As unpleasant as they may be, the symptoms of low blood sugar are useful. These symptoms tell you that you your blood sugar is low and you need to take action to bring it back into a safe range. But, many people have blood sugar 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 sugar 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 sugar 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 sugar levels are low or start to fall. This can be a big help for people with hypoglycemia unawareness. Hypoglycemia unawareness occurs more frequently in those who:.
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 sugar levels. This may mean increasing your target blood sugar 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 sugar levels. This can happen when your blood sugar 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 sugar, 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 sugar, the lower his or her risk of hypoglycemia. This is because you can see when blood sugar levels are dropping and can treat it before it gets too low. If you can, check often! Together, you can review all your data to figure out the cause of the lows.
The more information you can give your health care provider, the better they can work with you to understand what's causing the lows. Your provider may be able to help prevent low blood sugar by adjusting the timing of insulin dosing, exercise and meals or snacks. Changing insulin doses or the types of food you eat may also do the trick.
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Signs and symptoms of low blood sugar happen quickly Each person's reaction to low blood sugar is different. Treatment—The " Rule" The rule—have 15 grams of carbohydrate to raise your blood sugar and check it after 15 minutes.
Note: Young children usually need less than 15 grams of carbs to fix a low blood sugar level: Infants may need 6 grams, toddlers may need 8 grams, and small children may need 10 grams. This needs to be individualized for the patient, so discuss the amount needed with your diabetes team. Very low insulin requirements for basal and mealtime dosing in the infant and young child frequently require use of miniscule basal rates in pump therapy and one-half unit dosing increments with injections.
Management rarely requires the use of diluted insulin, e. Infants and toddlers may not recognize the symptoms of hypoglycemia and lack the ability to effectively communicate their distress. Caregivers must be particularly aware that changes in behavior such as a loss of temper may be a sign of hypoglycemia. Puberty is associated with insulin resistance, while at the same time the normal developmental stages of adolescence may lead to inattention to diabetes and increased risk for hypoglycemia.
As children grow, they often have widely fluctuating levels of activity during the day, which puts them at risk for hypoglycemia. Minimizing the impact of hypoglycemia on children with diabetes requires the education and engagement of parents, patients, and other caregivers in the management of the disease 42 , The youngest patients are most vulnerable to the adverse consequences of hypoglycemia.
Ongoing maturation of the central nervous system puts these children at greater risk for cognitive deficits as a consequence of hypoglycemia Recent studies have examined the impact of hypoglycemia on cognitive function and cerebral structure in children and found that those who experience this complication before the age of 5 years seem to be more affected than those who do not have hypoglycemia until later 7.
The long-term impact of hypoglycemia on cognition before the age of 5 years is unknown. Landmark data on the impact of hypoglycemia on adults with type 1 diabetes come from the Diabetes Control and Complications Trial DCCT and its follow-up study, where cognition has been systematically measured over time. In this cohort, performance on a comprehensive battery of neurocognitive tests at 18 years of follow-up was the same in participants with and without a history of severe hypoglycemia Despite such reassuring findings, recent investigation with advanced imaging techniques has demonstrated that adults with type 1 diabetes appear to call upon a greater volume of the brain to perform a working memory task during hypoglycemia These findings suggest that adults with type 1 diabetes must recruit more regions to preserve cognitive function during hypoglycemia than adults without the disease.
More work will be necessary to understand the significance of these observations on the long-term cognitive ability of adults with type 1 diabetes. There is growing evidence that patients with type 2 diabetes might be particularly vulnerable to adverse events associated with hypoglycemia.
Between them, a total of 24, patients with high cardiovascular risk were randomly assigned to either intensive glycemic control or standard therapy 3 — 5. In each, subjects who were randomly assigned to the intensive arm experienced more episodes of hypoglycemia than did those who were randomly assigned to the standard treatment arm.
A number of explanations have been offered to explain the findings of ACCORD, including chance, greater weight gain, and specific medication effects, but perhaps the most convincing candidate was hypoglycemia, which was threefold higher in the intensive arm of ACCORD 4.
The investigators thus suggest that hypoglycemia at the time of death was probably not responsible for the increased mortality rate in the intensive arm of ACCORD. However, the potential lethal mechanisms that might be provoked by hypoglycemia could cause mortality downstream of the hypoglycemic event, increasing the difficulty in establishing cause and effect. All three trials clearly demonstrated that an episode of severe hypoglycemia was associated with an increased risk of subsequent mortality.
In ACCORD, those who had one or more severe hypoglycemic episodes had higher rates of death than those without such episodes across both study arms hazard ratio 1. One-third of all deaths were due to cardiovascular disease, and hypoglycemia was associated with higher cardiovascular mortality. In VADT, a recent severe hypoglycemic event was the strongest independent predictor of death at 90 days 3.
Of course, in post hoc analyses a causal relationship cannot be established with certainty. It is possible that the association between hypoglycemia and death may be merely an indicator for vulnerability for death from any cause. The relationship between hypoglycemia and subsequent cognitive function in patients with type 2 diabetes has also been investigated. In a large population study, hypoglycemic episodes that required hospitalization or a visit to the emergency department between and were associated with approximately double the risk of incident dementia after 6.
However, since the study population did not undergo detailed tests of cognitive function prior to , it is possible that those with incident dementia actually had mild cognitive dysfunction prior to experiencing the episode s of severe hypoglycemia. The possibility that mild cognitive dysfunction might increase the risk of experiencing severe hypoglycemia has been supported by analyses from the ACCORD study In the ACCORD MIND Memory IN Diabetes study, in which cognitive function was assessed longitudinally, no difference was noted in the rate at which cognitive performance declined over time in subjects randomly assigned to the intensive versus the standard glucose arms despite the fact that they experienced three times as much hypoglycemia Future investigation will need to address this question because the existing data are somewhat contradictory.
Patients in the older age-groups are especially vulnerable to hypoglycemia. Epidemiological studies show that hypoglycemia is the most frequent metabolic complication experienced by older adults in the U.
Although severe hypoglycemia is common in older individuals with both type 1 and type 2 diabetes, patients with type 2 diabetes tend to have longer hospital stays and greater medical costs.
The most significant predictors of this condition are advanced age, recent hospitalization, and polypharmacy, as shown in a study of Tennessee Medicare patients Age-related declines in renal function and hepatic enzyme activity may interfere with the metabolism of sulfonylureas and insulin, thereby potentiating their hypoglycemic effects. Age-related impairment in counterregulatory hormone responses has been described in elderly patients with diabetes, especially with respect to glucagon and growth hormone Symptoms of neuroglycopenia are more prevalent With the prolonged duration of type 2 diabetes as is often seen in the elderly patient, the glucagon response to hypoglycemia is virtually absent The intensification of glycemic control in the elderly patient is associated with an increased reduction in the plasma glucose thresholds for epinephrine release and for the appearance of hypoglycemia As a result, changes in the level of glycemic control have a marked impact on the risk of developing hypoglycemia in the elderly.
Older adults with diabetes have a disproportionately high number of clinical complications and comorbidities, all of which can be exacerbated by and sometimes contribute to episodes of hypoglycemia. Older adults with diabetes are at much higher risk for the geriatric syndrome, which includes falls, incontinence, frailty, cognitive impairment, and depressive symptoms To minimize the risk of hypoglycemia in the elderly, careful education regarding the symptoms and treatment of hypoglycemia, with regular reinforcement, is extremely important because of the recognized gaps in the knowledge base of these individuals In addition, it is important to assess the elderly for functional status as part of the overall clinical assessment in order to properly apply individualized glycemic control goals.
Arbitrary short-acting insulin sliding scales, which are used much too often in long-term care facilities 60 , should be avoided, and glyburide should be discontinued in favor of shorter-acting insulin secretagogues or medications that do not cause hypoglycemia. The recently published Beers list of prohibited medications in long-term care facilities specifically lists insulin sliding scales and glyburide as treatment modalities that should be avoided Complex regimens requiring multiple decision points should be simplified, especially for patients with decreased functional status.
In addition, caregivers and staff in long-term care facilities need to be educated on the causes and risks of hypoglycemia and the proper surveillance and treatment of this condition. Inpatient hyperglycemia has been associated with prolonged hospital length of stay and with numerous adverse outcomes including mortality 64 , 66 — The understandable zeal to minimize the adverse consequences of inpatient hyperglycemia, together with the demonstration that intensive glycemic control improved outcomes in surgical intensive care unit ICU patients 69 , led to widespread adoption of aggressive glucose management among ICU patients.
However, subsequent studies showed that such aggressive lowering of glycemia in the ICU is not uniformly beneficial, markedly increases the risk of severe hypoglycemia, and may be associated with increased mortality 70 — The true incidence and prevalence of hypoglycemia among hospitalized patients with diabetes are not known precisely.
In a retrospective study of 31, patients admitted to the general wards of an academic medical center in , a total of 3, patients In another review of 5, inpatients admitted to ICUs, 1. The risk factors for inpatient hypoglycemia include older age, presence of comorbidities, diabetes, increasing number of antidiabetic agents, tight glycemic control, septic shock, renal insufficiency, mechanical ventilation, and severity of illness 75 , Maintaining blood glucose control in pregnancy as close to that of healthy pregnant women is important in minimizing the negative effects on the mother and the fetus This is true for women with pregestational type 1 or type 2 diabetes, as well for those with gestational diabetes mellitus.
For women with type 1 diabetes, severe hypoglycemia occurs 3—5 times more frequently in the first trimester and at a lower rate in the third trimester when compared with the incidence in the year preceding the pregnancy Risk factors for severe hypoglycemia in pregnancy include a history of severe hypoglycemia in the preceding year, impaired hypoglycemia awareness, long duration of diabetes, low HbA 1c in early pregnancy, fluctuating plasma glucose levels, and excessive use of supplementary insulin between meals.
Surprisingly, nausea and vomiting during pregnancy did not appear to add significant risk. Hypoglycemia is generally without risk for the fetus as long as the mother avoids injury during the episode. For women with preexisting diabetes, insulin requirements rise throughout the pregnancy and then drop precipitously at the time of delivery of the placenta, requiring an abrupt reduction in insulin dosing to avoid postdelivery hypoglycemia.
Breastfeeding may also be a risk factor for hypoglycemia in women with insulin-treated diabetes Hypoglycemia and the fear of hypoglycemia have a significant impact on quality-of-life measures in patients with both type 1 and type 2 diabetes Patients with recurrent hypoglycemia have been found to have chronic mood disorders including depression and anxiety 85 , 86 , although it is hard to establish cause and effect between hypoglycemia and mood changes. Interpersonal relationships may suffer as a result of hypoglycemia in patients with diabetes.
In-depth interviews of a small group of otherwise healthy young adults with type 1 diabetes revealed the presence of interpersonal conflict including fears of dependency and loss of control. These adults also reported difficulty talking about issues related to hypoglycemia with significant others This difficulty may carry over to their work life, where hypoglycemia has been linked to reduced productivity However, impaired awareness of hypoglycemia has not consistently been associated with an increased risk of car collisions 92 — This patient-centered approach requires that clinicians spend time developing an individualized treatment plan with each patient.
For very young children, the risks of severe hypoglycemia on brain development may require a strategy that attempts to avoid hypoglycemia at all costs. For healthy adults with diabetes, a reasonable glycemic goal might be the lowest HbA 1c that does not cause severe hypoglycemia, preserves awareness of hypoglycemia, and results in an acceptable number of documented episodes of symptomatic hypoglycemia.
With current therapies, a strategy that completely avoids hypoglycemia may not be possible in patients with type 1 diabetes who strive to minimize their risks of developing the microvascular complications of the disease. However, glycemic goals might reasonably be relaxed in patients with long-standing type 1 diabetes and advanced complications or in those who are free of complications but have a limited life expectancy because of another disease process. In such patients, the glycemic goal could be to achieve glucose levels sufficiently low to prevent symptoms of hyperglycemia.
For patients with type 2 diabetes, the risk of hypoglycemia depends on the medications used Early in the course of the disease, most patients are treated with lifestyle changes and metformin, neither of which causes hypoglycemia. As the disease progresses, it is likely that medications that increase the risk of hypoglycemia will be added. This, plus the presence of complications or comorbidities that limit life expectancy, means that glycemic goals may need to be less aggressive. Older individuals with gait imbalance and frailty may experience a life-changing injury if they fall during a hypoglycemia episode, so avoiding hypoglycemia is paramount in such patients.
Patients with cognitive dysfunction may have difficulty adhering to a complicated treatment strategy designed to achieve a low HbA 1c Such patients will benefit from a simplification of the treatment strategy with a goal to prevent hypoglycemia as much as possible.
Furthermore, the benefits of aggressive glycemic therapy in those affected are unclear. Recurrent hypoglycemia increases the risk of severe hypoglycemia and the development of hypoglycemia unawareness and HAAF. Effective approaches known to decrease the risk of iatrogenic hypoglycemia include patient education, dietary and exercise modifications, medication adjustment, careful glucose monitoring by the patient, and conscientious surveillance by the clinician.
There is limited research related to the influence of self-management education on the incidence or prevention of hypoglycemia. However, there is clear evidence that diabetes education improves patient outcomes 97 — As part of the educational plan, the individual with diabetes and his or her domestic companions need to recognize the symptoms of hypoglycemia and be able to treat a hypoglycemic episode properly with oral carbohydrates or glucagon.
In addition, patients must understand how their medications work so they can minimize the risk of hypoglycemia. Care should be taken to educate patients on the typical pharmacokinetics of these medications. Such a heuristic review of likely factors skipped or inadequate meal, unusual exertion, alcohol ingestion, insulin dosage mishaps, etc.
These programs have been successfully delivered in other settings , with comparable reductions in hypoglycemic risk Patients with frequent hypoglycemia may also benefit from enrollment in a blood glucose awareness training program. In such a program, patients and their relatives are trained to recognize subtle cues and early neuroglycopenic indicators of evolving hypoglycemia and respond to them before the occurrence of disabling hypoglycemia , Patients with diabetes need to recognize which foods contain carbohydrates and understand how the carbohydrates in their diet affect blood glucose.
To avoid hypoglycemia, patients on long-acting secretagogues and fixed insulin regimens must be encouraged to follow a predictable meal plan. Patients on more flexible insulin regimens must know that prandial insulin injections should be coupled to meal times. Dissociated meal and insulin injection patterns lead to wide fluctuations in plasma glucose levels. Patients on any hypoglycemia-inducing medication should also be instructed to carry carbohydrates with them at all times to treat hypoglycemia.
The best bedtime snack to prevent overnight hypoglycemia in patients with type 1 diabetes has been investigated without clear consensus — These conflicting reports suggest that the administration of bedtime snacks may need to be individualized and be part of a comprehensive strategy balanced diet, patient education, optimized drug regimens, and physical activity counseling for the prevention of nocturnal hypoglycemia. Physical activity increases glucose utilization, which increases the risk of hypoglycemia.
The risk factors for exertional hypoglycemia include prolonged exercise duration, unaccustomed exercise intensity, and inadequate energy supply in relation to ambient insulinemia , Postexertional hypoglycemia can be prevented or minimized by careful glucose monitoring before and after exercise and taking appropriate preemptive actions.
Preexercise snacks should be ingested if blood glucose values indicate falling glucose levels. Patients with diabetes should carry readily absorbable carbohydrates when embarking on exercise, including sporadic house or yard work. Because of the kinetics of rapid-acting and intermediate-acting insulin, it may be prudent to empirically adjust insulin doses on the days of planned exercise, especially in patients with well-controlled diabetes with a history of exercise-related hypoglycemia.
Hypoglycemic episodes that are not readily explained by conventional factors skipped or irregular meals, unaccustomed exercise, alcohol ingestion, etc. A thorough review of blood glucose patterns may suggest vulnerable periods of the day that mandate adjustments to the current antidiabetes regimen. Such adjustments may include substitution of rapid-acting insulin lispro, aspart, glulisine for regular insulin, or basal insulin glargine or detemir for NPH, to decrease the risk of hypoglycemia.
Continuous subcutaneous insulin infusion offers great flexibility for adjusting the doses and administration pattern of insulin to counteract iatrogenic hypoglycemia For patients with type 2 diabetes, sulfonylureas are the oral agents that pose the greatest risk for iatrogenic hypoglycemia and substitution with other classes of oral agents or even glucagon-like peptide 1 analogs should be considered in the event of troublesome hypoglycemia Interestingly, successful transplantation of whole pancreata or isolated pancreatic islet cells in patients with type 1 diabetes — results in marked improvements in glycemic control and near abolition of iatrogenic hypoglycemia.
Patients who develop hypoglycemia unawareness do so because of frequent and recurrent hypoglycemia. To avoid such frequent hypoglycemia, adjustments in the treatment regimen that scrupulously avoid hypoglycemia are necessary Table 1.
In published studies, this has required frequent almost daily contact between clinician and patient, and adjustments to caloric intake and insulin regimen based on blood glucose values 10 , , With this approach, restoration of autonomic symptoms of hypoglycemia occurred within 2 weeks, and complete reversal of hypoglycemia unawareness was achieved by 3 months.
In some but not all reports, the recovery of symptoms is accompanied by the improvement in epinephrine secretion 32 , 33 , , Glucose monitoring is essential in managing patients at risk for hypoglycemia. Patients treated with insulin, sulfonylureas, or glinides should check their blood glucose whenever they develop the symptoms of hypoglycemia in order to confirm that they must ingest carbohydrates to treat the symptoms and collect information that can be used by the clinician to adjust the therapeutic regimen to avoid future hypoglycemia.
Patients on basal-bolus insulin therapy should check their blood glucose before each meal and figure this value into the calculation of the dose of rapid-acting insulin to take at that time. Such care in dosing will likely reduce the risk of hypoglycemia.
Recent technological developments have provided patients with new tools for glucose monitoring. Real-time CGM, by virtue of its ability to display the direction and rate of change, provides helpful information to the wearer leading to proactive measures to avoid hypoglycemia, e.
The artificial pancreas, which couples a CGM to an insulin pump through sophisticated predictive algorithms, holds out the promise of completely eliminating hypoglycemia.
Several internationally collaborative groups are working on various approaches to the artificial pancreas. The report confirms that the rate of new diabetes diagnoses remains steady. However, the disease continues to represent a growing health problem: Diabetes was the seventh leading cause of death in the U. The report also includes county-level data for the first time, and shows that some areas of the country bear a heavier diabetes burden than others.
Now, more than ever, we must step up our efforts to reduce the burden of this serious disease. Diabetes is a serious disease that can often be managed through physical activity, diet, and the appropriate use of insulin and other medications to control blood sugar levels.
People with diabetes are at increased risk of serious health complications including premature death, vision loss, heart disease, stroke, kidney failure, and amputation of toes, feet, or legs. The National Diabetes Statistics Report, released approximately every two years, provides information on diabetes prevalence and incidence, prediabetes, risk factors for complications, acute and long-term complications, mortality, and costs in the U. By addressing diabetes, we limit other health problems such as heart disease, stroke, nerve and kidney diseases, and vision loss.
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