Diabetes Complications

Hypoglycemia: Symptoms, Causes, Management

In people without diabetes, blood glucose (sugar) is regulated by the body to promote healthy blood sugar levels.

High and low blood sugar levels can be dangerous and cause life-threatening problems. Therefore, the main goal when managing diabetes is to keep blood sugar levels in a healthy range to avoid health complications.

People without diabetes can even experience high or low blood sugar at times.

Being aware of the symptoms of blood sugar imbalances, such as low blood sugar, is essential to help prevent the development of Hypoglycemia.

What is Hypoglycemia?

The body’s primary source of energy is sugar in the form of blood glucose. There is always some sugar present in our blood for us to survive.

For our bodies to effectively use sugar to fuel our cells, the hormone insulin is required. Insulin helps sugar get from the blood into our cells; this action lowers our blood sugar.

Hypoglycemia is the term for low blood sugar, or when blood glucose falls below 70 milligrams per deciliter (mg/dL). When blood sugar is low, it causes harmful and disruptive symptoms.

Prolonged periods of severe hypoglycemia can cause insulin shock. Insulin shock can be life-threatening and lead to coma and death if it’s not treated quickly.

Hypoglycemia usually occurs in people with diabetes mellitus or diabetes. Diabetes occurs when the pancreas doesn’t make enough insulin, or it doesn’t respond to insulin-like it should.

Without enough insulin, blood sugar levels are too high. People with diabetes often take medication, such as insulin, to help lower blood sugar to a healthy level.

Hypoglycemia usually occurs when there is too much insulin present in the body, which explains the term insulin shock.

Signs and symptoms of Hypoglycemia

There are many warning signs of hypoglycemia.

The most common symptoms of hypoglycemia include:

  • Feeling shaky and/or dizzy

  • Sweating

  • Hunger

  • Feeling irritable or moody

  • Feeling anxious or nervous

  • Headache

Some people experience nocturnal hypoglycemia, which means it occurs overnight while sleeping. Signs of nocturnal hypoglycemia include:

  • Damp sheets or nightclothes, due to sweat during sleep

  • Nightmares

  • Feeling tired, irritable, or confused after waking.

If hypoglycemia isn’t treated, severe hypoglycemia can occur. Signs and symptoms of severe hypoglycemia include:

  • Clumsiness or jerky movements

  • Muscle weakness

  • Slurred speech or difficulty speaking.

  • Blurry or double vision

  • Drowsiness

  • Confusion

  • Convulsions or seizures

  • Unconsciousness/fainting

  • Coma

  • Death

What causes Hypoglycemia?

There are many causes of hypoglycemia. Many of them are related to diabetes, but some people without diabetes can also develop hypoglycemia.

Too much insulin

Injecting insulin lowers blood sugar more quickly than any other diabetes medication. The risk of low blood sugar is highest with short- and rapid-acting insulins.

Regular insulin is short-acting, and Humalog and Novolog are examples of rapid-acting insulins. Fast-acting insulin is usually taken around meals because eating raises blood sugar.

Long-acting or basal insulin works the slowest out of all of the different insulins. It is usually injected once or twice a day. Long-acting insulin mimics the body’s natural ability to release a minimal amount of insulin continuously, like a faucet dripping.

Examples of long-acting insulin include Lantus and Levemir. Newer concentrated and ultra-long-acting insulin such as Toujeo, Tresiba, and Basaglar are also considered basal insulins.

Intermediate-acting insulin works more slowly than fast-acting but is faster than basal insulin. Examples of intermediate insulins are Novolin N and Humulin N, or NPH insulin.

Insulin doses can overlap, which increases the risk of hypoglycemia. For example, taking a morning dose of NPH insulin as well as a dose of rapid-acting insulin before lunch can cause a “stacking up” of insulin levels in the body.

Too much of another kind of diabetes medication

Other diabetes medications that aren’t insulin can also cause hypoglycemia. These medications include:

  • Sulfonylureas, such as glipizide, glyburide, and glimepiride. Sulfonylureas help the pancreas make more insulin, which lowers blood sugar.

  • Meglitinides, such as Prandin and Starlix, stimulate the pancreas to release more insulin.

  • Exenatide (Byetta) can cause hypoglycemia if it’s also taken with a sulfonylurea; it usually doesn’t cause hypoglycemia on its own, though.

Hypoglycemia Unawareness

People who have had diabetes for a long time may not be as aware of the symptoms of hypoglycemia. This can occur as a result of autonomic neuropathy, which is a complication of long-term high blood sugar.

Not enough food, especially carbohydrates. Foods that contain carbohydrates, such as bread, milk, fruit, and starchy vegetables, turn into sugar when digested. If someone isn’t eating very many carbohydrates, especially if they’re also taking insulin, hypoglycemia can occur.

Exercise and Weight Loss

Physical activity stimulates the body to take up more glucose for energy, which can cause low blood sugar if food or drink containing carbohydrates aren’t taken in regular amounts while exercising for long periods of time.

This is one of the reasons marathon runners usually take energy gels or drinks containing sugar throughout their run.

The liver stores sugar in the form of glycogen. Glycogen helps provide our bodies with sugar when we are fasting and during exercise, thus reducing hypoglycemia risk.

During prolonged periods of exercise or fasting, glycogen stores can become used up. Severe weight loss can also use up glycogen stores due to being in a fasting state. Without enough glycogen, hypoglycemia can occur.

Reactive Hypoglycemia

Some people with and without diabetes produce too much insulin in response to eating, especially simple sugars like candy and juice. Reactive hypoglycemia usually occurs within a few hours after eating and can happen very quickly in some cases.

Gastroparesis

Gastroparesis is the slowing of stomach emptying, which can occur as a complication of diabetes. When food isn’t emptied from the stomach very quickly, it isn’t available to be digested and converted into sugar in the bloodstream.

Hypoglycemia risk increases in people with gastroparesis who take insulin. Some healthcare providers recommend taking mealtime insulin after a meal (instead of before) in the case of severe gastroparesis to reduce hypoglycemia risk.

Too much alcohol

Alcohol can cause an increase in insulin secretion as well as interferes with the liver’s ability to create sugar (gluconeogenesis), which can both cause hypoglycemia.

Other causes not related to diabetes: Pancreatic tumors, adrenal or pituitary problems, kidney problems, liver problems, and certain non-diabetic medications can all cause hypoglycemia.

Diagnosing Hypoglycemia

Hypoglycemia is diagnosed using a blood test. If you don’t have diabetes and aren’t checking your blood sugar regularly, it can be hard to know how low your blood sugar is.

On the other hand, people checking their blood sugar regularly can easily identify hypoglycemia by performing a fingerstick blood sugar test.

Hypoglycemia is diagnosed when blood glucose is below 70 mg/dL. Some people may feel symptoms of low blood sugar while their blood sugar is actively dropping.

In this case, it’s important to recheck blood sugar, even if the reading is normal because it could be low after the recheck.

If someone is experiencing low blood sugar outside of eating or fasting, blood sugar tests may be ordered for several days in a row.

For reactive hypoglycemia, a mixed meal tolerance test (MMTT) may be ordered. An MMTT involves drinking a drink containing protein, fat, and sugar, and having your blood sugar tested several times during the next few hours.

The results of the test can help determine how much insulin is being secreted in response to eating.

Complications of Hypoglycemia

  • Quality of Life: Hypoglycemia can interfere with your quality of life. The symptoms of hypoglycemia can make it difficult to perform daily tasks such as working, driving, and exercising. If someone has a hypoglycemic event while driving, it can cause danger to themselves and other people.

  • Fractures and Falls: Recent studies have associated severe hypoglycemia as a risk factor for dementia, falls, fractures, and heart attacks. Elderly people are at higher risk of hypoglycemia-related fractures; because of this, many healthcare providers are more lenient with blood sugar targets in the elderly.

  • Somogyi effect: Hypoglycemia can occasionally cause rebound hyperglycemia or the Somogyi effect. The Somogyi effect is different from the Dawn phenomenon because it usually is caused by low blood sugar overnight.

    To differentiate between the two, take your blood sugar a few times during the night. If blood sugars are high in the early morning hours, it likely isn’t the Somogyi effect. If blood sugars are low in the early morning hours, then high blood sugars in the morning are likely due to the rebound hyperglycemia/Somogyi effect.

  • Coma or even death: Severe hypoglycemia can lead to coma and even death. People who experience nocturnal hypoglycemia are at higher risk of serious complications because they may not be aware they are experiencing a low, or they may be too sleepy to be able to get help.

Prevention of Hypoglycemia

Eat Consistently

Eating a hypoglycemia diet, including protein, fat, and carbohydrates every few hours can help keep blood sugar levels stable.

Some people find protein helpful in preventing low blood sugar levels; for example, eating cheese and crackers for a snack instead of just crackers. Eating a very low carbohydrate diet, such as a ketogenic diet, may not be the best choice for someone with chronic hypoglycemia.

For people with reactive hypoglycemia, avoiding simple sugars may help prevent hypoglycemia. Simple sugars, such as soda and sweets, stimulate the pancreas to release insulin more quickly than foods like fruit and bread. A rapid increase in insulin levels can cause low blood sugar.

Take insulin and medications as prescribed

Insulin is a potentially dangerous medication because it’s so effective at reducing blood sugar. Insulin should only be used under the guidance of a healthcare provider, and only as prescribed.

If your blood sugar levels are high, discuss it with your healthcare provider; never increase insulin doses on your own, as this can cause episodes of hypoglycemia.

The timing of insulin is also crucial. A rapid-acting insulin is designed to be taken a few minutes before starting a meal. If you forget to take your rapid-acting insulin, it can be safer to skip that dose instead of taking it several hours after the meal.

Use snacks to your advantage

If you’re prone to hypoglycemia, snacks can be a very useful tool in preventing low blood sugar.

Having a snack before exercising or before bedtime can help provide enough sugar to offset the lowering of blood sugar. Having a bedtime snack is very important for people taking insulin at bedtime and who experience hypoglycemia often.

Don’t drink alcohol on an empty stomach

Drinking alcohol, while taking certain diabetes medications can increase hypoglycemia risk even more.

If you choose to drink, make sure you eat something first; drinking on an empty stomach can worsen hypoglycemia.

Treatment of Hypoglycemia

If blood glucose levels are below 70 mg/dL, take food or drink with 15 grams of carbohydrate.

Sugary drinks and hard candies are preferred as they turn into sugar quickly. You don’t need much juice to get to 15 grams of carbohydrates; about one-half cup is enough.

After taking some carbohydrates, check your blood sugar in 15 minutes. If it’s still below 70 mg/dL, repeat the treatment and retest blood sugar level in another 15 minutes.

If blood sugar levels don’t rise despite treatment, or if they are dangerously low, a glucagon emergency kit may be used. A medical professional must prescribe glucagon, and it’s in the form of an injection. Glucagon is a hormone that helps convert the body’s stored sugar (glycogen) into blood sugar.

Conclusion

Hypoglycemia can be inconvenient at best and life-threatening at worst. It most often affects people with diabetes, but it can also occur in people without diabetes.

Many steps can be taken to avoid hypoglycemia, such as eating consistently and taking medications as prescribed. Hypoglycemia can be treated at home, or for more severe cases, an injectable form of glucagon can be used to help correct low blood sugar.

Sources

  1. Kalra S, Mukherjee JJ, Venkataraman S, et al. Hypoglycemia: The neglected complication. Indian J Endocrinol Metab. 2013;17(5):819–834. doi:10.4103/2230-8210.117219
  2. Kumar JG, Abhilash KP, Saya RP, Tadipaneni N, Bose JM. A retrospective study on epidemiology of hypoglycemia in Emergency Department. Indian J Endocrinol Metab. 2017;21(1):119–124. doi:10.4103/2230-8210.195993
  3. Evans Kreider K, Pereira K, Padilla BI. Practical Approaches to Diagnosing, Treating and Preventing Hypoglycemia in Diabetes. Diabetes Ther. 2017;8(6):1427–1435. doi:10.1007/s13300-017-0325-9
  4. Cryer, P. (2015). Minimizing Hypoglycemia in Diabetes. Diabetes Care. 38 (8), p1583-1591.
  5. Lamounier, R.N., Geloneze, B., Leite, S.O. et al. Hypoglycemia incidence and awareness among insulin-treated patients with diabetes: the HAT study in Brazil. Diabetol Metab Syndr 10, 83 (2018) doi:10.1186/s13098-018-0379-5

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