Accessed 1SEP 2 The system is intended to complement, not replace, information obtained from standard blood glucose monitoring devices.

All therapy adjustments should be based on measurements obtained from standard blood glucose monitoring devices. All therapy adjustments should be based on measurements obtained using a home blood glucose meter and not on values provided by the system.

The system is intended to complement, not replace, information obtained from standard blood glucose monitoring devices, and is not recommended for people who are unwilling or unable to perform a minimum of two meter blood glucose tests per day, or for people who are unable or unwilling to maintain contact with their healthcare professional.

The system requires a functioning mobile electronic device with correct settings. If the mobile device is not set up or used correctly, you may not receive sensor glucose information or alerts.

Feeling shaky Being nervous or anxious Sweating, chills and clamminess Irritability or impatience Confusion Fast heartbeat. Tingling or numbness in the lips, tongue, or cheeks Headaches Coordination problems, clumsiness Nightmares or crying out during sleep Seizures.

Hypoglycemia unawareness As unpleasant as they may be, these symptoms are useful as they help let you know that action is needed to correct a low blood sugar. They are also less likely to wake up from an overnight low.

Know before you go low If you or someone you know has hypoglycemia unawareness, it is important to check blood sugar frequently or wear a continuous glucose monitor CGM. Hypoglycemia prevention involves an 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. The signs and symptoms of hypoglycemia vary depending on the severity of the event and can also differ between patients. Symptoms may be generally categorized as autonomic or neuroglycopenic.

Examples of adrenergic symptoms include tremor, palpitations, tachycardia, and anxiety; some cholinergic symptoms are sweating, hunger, and paresthesias.

Importantly, the blood-glucose threshold at which an individual patient will experience hypoglycemic symptoms depends on the degree of diabetes management.

That is, the threshold for hypoglycemia will be higher in patients with consistently elevated blood-glucose levels; conversely the threshold tends to be lower in those who experience frequent hypoglycemia.

Neuroglycopenic symptoms result from a lack of glucose in the central nervous system and may include dizziness, weakness, drowsiness, delirium, confusion, seizure, and potentially coma.

For diabetes patients who meet one or more of these criteria, individualized treatment plans should consider risks of treatment intensification versus potential benefits. Educating patients about strategies for hypoglycemia prevention is an important aspect of diabetes care. The following sections discuss considerations for hypoglycemia prevention, including medication, diet and physical activity, use of glucose monitoring, and screening and management of hypoglycemia unawareness.

TABLE 1 summarizes the associated hypoglycemia risk of common glucose-lowering medications. If a patient is struggling with severe or recurrent hypoglycemia, it is important for the clinician to critically evaluate the appropriateness of the continued use of high-risk medications.

Although physical activity has many health benefits and should be encouraged in patients with diabetes, it can contribute to hypoglycemia in at-risk individuals; therefore, caution is warranted and individualized strategies for hypoglycemia prevention should be developed.

The effect of exercise on glucose levels will vary depending on the timing of physical activity relative to meals and medication administration as well as the duration and intensity of physical activity. Monitoring via finger-stick glucose readings and a glucose meter or a continuous glucose monitor CGM is essential for the detection and avoidance of hypoglycemia.

Patients at risk for hypoglycemia should be counseled to check their blood glucose before engaging in potentially dangerous activities e. As noted previously, the threshold for experiencing hypoglycemia is often lower in patients who have frequent hypoglycemic events. The ADA also recommends that insulin-treated patients with hypoglycemia unawareness be advised to raise their glycemic target to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce the risk of future episodes.

While implementation of strategies to prevent hypoglycemia is critical, diabetes patients at risk for hypoglycemia e. Hypoglycemia treatment involves two main strategies: 1 administration of oral carbohydrates and 2 administration of glucagon in the setting of severe hypoglycemia.

The preferred treatment for hypoglycemia in conscious patients is glucose, but any readily available form of carbohydrate that contains glucose may be used.

The Rule of 15 both facilitates the appropriate resolution of hypoglycemia and prevents overtreatment of the hypoglycemic event in order to minimize rebound hyperglycemia.

Carbohydrate sources high in protein should be avoided, as protein will delay carbohydrate absorption and resolution of hypoglycemia. It may be helpful to provide patients with examples of carbohydrate sources that contain approximately 15 grams of carbohydrate, such as glucose tablets or gel carbohydrate content may vary , five or six Life Savers candies, 4 oz of juice or soda regular, not diet , and 8 oz of skim milk.

In situations where the patient is unconscious or otherwise unable to ingest oral carbohydrates, the administration of exogenous glucagon is indicated. Lyophilized glucagon has been available commercially for several decades. Newer Glucagon Formulations: The limitations of traditional lyophilized glucagon kits have led to the development of two new glucagon formulations that address barriers to use and appropriate administration.

The following paragraphs give a brief overview of the Baqsimi and Gvoke glucagon products see also TABLE 3. Baqsimi glucagon nasal powder — This product is a dry glucagon powder administered intranasally via a prefilled device.

Intranasal glucagon has been shown to be comparable to traditional glucagon emergency kits in terms of hypoglycemia resolution. While all glucagon formulations can lead to adverse effects such as nausea, vomiting, and headache, intranasal glucagon can also cause rhinorrhea, nasal congestion or discomfort, and epistaxis.

The Baqsimi nasal device comes in a yellow tube enclosed in shrink wrap. The device is gently inserted into one nostril, and the plunger is then firmly depressed all the way in to administer the full dose. Because this formulation is a nasal powder, it may be stored at temperatures up to 86°F; however, it should not be stored in moist or humid conditions, as moisture may render the drug ineffective.

Gvoke glucagon injection — This new glucagon solution, which is administered via injection, does not require reconstitution.

Hypoglycemia remains a significant barrier in the optimal management of diabetes. Pharmacists can play a critical role in educating diabetes patients about the prevention, recognition, and appropriate treatment of hypoglycemia in the ambulatory care setting.

The widespread availability of CGM systems and newer, easier-to-use glucagon formulations provides opportunities for pharmacists to educate patients about these treatment options if they are struggling with recurrent hypoglycemic events.

American Diabetes Association. Standards of Medical Care in Diabetes— Diabetes Care. McCoy RG, Lipska KJ, Yao X, et al. Intensive treatment and severe hypoglycemia among adults with type 2 diabetes. JAMA Intern Med. National Diabetes Statistics Report, Atlanta, GA: CDC;