Hypoglycemia: A challenge in the management of Diabetes

Hypoglycemia or low blood glucose is the biggest hurdle in managing diabetes, especially for patients on insulin therapy. It can also happen with some oral anti-diabetic agents called Sulfonylureas. Common symptoms of hypoglycemia are sudden giddiness, headache, sweating, extreme hunger and palpitations (feeling of increased heartbeats). Severe hypoglycemia can lead to fits or seizures and hypoglycemic coma. Repeated hypoglycemia leads to adaptation to it, and the patient does not feel any symptoms unless and until it is very severe or extremely low blood glucose e.g. blood glucose less than 50 mg/dl. This is known as hypoglycemic unawareness. This condition is very dangerous because it can directly lead to hypoglycemic coma without warning symptoms. Generally, hypoglycemic symptoms start when blood sugar is less than 80 mg/dl. Symptoms between 60-80 mg/dl of blood sugar are known as adrenergic symptoms like sweating, palpitation etc. When blood sugar is less than 60ng/dl, symptoms are more of brain related eg headache, giddiness, memory problems, confusion and in extreme cases seizures or coma. These brains related symptoms are known as neuroglycopenia.

Management of  hypoglycemia:

The best is to check your blood glucose if you have your glucometer immediately. Many patients take sweets and sugar for simple giddiness without true hypoglycemia. Their blood sugar never comes under control due to this. That is why it is very important to document it by checking with a glucometer. Mild hypoglycemic symptoms can subside with simple food without consuming sweets or sugary drinks. However, if symptoms are, severe, one should manage it with glucose water or sugary drinks. But the effect of glucose or sugary drink may last only for a few minutes. And chances are that after 1/2 hour you may again land up with hypoglycemia. So glucose or sugary drink must be followed by some solid food intake when the patient is alert. We should not try to feed if the patient is in a coma due to hypoglycemia. In that case, he will require intravenous glucose in the hospital.

Prevent Hypoglycemia : Important Clues

1. Hypoglycemia is often due to delayed or poor quantity of food: Most diabetes drugs (SULFONYLUREAS) keep working even if food intake is less or not there. Hence it can be dangerous to delay or avoid food while using these drugs. Timely and disciplined food habit is the key for successful diabetes management.

2. Hypoglycemia is expected during an acute illness like diarrhoea or vomiting: Blood glucose can increase or reduce during acute illness. So best way during acute infection is to have extra blood glucose testing and decide. If blood glucose is low (less than 80mg/di) it is advisable to reduce or omit diabetes medicine after discussion with your physician.

3. Diabetes drug over dosage can result in hypoglycemia: Taking extra medicine is a bad habit if you have not followed the diet. Different drugs can cause severe and sustained hypoglycemia.

4. Self-monitoring of blood glucose {SMBG) with glucometer is an important tool to prevent hypoglycemia: Home monitoring of blood glucose is the key to avoiding hypoglycemic emergencies. Prompt action can prevent emergency hospitalization.

5. Hypoglycemia is common in kidney & liver disease patients: Most diabetes drugs, including insulin, are metabolized in the liver and then excreted through the kidney. So it is prudent to have blood tests for liver and kidney function when there is unexplained recurrent hypoglycemia.

6. Blood glucose less than 70 is clear hypoglycemia even if you don't have complaints: This is known as hypoglycemic unawareness. Recurrent episodes of hypoglycemia cause blunting of classical symptoms of hypoglycemia. This invites severe Hypoglycemia leading directly to coma without any warning signals. Therefore, it is better to keep fasting blood glucose a little higher (100- 120mg/di) in these types of patients.

7. Night hypoglycemia is more common in type 1 diabetes: Type 1 Diabetes patients often face this problem. Morning headache, tiredness & restlessness or sweating during sleep indicates this possibility. Reducing the evening dosage of insulin can prevent this problem.

8. Sweating, palpitation & giddiness are classic symptoms of hypoglycemia: These symptoms suggest you must have some food (if symptoms are mild) or sweet things/glucose powder (if symptoms are severe). Ignoring these symptoms can lead to coma or some other serious medical problems.

9. Mild & severe Hypoglycemia: When a patient can manage himself, it is known as mild hypoglycemia; when he/she needs assistance from others or hospitalization, it is known as severe hypoglycemia.

(Dr. Modi's Clinic, Endocrine & Diabetes Centre, Ph: 04023591359, 9494094941, Fax: 91-40-23591358, Email: drmodisclinic@gmail.com)