Diabetic hypoglycemia– Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Abnormally low concentration of glucose in circulating blood of diabetic; often referred to as an insulin reaction
- Classification includes:
- Severe hypoglycemia: An event requiring assistance of another person to actively administer treatment
- Documented symptomatic hypoglycemia: An event during which typical symptoms are accompanied by a measured plasma glucose of ≤70 mg/dL (3.9 mmol/L)
- Asymptomatic hypoglycemia: An event not accompanied by symptoms, but a measured glucose of ≤70 mg/dL (3.9 mmol/L)
- Probable symptomatic hypoglycemia: Event with symptoms, but glucose not tested
- Relative hypoglycemia: An event with typical symptoms, but glucose >70 mg/dL (3.9 mmol/L)
- Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes.
- System(s) affected: Endocrine/Metabolic
- Major risk factor for severe hypoglycemic reactions
- Most commonly found in patients with long-standing type 1 diabetes and children <7 years
From the Accord Study, the annual incidence of hypoglycemia was:
- 3.14% in the intensive treatment group
- 1.03% in the standard group
- Increased risk among women, African Americans, those with less than a high school education, aged participants, and those who used insulin at trial entry
- From the RECAP-DM study: Hypoglycemia was reported in 38% of type 2 patients who added a sulphonylurea or a thiazolinedione to metformin therapy during the past year.
- Most common in type 1 diabetics:
- If tightly controlled: Often experience hypoglycemia frequently, weekly
- Type 2 diabetics:
- Common if treated with insulin and/or insulin secretagogues
- Nearly 3/4 of severe hypoglycemic episodes occur during sleep.
- Autonomic neuropathy
- Illness, stress, and unplanned life events
- Duration of diabetes >5 years, advanced age, renal/liver disease, CHF, hypothyroidism, hypoadrenalism, gastroenteritis
- Starvation or prolonged fasting
- Alcoholism: Evening consumption of alcohol is associated with an increased risk of nocturnal and fasting hypoglycemia, especially in type 1 patients.
- Current smokers with type 1 diabetes
- Oral hypoglycemics with long duration and high potency have greater hypoglycemic risks.
- α-Glucosidase inhibitors, biguanides, and thiazolidinediones, when used in combination with insulin and/or sulfonylureas or meglitinides
- In patients 80 years or older, severe hypoglycemia is associated with comorbid conditions and in users of a long-activing sulphonylurea
- Maintain routine schedule of diet, medication, and exercise.
- Stabilize daily carbohydrate intake.
- Regular blood glucose testing:
- ≥3 times daily testing if multiple injections of insulin
- Diabetes treatment and teaching programs (DTTPs) especially for high-risk type 1 patients, which teach flexible insulin therapy to enable dietary freedom
- Hypoglycemia rates are reduced by up to 70% using continuous subcutaneous insulin infusion pumps compared with multiple daily injections (1)[C].
- Loss of hormonal counter-regulatory mechanism in glucose metabolism
- Diet: Too little food (skipping meal), decreased carbohydrate intake
- Medication: Too much insulin or oral hypoglycemic agent (improper dose or timing)
- Erratic absorption of insulin or oral hypoglycemics
- Adverse reaction from other medications
- Exercise: Unplanned or excessive
- Alcohol consumption
- Vomiting or diarrhea
Commonly Associated Conditions
- Autonomic dysfunction
- Symptoms are idiosyncratic and vary considerably between individuals (2).
- Adrenergic hypoglycemia symptoms:
- Hunger, trembling, pallor
- Sweating, shaking, pounding heart, anxiety
- Neuroglycopenic hypoglycemia symptoms:
- Dizziness, poor concentration, drowsiness, weakness, confusion, lightheadedness, slurred speech, blurred vision, double vision, unsteadiness, poor coordination
- Behavioral hypoglycemia symptoms:
- Tearfulness, confusion, fatigue, irritability, aggressiveness
- Patients’ reports of hypoglycemic symptoms are associated with a significantly lower treatment satisfaction and with barriers to adherence (3)[A].
- General: Confusion, lethargy
- HEENT: Diplopia
- Cor: Tachycardia
- Neuro: Tremulousness, weakness, paresthesias, stupor, seizure, or coma
- Mental status: Irritability, inability to concentrate, or short-term memory loss
- Skin: Pale, diaphoresis
- End organ damage: Microvascular, macrovascular, ophthalmologic, neurologic, renal
Diagnostic Tests & Interpretation
- Plasma or whole-blood glucose <70 mg/dL
- Suspect hypoglycemic unawareness in type 1 asymptomatic diabetes with low/normal HgbA1c.
- Chronic hypoglycemia is indicated by low glycohemoglobin level.
- Disorders that may alter lab results:
- Hemoglobinopathies may alter HgbA1c results.
- Hypoglycemia is well documented in chronic alcoholics and binge drinkers.
- GI dysfunction causing postprandial hypoglycemia or alimentary reactive hypoglycemia
- Hormonal deficiency states (hormonal reactive hypoglycemia)
- Idiopathic reactive hypoglycemia (reactive hypoglycemia, a popular diagnosis 20 years ago, is actually quite rare)
- Hypoglycemia of sepsis
- Islet cell tumors
- Factitious hypoglycemia from surreptitious injection of insulin
- Hypoglycemia may be found in nondiabetics under certain conditions such as early pregnancy, prolonged fasting, long periods of strenuous exercise, heart failure, malignancy, and renal or liver disease.
- Oral administration of small-molecule sugars (saccharose/glucose); glucose preferred
- ∼60–90 carbohydrate calories (15–20 g glucose) repeated every 15 minutes until blood sugar is ≥100 mg/dL (5.55 mmol/L)
- Takes ∼15 minutes for carbohydrates to be digested and enter bloodstream as glucose
- Once sugar has normalized, then a meal or snack should be consumed to prevent recurrence of hypoglycemia (4)[C].
- In patients with loss of consciousness at home:
- Administer glucagon IM or SC in the deltoid or anterior thigh:
- <5 years old: 0.25–0.50 mg
- 5–10 years old: 0.50–1 mg
- >10 years: 1 mg
- Administer glucagon IM or SC in the deltoid or anterior thigh:
- In unconscious, if emergency medical personnel are present or patient hospitalized:
- Give 1/2 ampule 50% dextrose every 5–10 minutes until patient awakens.
- Then feed orally and/or administer 5% dextrose IV at level that will maintain blood glucose >100 mg/dL.
- Patients with hypoglycemia secondary to oral hypoglycemics should be monitored for 24–48 hours, because hypoglycemia may recur after apparent clinical recovery.
- Significant possible interactions:
- Treatment may cause hyperglycemia (called Somogyi phenomenon).
- Clearance of certain oral hypoglycemics from plasma may be prolonged in persons with liver disease.
- Glucose: Preferred treatment; however, any form of carbohydrate that contains glucose should be effective (4)[C]
- Any sugar-containing food or beverage that can be rapidly absorbed: Juice (4–6 ounces), candy (5–6 pieces of hard candy), or nondiet soda
- OTC glucose tablets or gels
- Glucagon: People in close contact with people with diabetes should be instructed in using an emergency glucagon kit (4)[C].
- Glucagon should be prescribed to patients at significant risk of severe hypoglycemia (4)[C].
- If a patient using acarbose suffers from a bout of hypoglycemia, the patient should eat something containing monosaccharides, such as glucose tablets. Since acarbose will prevent the digestion of complex carbohydrates, starchy foods will not effectively reverse a hypoglycemic episode in a patient taking it.
Issues for Referral
- Frequent, recurring, or episodes that do not readily respond to treatment
- Consultant pharmacists can play a critical role in preventing hypoglycemia in long-term care facilities (5)[A] by recommending:
- More physiologic insulin regimens
- Facility protocols
- Staff education
Use of a continuous glucose monitoring system in the management of severe hypoglycemia decreases the number of hypoglycemic values (6)[B].
- Any doubt of cause
- Expectation of prolonged hypoglycemia (e.g., caused by sulfonylurea drug)
- Inability of patient to drink
- Treatment has not resulted in prompt recovery of sensorium.
- Seizures, coma, or altered behavior (e.g., ataxia, disorientation, unstable motor coordination, dysphasia) secondary to documented or suspected hypoglycemia
Patient has normoglycemia and risk of severe hypoglycemia is negligible.
Rest until glucose is normal.
Self-monitoring of blood glucose
- If alcohol consumed, combine with food to reduce risk of hypoglycemia
- Protein does not slow absorption of carbohydrates.
- Fats may slow absorption of carbohydrates and may retard and then prolong the acute glycemic response (7)[C].
- Always have access to quick-acting carbohydrate.
- For patients taking insulin:
- For planned exercise, consider a reduced insulin dosage.
- Additional carbohydrates may be needed for unplanned exercise.
- Moderate-intensity exercise increases glucose uptake by 2–3 mg/kg/min above usual requirements (70-kg person needs 10–15 g carbohydrates per hour for moderate physical activity).
- For patients with hypoglycemia unawareness or 1 or more episodes of severe hypoglycemia, glycemic targets should be raised to avoid further hypoglycemia for at least several weeks (4)[C].
- Educate patients and their relatives, close friends, teachers, and supervisors:
- Blood glucose testing should be available at school or workplace.
- Personnel should be aware of diabetes diagnosis and signs/symptoms of hypoglycemia and treatment.
- Teach self-monitoring of blood glucose and self-adjustment for insulin therapy, diet control, and exercise regimen.
- Patient should wear medical alert identification bracelet or necklace.
Full recovery usually depends on rapidity of diagnosis and treatment.
- Coma, seizure
- Prolonged or severe hypoglycemia may cause permanent neurologic damage and/or cognitive impairment.
- Repeated episodes of severe hypoglycemia not necessarily associated with cognitive dysfunction (8)
- MI, stroke, especially in elderly
In the ACCORD trial of adults with type 2 diabetes at especially high risk for heart attack and stroke, the medical strategy to intensively lower blood glucose (sugar) below current recommendations increased the risk of death compared with a less-intensive standard treatment strategy (9)[B].
1. Cohen ND, et al. Diabetes: Advances in treatment. Internal Med J. 2007;37:383–8.
2. McAulay V, et al. Symptoms of hypoglycaemia in people with diabetes. Diabetes UK, Diabetic Med. 2001;18:690–705.
3. Alvarez Guisasola F, Tofé Povedano S, Krishnarajah G, Lyu R, Mavros P, Yin D et al. Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) Study. Diabetes Obes Metab. 2008;10(Suppl 1):25–32.
4. American Diabetes Association. Executive summary: standards of medical care – 2009. Diabetes Care. 2009;32(Suppl 1):S6–12.
5. Garza H et al. Minimizing the risk of hypoglycemia in older adults: a focus on long-term care. Consult Pharm. 2009;24(Suppl B):18–24.
6. Ryan EA, Germsheid J et al. Use of continuous glucose monitoring system in the management of severe hypoglycemia. Diabetes Technol Ther. 2009;11:635–9.
7. American Diabetes Association, Bantle JP, Wylie-Rosett J, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care.2008;31(Suppl 1):S61–78.
8. Adverse events and their association with treatment regimens in the diabetes control and complications trial. Diabetes Care. 1995;18:1415–27.
9. National Institutes of Health. For safety, NHLBI changes intensive blood sugar treatment in clinical trial of diabetes and cardiovascular fitness. Accessed March 24, 2008 at:http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id = 2551.
Miller ME, Bonds DE, Gerstein HC, et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340:b5444.
See Also (Topic, Algorithm, Electronic Media Element)
Diabetes Mellitus, Type 1
- 250.80 Diabetes mellitus with other specified manifestations, type ii or unspecified type, not stated as uncontrolled
- 250.81 Diabetes mellitus with other specified manifestations, type I (juvenile type) not stated as uncontrolled
237633009 Hypoglycemic state in diabetes (disorder)
- Hypoglycemic unawareness is most commonly found in patients with tightly controlled, and long-standing type 1 diabetes and children <7 years. Reduction in unawareness may be improved by temporarily liberalizing blood sugar control to eliminate episodes of hypoglycemia.
- Any form of carbohydrate that contains glucose should be effective for management, such as sugar-containing food or beverage that can be rapidly absorbed:
- 4–6 ounces juice
- 5–6 pieces of hard candy
- Nondiet soda
- OTC glucose tablets or gels