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How Does Diabetes Cause Hypoglycemia?

Patient Education: Hypoglycemia (low Blood Sugar) In Diabetes Mellitus (beyond The Basics)

Patient Education: Hypoglycemia (low Blood Sugar) In Diabetes Mellitus (beyond The Basics)

LOW BLOOD SUGAR OVERVIEW Hypoglycemia, also known as low blood sugar, occurs when levels of glucose (sugar) in the blood are too low. Hypoglycemia is common in people with diabetes who take insulin and some (but not all) oral diabetes medications. WHY DO I GET LOW BLOOD SUGAR? Low blood sugar happens when a person with diabetes does one or more of the following: Takes too much insulin (or an oral diabetes medication that causes your body to secrete insulin) Does not eat enough food Exercises vigorously without eating a snack or decreasing the dose of insulin beforehand Waits too long between meals Drinks excessive alcohol, although even moderate alcohol use can increase the risk of hypoglycemia in people with type 1 diabetes LOW BLOOD SUGAR SYMPTOMS The symptoms of low blood sugar vary from person to person, and can change over time. During the early stages low blood sugar, you may: Sweat Tremble Feel hungry Feel anxious If untreated, your symptoms can become more severe, and can include: Difficulty walking Weakness Difficulty seeing clearly Bizarre behavior or personality changes Confusion Unconsciousness or seizure When possible, you should confirm that you have low blood sugar by measuring your blood sugar level (see "Patient education: Self-monitoring of blood glucose in diabetes mellitus (Beyond the Basics)"). Low blood sugar is generally defined as a blood sugar of 60 mg/dL (3.3 mmol/L) or less. Some people with diabetes develop symptoms of low blood sugar at slightly higher levels. If your blood sugar levels are high for long periods of time, you may have symptoms and feel poorly when your blood sugar is closer to 100 mg/dL (5.6 mmol/L). Getting your blood sugar under better control can help to lower the blood sugar level when you begin to feel symptoms. Hypoglyc Continue reading >>

Diabetes Mellitus (dm) And Disorders Of Blood Sugar Metabolism

Diabetes Mellitus (dm) And Disorders Of Blood Sugar Metabolism

Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other drugs, critical illness or organ failure, a reaction to carbohydrates (in susceptible people), an insulin-producing tumor in the pancreas, and some types of bariatric (weight loss) surgery. A fall in blood glucose causes symptoms such as hunger, sweating, shakiness, fatigue, weakness, and inability to think clearly, whereas severe hypoglycemia causes symptoms such as confusion, seizures, and coma. The diagnosis for a person who has diabetes is based on finding low glucose levels in the blood while the person is experiencing symptoms. Normally, the body maintains the level of glucose in the blood within a range of about 70 to 110 milligrams per deciliter (mg/dL) of blood. In hypoglycemia, the glucose level becomes too low. Although diabetes mellitus, a disorder involving blood glucose levels, is characterized by high levels of glucose in the blood (hyperglycemia), many people with diabetes periodically experience hypoglycemia due to side effects of diabetes treatment. Hypoglycemia is uncommon among people without diabetes. Very low levels of glucose in the blood may interfere with the function of certain organ systems. The brain is particularly sensitive to low glucose levels because sugar is the brain's major energy source. To prevent glucose levels in the blood from falling too far below their usual range, the brain responds by stimulating the All of these hormones cause the liver to release glucose into the blood, but sometimes these hormones do not raise the blood glucose level enough to overcome the hypoglycemia. If the blood glucose level remains too low, the brain will get Continue reading >>

Low Blood Sugar

Low Blood Sugar

People with diabetes get hypoglycemia () when their bodies don't have enough sugar to use as fuel. It can happen for several reasons, including diet, some medications and conditions, and exercise. If you get hypoglycemia, write down the date and time when it happened and what you did. Share your record with your doctor, so she can look for a pattern and adjust your medications. Call your doctor if you have more than one unexplained low blood sugar reaction in a week. Most people feel symptoms of hypoglycemia when their blood sugar is 70 milligrams per deciliter (mg/dL) or lower. Each person with diabetes may have different symptoms of hypoglycemia. You'll learn to spot yours. Early symptoms include: Confusion Dizziness Feeling shaky Hunger Headaches Irritability Pounding heart; racing pulse Pale skin Sweating Trembling Weakness Anxiety Without treatment, you might get more severe symptoms, including: Poor coordination Poor concentration Numbness in mouth and tongue Passing out Ask your doctor if any of your medicines can cause low blood sugar. Insulin treatment can cause low blood sugar, and so can a type of diabetes medications called "sulfonylureas." Commonly used sulfonylureas include: Glibenclamide (Glyburide, Micronase) Gliclazide Older, less common sulfonlyureas tend to cause low blood sugar more often than some of the newer ones. Examples of older drugs include: You can also get low blood sugar if you drink alcohol or take allopurinol (Zyloprim), aspirin, Benemid, probenecid (Probalan), or warfarin (Coumadin) with diabetes medications. You shouldn't get hypoglycemia if you take alpha-glucosidase inhibitors, biguanides (such as metformin), and thiazolidinediones alone, but it can happen when you take them with sulfonylureas or insulin. You can get low blood sugar Continue reading >>

Understanding Hypoglycemia

Understanding Hypoglycemia

When you think about diabetes and blood glucose control, the first thing that comes to mind is probably avoiding high blood glucose levels. After all, the hallmark of diabetes is high blood glucose, or hyperglycemia. But controlling blood glucose is more than just managing the “highs”; it also involves preventing and managing the “lows,” or hypoglycemia. Most people are aware that keeping blood glucose levels as close to normal as possible helps prevent damage to the blood vessels and nerves in the body. But keeping blood glucose levels near normal can carry some risks as well. People who maintain “tight” blood glucose control are more likely to experience episodes of hypoglycemia, and frequent episodes of hypoglycemia — even mild hypoglycemia and even in people who don’t keep blood glucose levels close to normal — deplete the liver of stored glucose (called glycogen), which is what the body normally draws upon to raise blood glucose levels when they are low. Once liver stores of glycogen are low, severe hypoglycemia is more likely to develop, and research shows that severe hypoglycemia can be harmful. In children, frequent severe hypoglycemia can lead to impairment of intellectual function. In children and adults, severe hypoglycemia can lead to accidents. And in adults with cardiovascular disease, it can lead to strokes and heart attacks. To keep yourself as healthy as possible, you need to learn how to balance food intake, physical activity, and any diabetes medicines or insulin you use to keep your blood glucose as close to normal as is safe for you without going too low. This article explains how hypoglycemia develops and how to treat and prevent it. What is hypoglycemia? Blood glucose levels vary throughout the day depending on what you eat, how Continue reading >>

Non-diabetic Hypoglycemia: Symptoms, Causes, Diagnosis, Treatment

Non-diabetic Hypoglycemia: Symptoms, Causes, Diagnosis, Treatment

Passing out, loss of consciousness, seizures To diagnose non-diabetic hypoglycemia, your doctor will do a physical exam and ask questions about any medicines you take. Hell want to know all about your health and any history of diseases or stomach surgery. Hell check your blood glucose level, especially when you are having symptoms. Hell also check to see if you feel better when your glucose goes back to a normal level. If your doctor suspects hypoglycemia, you may have to fast until you start to have symptoms. Hell test your blood glucose level at different times throughout the fast. To check for reactive hypoglycemia, you may have to take a test called a mixed-meal tolerance test (MMTT). For this, you take a special drink that raises your blood glucose. The doctor will check your blood glucose levels over the next few hours. Right away, you should reverse the low blood sugar by eating or drinking 15 to 20 grams of carbohydrates. You can take juice, hard candy, or glucose tablets. This will usually help your symptoms go away. Check your blood sugar again in 15 minutes and treat every 15 minutes if levels are still low. Call 911 if you dont feel well or if you cant get your blood sugar back up. For severe symptoms -- passing out, seizures , or confusion -- call 911 right away. If you have serious attacks, ask your doctor if you should keep a home glucagon kit. This hormone made in your pancreas causes your liver to release sugar. The kid contains a little bottle (the doctor will call it a vial) and a syringe to inject yourself with it. People youre with -- loved ones or caregivers -- should know how to give you the injection. For a long-term solution, how you treat hypoglycemia depends on what's causing it. If a medicine triggers your low blood sugar, you may need to ch Continue reading >>

Diabetic Hypoglycemia

Diabetic Hypoglycemia

Diabetic hypoglycemia is a low blood glucose level occurring in a person with diabetes mellitus. It is one of the most common types of hypoglycemia seen in emergency departments and hospitals. According to the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), and based on a sample examined between 2004 and 2005, an estimated 55,819 cases (8.0% of total admissions) involved insulin, and severe hypoglycemia is likely the single most common event.[1] In general, hypoglycemia occurs when a treatment to lower the elevated blood glucose of diabetes inaccurately matches the body's physiological need, and therefore causes the glucose to fall to a below-normal level. Definition[edit] A commonly used "number" to define the lower limit of normal glucose is 70 mg/dl (3.9 mmol/l), though in someone with diabetes, hypoglycemic symptoms can sometimes occur at higher glucose levels, or may fail to occur at lower. Some textbooks for nursing and pre-hospital care use the range 80 mg/dl to 120 mg/dl (4.4 mmol/l to 6.7 mmol/l). This variability is further compounded by the imprecision of glucose meter measurements at low levels, or the ability of glucose levels to change rapidly. Signs and symptoms[edit] Diabetic hypoglycemia can be mild, recognized easily by the patient, and reversed with a small amount of carbohydrates eaten or drunk, or it may be severe enough to cause unconsciousness requiring intravenous dextrose or an injection of glucagon. Severe hypoglycemic unconsciousness is one form of diabetic coma. A common medical definition of severe hypoglycemia is "hypoglycemia severe enough that the person needs assistance in dealing with it". A co-morbidity is the issue of hypoglycemia unawareness. Recent research using machine learning methods have proved to Continue reading >>

Hypoglycemia In Diabetes

Hypoglycemia In Diabetes

Iatrogenic hypoglycemia causes recurrent morbidity in most people with type 1 diabetes and many with type 2 diabetes, and it is sometimes fatal. The barrier of hypoglycemia generally precludes maintenance of euglycemia over a lifetime of diabetes and thus precludes full realization of euglycemia’s long-term benefits. While the clinical presentation is often characteristic, particularly for the experienced individual with diabetes, the neurogenic and neuroglycopenic symptoms of hypoglycemia are nonspecific and relatively insensitive; therefore, many episodes are not recognized. Hypoglycemia can result from exogenous or endogenous insulin excess alone. However, iatrogenic hypoglycemia is typically the result of the interplay of absolute or relative insulin excess and compromised glucose counterregulation in type 1 and advanced type 2 diabetes. Decrements in insulin, increments in glucagon, and, absent the latter, increments in epinephrine stand high in the hierarchy of redundant glucose counterregulatory factors that normally prevent or rapidly correct hypoglycemia. In insulin-deficient diabetes (exogenous) insulin levels do not decrease as glucose levels fall, and the combination of deficient glucagon and epinephrine responses causes defective glucose counterregulation. Reduced sympathoadrenal responses cause hypoglycemia unawareness. The concept of hypoglycemia-associated autonomic failure in diabetes posits that recent antecedent hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal (including epinephrine) and the resulting neurogenic responses to lower plasma glucose concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent hypoglycemia and further impair Continue reading >>

All About Hypoglycemia (low Blood Sugar)

All About Hypoglycemia (low Blood Sugar)

Hypoglycemia refers to an abnormally low level of sugar, or glucose, in the blood. Hypoglycemia is not a disease in itself, it is a sign of a health problem. The brain uses a lot of energy and needs glucose to function. Because the brain cannot store or manufacture glucose, it needs a continuous supply. Signs of low blood sugar include hunger, trembling, heart racing, nausea, and sweating. Hypoglycemia is commonly linked with diabetes, but many other conditions can also cause low blood sugar. This article will discuss the causes, diagnosis, and treatment of hypoglycemia, and the difference between hypoglycemia and hyperglycemia. We will also look at how to prevent it. Here are some key points about hypoglycemia. More detail is in the main article. Hypoglycemia is not a disease but a symptom of another condition. Early symptoms include hunger, sweating, and trembling. A common cause is diabetes. Alcohol abuse and kidney disorders can also lower blood sugar levels. What is hypoglycemia? Hypoglycemia is a condition where there is not enough glucose, or sugar, in the blood. Levels of blood sugar are below 4 mmol/L (72mg/dL). Adults and children with mild hypoglycemia may experience the following early symptoms: hunger tremor or trembling sweating irritability a pale face heart palpitations accelerated heart rate tingling lips dizziness weakness Severe hypoglycemia is sometimes called diabetic shock. It may involve: concentration problems confusion irrational and disorderly behavior, similar to intoxication inability to eat or drink Complications If a person does not take action when symptoms of hypoclycemia appear, it can lead to: A person who regularly experiences hypoglycemia may become unaware that it is happening. They will not notice the warning signs, and this can lea Continue reading >>

Can You Have Hypoglycemia Without Having Diabetes?

Can You Have Hypoglycemia Without Having Diabetes?

Hypoglycemia is a condition that occurs when the sugar levels in your blood are too low. Many people think of hypoglycemia as something that only occurs in people with diabetes. However, it can also occur in people who don’t have diabetes. Hypoglycemia is different from hyperglycemia, which occurs when you have too much sugar in your bloodstream. Hypoglycemia can happen in people with diabetes if the body produces too much insulin. Insulin is a hormone that breaks down sugar so that you can use it for energy. You can also get hypoglycemia if you have diabetes and you take too much insulin. If you don’t have diabetes, hypoglycemia can happen if your body can’t stabilize your blood sugar levels. It can also happen after meals if your body produces too much insulin. Hypoglycemia in people who don’t have diabetes is less common than hypoglycemia that occurs in people who have diabetes or related conditions. Here's what you need to know about hypoglycemia that occurs without diabetes. Everyone reacts differently to fluctuations in their blood glucose levels. Some symptoms of hypoglycemia may include: You may have hypoglycemia without having any symptoms. This is known as hypoglycemia unawareness. Hypoglycemia is either reactive or non-reactive. Each type has different causes: Reactive hypoglycemia Reactive hypoglycemia occurs within a few hours after a meal. An overproduction of insulin causes reactive hypoglycemia. Having reactive hypoglycemia may mean that you’re at risk for developing diabetes. Non-reactive hypoglycemia Non-reactive hypoglycemia isn't necessarily related to meals and may be due to an underlying disease. Causes of non-reactive, or fasting, hypoglycemia can include: some medications, like those used in adults and children with kidney failure any d Continue reading >>

Low Blood Glucose (hypoglycemia)

Low Blood Glucose (hypoglycemia)

What is hypoglycemia? Hypoglycemia, also called low blood glucose or low blood sugar, occurs when the level of glucose in your blood drops below normal. For many people with diabetes, that means a level of 70 milligrams per deciliter (mg/dL) or less. Your numbers might be different, so check with your health care provider to find out what level is too low for you. What are the symptoms of hypoglycemia? Symptoms of hypoglycemia tend to come on quickly and can vary from person to person. You may have one or more mild-to-moderate symptoms listed in the table below. Sometimes people don’t feel any symptoms. Severe hypoglycemia is when your blood glucose level becomes so low that you’re unable to treat yourself and need help from another person. Severe hypoglycemia is dangerous and needs to be treated right away. This condition is more common in people with type 1 diabetes. Hypoglycemia Symptoms Mild-to-Moderate Severe Shaky or jittery Sweaty Hungry Headachy Blurred vision Sleepy or tired Dizzy or lightheaded Confused or disoriented Pale Uncoordinated Irritable or nervous Argumentative or combative Changed behavior or personality Trouble concentrating Weak Fast or irregular heart beat Unable to eat or drink Seizures or convulsions (jerky movements) Unconsciousness Some symptoms of hypoglycemia during sleep are crying out or having nightmares sweating enough to make your pajamas or sheets damp feeling tired, irritable, or confused after waking up What causes hypoglycemia in diabetes? Hypoglycemia can be a side effect of insulin or other types of diabetes medicines that help your body make more insulin. Two types of diabetes pills can cause hypoglycemia: sulfonylureas and meglitinides . Ask your health care team if your diabetes medicine can cause hypoglycemia. Although ot Continue reading >>

Hypoglycemia

Hypoglycemia

Hypoglycemia, also known as low blood sugar, is when blood sugar decreases to below normal levels.[1] This may result in a variety of symptoms including clumsiness, trouble talking, confusion, loss of consciousness, seizures, or death.[1] A feeling of hunger, sweating, shakiness, and weakness may also be present.[1] Symptoms typically come on quickly.[1] The most common cause of hypoglycemia is medications used to treat diabetes mellitus such as insulin and sulfonylureas.[2][3] Risk is greater in diabetics who have eaten less than usual, exercised more than usual, or have drunk alcohol.[1] Other causes of hypoglycemia include kidney failure, certain tumors, such as insulinoma, liver disease, hypothyroidism, starvation, inborn error of metabolism, severe infections, reactive hypoglycemia, and a number of drugs including alcohol.[1][3] Low blood sugar may occur in otherwise healthy babies who have not eaten for a few hours.[4] The glucose level that defines hypoglycemia is variable.[1] In people with diabetes levels below 3.9 mmol/L (70 mg/dL) is diagnostic.[1] In adults without diabetes, symptoms related to low blood sugar, low blood sugar at the time of symptoms, and improvement when blood sugar is restored to normal confirm the diagnosis.[5] Otherwise a level below 2.8 mmol/L (50 mg/dL) after not eating or following exercise may be used.[1] In newborns a level below 2.2 mmol/L (40 mg/dL) or less than 3.3 mmol/L (60 mg/dL) if symptoms are present indicates hypoglycemia.[4] Other tests that may be useful in determining the cause include insulin and C peptide levels in the blood.[3] Hyperglycemia (high blood sugar) is the opposite condition. Among people with diabetes, prevention is by matching the foods eaten with the amount of exercise and the medications used.[1] When Continue reading >>

Hypoglycemia

Hypoglycemia

Print Overview Hypoglycemia is a condition characterized by an abnormally low level of blood sugar (glucose), your body's main energy source. Hypoglycemia is commonly associated with the treatment of diabetes. However, a variety of conditions, many of them rare, can cause low blood sugar in people without diabetes. Like fever, hypoglycemia isn't a disease itself — it's an indicator of a health problem. Immediate treatment of hypoglycemia involves quick steps to get your blood sugar level back into a normal range — about 70 to 110 milligrams per deciliter, or mg/dL (3.9 to 6.1 millimoles per liter, or mmol/L) — either with high-sugar foods or medications. Long-term treatment requires identifying and treating the underlying cause of hypoglycemia. Symptoms Similar to the way a car needs gas to run, your body and brain need a constant supply of sugar (glucose) to function properly. If glucose levels become too low, as occurs with hypoglycemia, it can cause these signs and symptoms: Heart palpitations Fatigue Pale skin Shakiness Anxiety Sweating Hunger Irritability Tingling sensation around the mouth Crying out during sleep As hypoglycemia worsens, signs and symptoms may include: Confusion, abnormal behavior or both, such as the inability to complete routine tasks Visual disturbances, such as blurred vision Seizures Loss of consciousness People with severe hypoglycemia may appear as if they're intoxicated. They may slur their words and move clumsily. Many conditions other than hypoglycemia may cause these signs and symptoms. A blood sample to test your blood sugar level at the time of these signs and symptoms is how to know for sure that hypoglycemia is the cause. When to see a doctor Seek a doctor's help immediately if: You have what may be symptoms of hypoglycemia an Continue reading >>

Nondiabetic Hypoglycemia

Nondiabetic Hypoglycemia

What is non-diabetic hypoglycemia? Hypoglycemia is the condition when your blood glucose (sugar) levels are too low. It happens to people with diabetes when they have a mismatch of medicine, food, and/or exercise. Non-diabetic hypoglycemia, a rare condition, is low blood glucose in people who do not have diabetes. There are two kinds of non-diabetic hypoglycemia: Reactive hypoglycemia, which happens within a few hours of eating a meal Fasting hypoglycemia, which may be related to a disease Glucose is the main source of energy for your body and brain. It comes from what we eat and drink. Insulin, a hormone, helps keep blood glucose at normal levels so your body can work properly. Insulin’s job is to help glucose enter your cells where it’s used for energy. If your glucose level is too low, you might not feel well. What causes non-diabetic hypoglycemia? The two kinds of non-diabetic hypoglycemia have different causes. Researchers are still studying the causes of reactive hypoglycemia. They know, however, that it comes from having too much insulin in the blood, leading to low blood glucose levels. Types of nondiabetic hypoglycemia Reactive hypoglycemia Having pre-diabetes or being at risk for diabetes, which can lead to trouble making the right amount of insulin Stomach surgery, which can make food pass too quickly into your small intestine Rare enzyme deficiencies that make it hard for your body to break down food Fasting hypoglycemia Medicines, such as salicylates (such as aspirin), sulfa drugs (an antibiotic), pentamidine (to treat a serious kind of pneumonia), quinine (to treat malaria) Alcohol, especially with binge drinking Serious illnesses, such as those affecting the liver, heart, or kidneys Low levels of certain hormones, such as cortisol, growth hormone, glu Continue reading >>

Hypoglycemia: Practice Essentials, Background, Pathophysiology

Hypoglycemia: Practice Essentials, Background, Pathophysiology

Hypoglycemia is characterized by a reduction in plasma glucose concentration to a level that may induce symptoms or signs such as altered mental status and/or sympathetic nervous system stimulation. This condition typically arises from abnormalities in the mechanisms involved in glucose homeostasis. The most common cause of hypoglycemia in patients with diabetes is injecting a shot of insulin and skipping a meal or overdosing insulin. The image below depicts a diagnostic algorithm for hypoglycemia. Diagnostic algorithm. A systematic approach is often required to establish the true cause of hypoglycemia, using an algorithmic approach. The glucose level at which an individual becomes symptomatic is highly variable (threshold generally at < 50 mg/dL). Carefully review the patient's medication and drug history for potential causes of hypoglycemia (eg, new medications, insulin usage or ingestion of an oral hypoglycemic agent, possible toxic ingestion). The patients medical and/or social history may reveal the following: Diabetes mellitus, renal insufficiency/failure, alcoholism, hepatic cirrhosis/failure, other endocrine diseases, or recent surgery Central nervous system: Headache, confusion, personality changes Ethanol intake and nutritional deficiency Neurogenic or neuroglycopenic symptoms of hypoglycemia may be categorized as follows: Neurogenic (adrenergic) (sympathoadrenal activation) symptoms: Sweating, shakiness, tachycardia, anxiety, and a sensation of hunger Neuroglycopenic symptoms: Weakness, tiredness, or dizziness; inappropriate behavior (sometimes mistaken for inebriation), difficulty with concentration; confusion; blurred vision; and, in extreme cases, coma and death Reactive hypoglycemic include the following features: More common in overweight and obese peop Continue reading >>

Hypoglycemia In Type 1 Diabetes

Hypoglycemia In Type 1 Diabetes

In subjects with type 1 diabetes, autoimmune destruction of pancreatic β-cells leads eventually to an absolute requirement for insulin replacement therapy. Insulin delivered exogenously is not subject to normal physiological feedback regulation, so it may induce hypoglycemia even in the presence of an intact counterregulatory response. The average individual with type 1 diabetes experiences about two episodes of symptomatic hypoglycemia per week, a figure that has not changed substantially in the last 20 years (1). Severe hypoglycemia (requiring help for recovery) has an annual prevalence of 30–40% and an annual incidence of 1.0 – 1.7 episodes per patient per year (1). This risk is increased markedly with the increasing duration of the disease and strict glycemic control. In subjects with type 2 diabetes, the increasing duration of the disease and the more widespread use of insulin therapy also increase the risk of severe hypoglycemia. This was reflected in a recent survey in Tayside, Scotland, which found the proportion of severe hypoglycemic episodes needing emergency medical assistance was similar between type 1 and insulin-treated type 2 diabetic patients (2). The experience of hypoglycemia is not limited to a transient impairment of cognition. We now recognize that hypoglycemia carries with it a recognized morbidity and mortality (3) and creates a negative mood-state characterized by reduced energy and increased tension (4). This may explain why hypoglycemia is greatly feared by individuals with diabetes; so much so that the fear of hypoglycemia is rated with the same degree of concern as the development of sight-threatening retinopathy or end-stage renal disease. This fear of hypoglycemia influences an individual's ability to adhere to optimal insulin replace Continue reading >>

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