What Persons with Diabetes Need to Know About Severe Hypoglycemia Severe hypoglycemia, often referred to as a severe low blood sugar event, is a serio...

What Persons with Diabetes Need to Know About Severe Hypoglycemia

Severe hypoglycemia, often referred to as a severe low blood sugar event, is a serious and potentially life-threatening complication of diabetes treatment, particularly for individuals using insulin or certain oral medications that stimulate insulin release. Understanding severe hypoglycemia, its causes, symptoms, treatment, and prevention is crucial for people with diabetes and their caregivers to manage diabetes safely and effectively. This comprehensive guide delves into all aspects of severe hypoglycemia, providing essential knowledge to empower those living with diabetes.

What is Severe Hypoglycemia?

Hypoglycemia occurs when blood glucose levels drop too low, typically below 70 mg/dL. While mild to moderate hypoglycemia can be managed with quick-acting carbohydrates, severe hypoglycemia is characterized by a blood sugar level that is so low that the individual requires assistance from another person to recover. This may involve administering glucagon or seeking emergency medical attention. The hallmark of severe hypoglycemia is the inability of the person to self-treat due to confusion, loss of consciousness, seizures, or other neurological impairments.

Defining Features of Severe Hypoglycemia:

Blood glucose levels requiring external intervention: Typically below 50 mg/dL, but can vary based on individual thresholds and circumstances.
Cognitive impairment: Confusion, disorientation, difficulty concentrating.
Physical symptoms: Seizures, loss of consciousness, inability to swallow safely.
Necessity for assistance: Requires another person to administer glucagon or call for emergency help.

Causes of Severe Hypoglycemia

Understanding the causes of severe hypoglycemia is vital for preventing future episodes. Several factors can contribute to a dangerous drop in blood sugar:

Excessive Insulin Dose: Taking too much insulin relative to food intake or activity levels is a primary cause. This includes accidental overdoses or incorrect dosing.
Missed or Delayed Meals: Skipping meals or significant delays between meals and insulin injections can lead to hypoglycemia.
Increased Physical Activity: Exercise increases insulin sensitivity, so unexpected or prolonged physical activity without adjusting insulin or carbohydrate intake can lower blood sugar levels dramatically.
Alcohol Consumption: Alcohol can impair the liver's ability to release glucose, especially when consumed without food, potentially leading to delayed hypoglycemia.
Certain Medications: Some oral diabetes medications (sulfonylureas like glipizide and glyburide) stimulate the pancreas to release more insulin, increasing the risk of hypoglycemia, particularly when combined with other risk factors.
Kidney or Liver Disease: These conditions can affect how the body processes insulin and other diabetes medications, increasing the risk of hypoglycemia.
Hormonal Deficiencies: Conditions like adrenal insufficiency can impair the body's ability to regulate blood sugar.
Errors in Insulin Administration: Using the wrong type of insulin, injecting insulin improperly (e.g., into muscle instead of subcutaneous tissue), or mixing up insulin pens or syringes can lead to unexpected fluctuations in blood sugar.
Illness: Infections and other illnesses can affect appetite, food intake, and insulin sensitivity, increasing the risk of hypoglycemia.

Example Scenario:

Imagine a person with type 1 diabetes who takes their usual insulin dose before dinner but then gets caught up in an unexpected and strenuous activity. They forget to eat their meal. The combination of the insulin and the increased physical activity without food intake can trigger a severe hypoglycemic event.

Symptoms of Severe Hypoglycemia

Recognizing the symptoms of hypoglycemia, both mild and severe, is critical for prompt intervention. While the initial symptoms of mild hypoglycemia can serve as warning signs, severe hypoglycemia presents with more pronounced and alarming symptoms.

Initial Symptoms (Mild to Moderate Hypoglycemia):

Shakiness
Sweating
Dizziness
Rapid heartbeat
Anxiety or nervousness
Irritability or confusion
Hunger
Blurred vision
Weakness

Symptoms of Severe Hypoglycemia:

Confusion or Disorientation: Difficulty thinking clearly or understanding surroundings.
Loss of Consciousness: Passing out or becoming unresponsive.
Seizures: Uncontrolled muscle contractions.
Inability to Swallow: Making it impossible to safely consume oral glucose.
Slurred Speech: Difficulty speaking clearly.
Unusual Behavior: Irritability, combativeness, or irrational actions.

Important Note: Some people with long-standing diabetes may develop hypoglycemia unawareness, where they no longer experience the early warning signs of low blood sugar. This increases the risk of severe hypoglycemia because they don't have the opportunity to treat it early. Regular blood glucose monitoring and working with a healthcare provider to adjust treatment plans are crucial for these individuals.

Treating Severe Hypoglycemia

Severe hypoglycemia requires immediate intervention from another person. The primary treatment options are glucagon administration and, if that's not available or feasible, emergency medical services.

1. Glucagon Administration

Glucagon is a hormone that raises blood sugar levels by stimulating the liver to release stored glucose. It's available as an injectable medication or a nasal spray.

Glucagon Kit (Injectable):
1. Locate the glucagon emergency kit.
2. Follow the instructions provided in the kit to mix the glucagon and inject it into the person’s thigh or arm.
3. Turn the person onto their side in case they vomit (recovery position).
4. Call for emergency medical assistance (911 in the US) immediately, even after administering glucagon. The effects of glucagon are temporary, and further medical care may be needed.
5. If the person regains consciousness and can swallow, give them a fast-acting source of sugar, such as juice or glucose tablets, followed by a longer-acting carbohydrate source like crackers or a sandwich.
Nasal Glucagon:
1. Remove the device from its packaging.
2. Following instructions, insert the tip of the device into one nostril and press the plunger to deliver the glucagon.
3. Call for emergency medical assistance (911 in the US) immediately.
4. Turn the person onto their side in case they vomit (recovery position).
5. Once the person regains consciousness and can swallow, administer a fast-acting carbohydrate followed by a longer-acting one.

Important Notes About Glucagon:

Educate Family and Friends: Ensure that family members, friends, and caregivers know how to recognize severe hypoglycemia and how to administer glucagon. Regularly review the instructions.
Check Expiration Dates: Glucagon kits have expiration dates. Regularly check the date and replace expired kits.
Side Effects: Common side effects of glucagon include nausea and vomiting.
Glucagon is Not a Substitute for Medical Care: Always seek emergency medical attention after administering glucagon.

2. Emergency Medical Services (EMS)

If glucagon is not available or if the person does not regain consciousness after glucagon administration, call emergency medical services (911 in the US) immediately. EMS personnel can administer intravenous glucose and provide further medical care.

Do NOT:

Attempt to give food or liquids to an unconscious person. This can cause choking.
Inject insulin. This will lower blood sugar further.

Preventing Severe Hypoglycemia

Prevention is the cornerstone of managing diabetes safely and minimizing the risk of severe hypoglycemia. A multi-faceted approach, including careful monitoring, medication management, education, and lifestyle adjustments, is essential.

1. Regular Blood Glucose Monitoring

Frequency: Check blood glucose levels frequently, especially before meals, before bedtime, before, during, and after exercise, and whenever symptoms of hypoglycemia are suspected. Continuous Glucose Monitors (CGMs) are particularly valuable as they provide real-time glucose readings and can alert the user to impending low blood sugar levels.
Target Range: Work with a healthcare provider to establish a target blood glucose range.

2. Medication Management

Insulin Dosing: Carefully calculate insulin doses based on carbohydrate intake, activity levels, and blood glucose readings. Use insulin pens or syringes with clearly marked doses.
Timing: Adhere to prescribed medication schedules and understand the onset, peak, and duration of action of all diabetes medications.
Sulfonylureas: If taking sulfonylureas, be aware of their potential to cause hypoglycemia, especially in combination with other risk factors. Discuss alternatives with a healthcare provider if hypoglycemia is a frequent problem.
Medication Review: Regularly review all medications with a healthcare provider or pharmacist, including over-the-counter drugs and supplements, to identify potential interactions that could affect blood glucose control.

3. Meal Planning

Consistent Timing: Eat meals and snacks at regular intervals to avoid prolonged periods without food.
Carbohydrate Counting: Learn how to count carbohydrates accurately to match insulin doses to food intake.
Snacks: Carry snacks, such as glucose tablets, fruit, or crackers, to treat hypoglycemia promptly.
Balanced Meals: Include a balance of carbohydrates, protein, and healthy fats in meals to promote stable blood sugar levels.

4. Exercise Planning

Monitor Blood Sugar: Check blood glucose levels before, during, and after exercise.
Adjust Insulin or Carbohydrates: Adjust insulin doses or carbohydrate intake as needed based on the intensity and duration of exercise. A general guideline is to reduce insulin doses by 10-20% for moderate exercise or consume an extra 15-30 grams of carbohydrates per hour of activity.
Carry Snacks: Always carry a fast-acting source of carbohydrate during exercise.

5. Alcohol Consumption

Eat Food: Consume alcohol with food to slow the absorption of alcohol and prevent hypoglycemia.
Monitor Blood Sugar: Check blood glucose levels more frequently when drinking alcohol, especially before bedtime.
Avoid Excessive Amounts: Limit alcohol intake to moderate amounts.
Be Aware of Delayed Effects: Hypoglycemia can occur several hours after drinking alcohol.

6. Education and Communication

Diabetes Education: Participate in a comprehensive diabetes education program to learn about diabetes management, including hypoglycemia prevention and treatment.
Family and Friends: Educate family members, friends, and caregivers about diabetes, hypoglycemia, and how to administer glucagon.
Medical Alert Identification: Wear a medical alert bracelet or necklace indicating that you have diabetes and are at risk for hypoglycemia.
Open Communication: Communicate openly with your healthcare provider about any episodes of hypoglycemia or concerns about blood glucose control.

7. Continuous Glucose Monitoring (CGM)

Real-Time Monitoring: CGMs provide continuous glucose readings and can alert users to impending low or high blood sugar levels, allowing for proactive adjustments.
Trend Information: CGMs display glucose trends, helping users understand how their blood sugar levels are changing over time and identify patterns.
Alarm Features: CGMs can be programmed with alarms that alert users when their blood sugar falls below a specified threshold, providing an early warning of hypoglycemia.

8. Address Hypoglycemia Unawareness

Avoid Lows: Work with your healthcare provider to adjust your treatment plan to avoid frequent episodes of hypoglycemia.
Raise Target Blood Sugar: Temporarily raising the target blood sugar range can help restore awareness of hypoglycemia.
Consider CGM: CGM use can be particularly beneficial for people with hypoglycemia unawareness, as it can provide alerts to low blood sugar levels even if the person doesn't feel any symptoms.

When to Consult a Healthcare Provider

It's essential to consult a healthcare provider in the following situations:

Frequent Hypoglycemia: If experiencing frequent episodes of hypoglycemia (more than once or twice a week), even if they are mild.
Severe Hypoglycemia: After experiencing an episode of severe hypoglycemia, to review the treatment plan and identify potential causes.
Hypoglycemia Unawareness: If developing hypoglycemia unawareness.
Changes in Medication: When starting or changing diabetes medications.
Illness: During illness, as blood sugar control can be affected.
Pregnancy: During pregnancy, as blood sugar targets may need to be adjusted.
Unexplained Blood Sugar Fluctuations: If experiencing unexplained blood sugar fluctuations.

Living with Diabetes and Severe Hypoglycemia Risk: A Summary

Severe hypoglycemia is a significant concern for individuals with diabetes, especially those on insulin or sulfonylureas. Understanding the causes, recognizing the symptoms, knowing how to treat it, and implementing preventive strategies are vital for safe and effective diabetes management. Regular blood glucose monitoring, medication management, meal planning, exercise planning, alcohol awareness, education, and communication with healthcare providers are all essential components of a comprehensive approach to minimizing the risk of severe hypoglycemia. By being proactive and informed, individuals with diabetes can live full and healthy lives while effectively managing their blood sugar levels and avoiding dangerous low blood sugar events.