Hypogycemia: A Deadly Life Partner of Diabetes

We already know very well that diabetes has many complications. Some take long time to develop, some are instantaneous. I am going to talk about one of those complications that actually do not give us time to think. A diabetic may need immediate hospitalization with these and there may be no other option. I think every diabetic person and their family members, even office colleagues should know about it.

It is hypoglycemia. 'Hypo' means less and 'glycemia' means glucose in blood. So, altogether it means a condition when there is drop in blood sugar level below normal in the body. Anyone, yes, anyone with or without diabetes may have hypoglycemia. Perhaps you who is reading this article had an episode of hypoglycemia in your life! Its very simple; when a person go on fasting or working hard without taking meal for a longtime may run out of sugar in his blood and ultimately becomes dizzy, disoriented with sweating & palpitation, sometimes may fall down from standing. When someone acts stupid we sometimes make joke of it if- are you getting hypo?

The funny part is, even you, who have no relation with diabetes or do not have any diabetic partner in the office should also know well about hypoglycemia. Who knows the person sitting next by you on a bus may loose his consciousness with no time may need your attention for survival!

The question is, if diabetes (diabetes mellitus) means excess glucose in blood, why on earth a diabetic may get hypoglycemia? The answer is very simple - treatment is the cause! We generally know to control diabetes one has to take insulin or oral drugs. There should be a balance between the drugs and patient's blood sugar. When a person takes insulin or tablets more than his need, blood sugar begins to fall ultimately leading towards hypoglycemia. Let us go through a case scenario.

Mr. Babar a sedentary worker, just retired from his managerial post from a reputed industry was in good control of his diabetes. For the last few days he was very much busy both physically and mentally supervising a construction of a sixteen storied commercial building in Uttara. Sometimes he felt dizzy in the evening after a tiresome day. He was thinking of consulting his doctor. But unfortunately he somehow could not make it. The following day he just missed his lunch having been busy with his architect and at 5:10 pm he suddenly fell down while he was returning home. He was brought soon in BIRDEM emergency. So, what happened here? As an emergency protocol his blood sugar was checked and it was found to be only 1.3 mmol/L, that is severe hypoglycemia.

So, who is responsible here? Doctor who prescribes without follow up or the patient who is reluctant to consult with his doctor. Better not to debate on it. The best way to avoid this drug related hypoglycemia is to keep a small glucometer at home and practice regular monitoring. It is good to keep in mind that anti-diabetics that are most frequently associated with hypoglycemia is insulin (specially longer acting) and some oral anti-diabetic drugs specially sulfonylurea groups such as glibenclamide, glipizide, glimipride etc (please read the papers supplied with your drugs carefully).

Can a person taking proper dose of insulin or oral anti-diabetics be hypoglycemic? Unfortunately yes. The case story above is an example. If the patient misses his meal, take small amount than requirement, do excessive exercise or physical work, or has mal-absorption syndrome or other hormonal disorder- there is every chance of hypoglycemia. There are two types of diabetes mellitus- type I and type II. Type I are totally depended on insulin as they have no insulin produced by the body. It is very difficult to maintain their blood sugar in a narrow normal range by giving outside insulin. So naturally very often they get insulin overdose and easily get hypoglycemia. On the other hand type II have insulin but not in adequate amount. To overcome it oral drugs are given to stimulate the insulin to be secreted more or act more. But many of them ultimately fail to produce insulin adequately. So, additional outside(exogenous) insulin is given besides oral drugs. So, they have chances of hypoglycemia also. But as a whole the type I are more prone to hypoglycemia than type II.

Why is hypoglycemia bad?

The body needs fuel to work. One of its major fuel sources is sugar, which the body gets from what is consumed as either simple sugar or complex carbohydrates. For emergency situations (like prolonged fasting), the body stores sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to "make new sugar") and converts these stores of glycogen to sugar. So you see there is always ready and backup fuel for our body. On the other hand, of all the organs in the body, the brain depends on sugar almost exclusively. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. So if the glucose level in the blood falls there can be effects on the function of the brain. There may be irreversible brain damage if there is prolonged hypoglycemia. Suppose a person has taken insulin in a very high dose at night (a double dose, wrong insulin, wrong syringe or due to any fault) he may get hypoglycemia at night and remain un-noticed for the whole night! There is every chance of permanent brain damage here.

So, what I am trying to say that, please be careful both who prescribes new anti-diabetic agents specially insulin for the very first time and the patient who receives it. Please discuss what is hypoglycemia very well with your patients before prescribing. Check the insulin including the syringe and show your patient the proper technique, such as matching the units of the syringe with that of the insulin. Tell clearly to withdraw insulin or to reduce the dose if patient misses a meal or unable to eat or vomits out what he ate. Advice for the patients and the attendants- please do not go away confused with the prescription! Just discuss clearly with your diabetologist if you have any thing to clarify. Inform your doctor if you have any major change in lifestyle such as getting a different new job or change of place. Buy a good small glucometer and monitor blood sugar at home and adjust insulin accordingly and it is very very important. There are many quality glucometers in the markets. Many of my patients simply monitor sugar by the glucometer and adjust their insulin well. But before buying a new one please be sure that the strips are fairly available in your area with reasonable prices.

Perhaps I am losing my track. I was talking about hypoglycemia. When do we say it is hypoglycemia? There is a controversy here, but I will try to make it as easy as possible. In a normal person after a overnight fast blood glucose falls. In full stomach it rises. By definition when blood sugar goes bellow 2.5 mmol/L(45 mg/dl), it is absolute hypoglycemia. But many old diabetic with high blood sugar such as 15 to 20 mmol/L may show symptoms of hypoglycemia even when his sugar is 5 or 6. This phenomenon is called relative hypoglycemia. It happens as they are accustomed with high blood sugar, when it falls a bit, their body cannot compensate with the fall.

It is very important to know by what symptoms you can predict that you are having hypoglycemia. It is quite difficult to explain as both the hyperglycemia and hypoglycemia share some common clinical features. It is you who knows more than a doctor what you are having hypo or hyperglycemia! By circumstantial evidence like missed meal, insulin overdose, vomiting or diarrhoea, one can predict that he or she is having hypoglycemia. But it is always better to use a glucometer to confirm that.

So, what are the features? It is better to divide it in two ways: mild to moderate hypoglycemia and severe hypoglycemia. In the first group there is little fall of glucose and majority of the patient remain conscious and can take necessary actions. This is manifested by sweating, tremor, rapid pulse, palpitation, nerviousness, confusion, intense hunger, sudden weakness etc. It is better to remember it by comparing with the feeling when we become afraid or get panicked. Actually it is the adrenaline rush to compensate the effect of low sugar.

Can the body protect itself from hypoglycemia?

When the circulating level of blood glucose falls, the brain actually senses the drop. The brain then sends out messages that trigger a series of events, including changes in hormone and nervous system responses that are aimed at increasing blood glucose levels. Insulin secretion decreases and hormones that promote higher blood glucose levels, such as glucagon, cortisol, growth hormone and epinephrine, all increase. Also there is a store in the liver of glycogen that can be converted to glucose rapidly.

In addition to the biochemical processes that occur, the body starts to consciously alert the affected person that he needs food by causing the signs and symptoms of hypoglycemia discussed above. This mild to moderate hypoglycemia thus automatically corrected. But we should not waste time waiting to be corrected automatically. Give the patient some sugar to eat. It may be plain sugar, glucose, chocolate, honey even fruit juice. The basic mechanism is to restore the low blood sugar rapidly. So, it is very much important to carry a packet of glucose or chocolate with you if you are diabetic. Many of patients are advised to take bread, cake, biscuits, even rice. But it is wrong. In crisis moment we need a quick sugar that is glucose a mono-saccharide. Plain sugar, honey, fruit juice or even a can of coke is a good source of glucose. Rice, cakes etc are complex sugars and advised to be taken later after correcting hypoglycemia to maintain adequate sugar in blood. So, it is clear that treating mild to moderate hypoglycemia needs no assistance. Patient himself is enough for his recovery.

Now about the 2nd type that is, severe hypoglycemia. This type is different and most of the times patient may lose his/her consciousness. Hospital admission or outside assistance is a must here. Here sugar falls beyond 2.5 mmol/L or even less. Many a patient are hospitalized with blood glucose 1.6 or 1.4 only. Wrong insulin, double dose, wrong dose of insulin or new onset intercurrent illness are the major causes for severe hypoglycemia. The symptoms are also different. Brain related symptoms are more prominent here. As glucose is the only fuel for our brain, so, when sugar falls bellow a critical level there is confusion, headache, visual disturbance and ultimately progressing to convulsion, coma or loss of consciousness very rapidly. As these patients usually found unconscious, it is better to bring the patient to hospital as early as possible. If it is diagnosed clearly (by a glucometer at home) a intravenous fluid of 25% dextrose or any glucose containing intravenous(iv) fluid can be given on the way to hospital.

In hospital we usually give iv glucose. Glucagons injection- a counter hormone for insulin is another option. If the patient comes early it is hopeful that after proper management he/she may regain consciousness and be normal again very rapidly within minutes to hours. But unfortunately a big chunk of patient reach to emergency after 6 to 10 hours of severe hypoglycemia and it becomes very difficult to recover them.

Death occupies a considerable portion of their fate though some lives can be saved. But if life can be saved there may be significant brain damage that is almost always irreversible.

Unfortunately the responsibility of some of the brain damage cases are directly or indirectly goes to the doctors. As for example if a patient is getting steroid and knowing that steroid increases blood sugar a doctor may prescribe high dose of insulin.

There is no fault. But it should be well understood by the patient. If not he/she may stop steroid suddenly without reducing insulin and may get hypoglycemia eventually. Same advice to the bedridden patients when they improve and start physical exercise, please reduce the dose of insulin.

I already have mentioned one should have a glucometer and monitor regularly to avoid complications. Some may argue that the device is expensive but think over it, what you will have to pay if you need emergency hospital admission and imagine what will be the price if there is some permanent brain injury!

There are some special situations one has to keep in mind. If a diabetic takes non selective beta blocker (an antihypertensive acting mostly on heart) due to his high blood pressure, may not feel the effects of hypoglycemia like palpitation, rapid pulse.

This drug can easily musk the symptoms of hypoglycemia. So, one should be alert or may request his doctor to change it if he had repeated hypoglycemia. Some anti-depressant drugs and unnecessarily used sedatives may also hide the crucial features of hypo specially at night and patient may remain unconscious unnoticed. Long standing diabetics may loose their nervous sensation and in those group severe hypoglycemia may occur without any warning. There is another uncommon group, those who manifest nocturnal hypoglycemia, that is they use to have hypoglycemia at late night (usually 2:00 AM to 4:00 AM). It is very difficult to recognize it. But during the episode there may be abnormal sweating, nightmares, tremors or even convulsions usually observed by another person near by. If so, it should be confirmed by checking sugar with a glucometer immediately. Treatment is to reduce or take night-time insulin in the evening time.

Some patients even after proper monitoring and dose adjustment may have repeated hypoglycemia, usually in milder form. The practical advice to them is to carry a diabetic card with them. In developed countries it is seen that patients are wearing bracelets or necklaces with "I am a diabetic, please call my doctor if necessary- 012 … (tel no.)" written on it. It will be very helpful if one at least keeps a card with his diagnosis and important contact numbers on it.

Last of all, a common situation faced by a big portion of diabetic in our country that many of them have no glucometer of their own and in the peripheries, it is sometimes difficult or even impossible to get one. So, it is pretty difficult to take decision if anyone gets hypoglycemia. My suggestion is if any diabetic suddenly falls, loss his orientation, sweats profusely or becomes thirsty please treat him as a case of hypoglycemia keeping other evidence in mind. Give the patient some sugar orally. If so he/she will recover soon and then take the patient to a suitable hospital if needed. Many cases need not to be admitted; correcting hypoglycemia is enough but please do a serious check up later why it happened. But if the symptoms are due to high blood sugar what will happen if we give sugar unknowingly? There is actually no significant harm but the patient's condition will remain so and it is better to check by a meter or transfer the patient to a proper setup. Remember prolonged hypoglycemia is much worse than hyperglycemia (high blood sugar). All these situations can easily be avoided by simply possessing a glucometer or at least keeping a list of places where you can get the test done rapidly. So, control your diabetes and also monitor it. Monitoring is very important and self monitoring by a glucometer is probably the best way till today to avoid complications of diabetes and it's treatment.

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