version. Overview Hypoglycemia is a condition in which your blood sugar glucose level is lower than the standard range. Request an appointment. Thank you for subscribing! Sorry something went wrong with your subscription Please, try again in a couple of minutes Retry. Continuous glucose monitor and insulin pump Enlarge image Close. Continuous glucose monitor and insulin pump A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. By Mayo Clinic Staff. Show references AskMayoExpert. Unexplained hypoglycemia in a nondiabetic patient. Mayo Clinic; American Diabetes Association. Standards of medical care in diabetes — Diabetes Care. Accessed Nov. Hypoglycemia low blood sugar. Low blood glucose hypoglycemia. National Institute of Diabetes and Digestive and Kidney Diseases. Cryer PE. Hypoglycemia in adults with diabetes mellitus. Vella A. Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes. Merck Manual Professional Version. What is diabetes? Centers for Disease Control and Prevention. Kittah NE, et al. Management of endocrine disease: Pathogenesis and management of hypoglycemia. European Journal of Endocrinology. Vella A expert opinion. Mayo Clinic. Castro MR expert opinion. Mayo Clinic Press Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book. Show the heart some love! |
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