Preventing Hypoglycemia In Type 2 Diabetes
The Journal of Clinical Endocrinology & Metabolism Preventing Hypoglycemia in Type 2 Diabetes Correspondence and Reprint Requests: Antoinette P. Wrighton, Associate Director, Publishing Production, Endocrine Society, 2055 L Street NW, Suite 600, Washington, DC 20036. E-mail: [email protected] . Search for other works by this author on: The Journal of Clinical Endocrinology & Metabolism, Volume 103, Issue 4, 1 April 2018, Pages 12651268, Robert W Lash, Deborah O Lucas, Judit Illes; Preventing Hypoglycemia in Type 2 Diabetes, The Journal of Clinical Endocrinology & Metabolism, Volume 103, Issue 4, 1 April 2018, Pages 12651268, Ask a colleague to list the complications of diabetes. His or her answer is likely to include the usual suspects: microvascular and macrovascular disease, along with their sequelae. Less likely to be on the list is hypoglycemia. However, hypoglycemia, an adverse drug event (ADE) related to insulin and sulfonylurea use, has been identified as one of the top three preventable ADEs by the US Department of Health and Human Services (HHS) ( 1 ). Although the connection between hypoglycemia and type 1 diabetes (T1D) is well recognized, the prevalence and consequences of hypoglycemia in patients with type 2 diabetes (T2D) are often underappreciated. A recent meta-analysis suggests that the incidence of hypoglycemia among patients with T2D on insulin is, on average, 23 mild or moderate events and 1 severe episode per year ( 2 ). Although even mild or moderate hypoglycemia can significantly affect a persons quality of life, social life, work productivity, and ability to drive safely, more serious cases of hypoglycemia resulted in nearly 300,000 emergency room visits for adult patients with T1D or T2D in 2009 ( 3 ). For Medicare beneficiaries in 2010, Continue reading >>
Hypoglycemia In Type 2 Diabetes—consequences And Risk Assessment
Hypoglycemia in patients with type 2 diabetes is not often recognized as a risk with potential health consequences. Although the risk of hypoglycemia in patients with type 2 diabetes is not as great as that of patients with type 1 diabetes, the prevalence of type 2 diabetes is much greater, making it a clinically significant concern. As such, clinicians need to be aware of the hypoglycemic risk in patients with type 2 diabetes, as well as the immediate and long-term consequences of hypoglycemia. This article will review the prevalence of hypoglycemia in patients with type 2 diabetes, assess the consequences of hypoglycemia, discuss how to identify patients at risk of hypoglycemia, and provide an overview of diabetes management strategies aimed at lowering the risk of hypoglycemia. Definition of Hypoglycemia Hypoglycemia is a frequent complication of diabetes therapy, yet there is no consensus definition. The formal definition of hypoglycemia is a condition characterized by a reduction in either plasma glucose concentration or its tissue utilization to a level that may induce symptoms or signs such as altered mental status and/or sympathetic nervous system stimulation. Criteria known as Whipple’s triad are usually used to diagnose hypoglycemia. This triad consists of low plasma glucose, presence of symptoms, and reversal of these symptoms when the plasma glucose level is restored to normal.1 The level at which a patient becomes symptomatic differs between individuals, and thus there is great controversy when it comes to defining a clear threshold. In the last decade, the American Diabetes Association (ADA),2 Canadian Diabetes Association (CDA),3 and European Agency for the Evaluation of Medicinal Products (EMEA)4 have each set different thresholds for hypoglycemia, fro Continue reading >>
Hypoglycemia In Type 2 Diabetes
Pathophysiology, frequency, and effects of different treatment modalities The importance of strict glycemic control to limit the risk of diabetic vascular complications is indisputable, but many barriers obstruct its attainment. Hypoglycemia is recognized to be a major limitation in achieving good control in type 1 diabetes (1) but has been considered to be a minor problem of the treatment modalities used for type 2 diabetes (2). This may be a misperception based on inadequate information. The burden of covert hypoglycemia associated with oral antidiabetic agents may be underestimated, and with the increasing use of insulin to treat type 2 diabetes, the actual prevalence of hypoglycemia is likely to escalate. The frequency and pathophysiology of hypoglycemia in type 2 diabetes and the relationship to different therapies was reviewed by conducting a literature search using the bibliographic database PubMed to identify publications in English from 1984 until 2005 related to hypoglycemia associated with treatment of type 2 diabetes, and the bibliographies of relevant articles were scrutinized for additional citations. Search terms included “type 2 diabetes,” “NIDDM,” “non-insulin-dependent diabetes,” “hypoglycemia,” and “hypoglycaemia.” PATHOPHYSIOLOGY OF HYPOGLYCEMIA Normal physiological responses to hypoglycemia The human brain primarily uses glucose as its source of energy. Under normal conditions, the brain is unable to synthesize or store glucose and is exquisitely vulnerable to glucose deprivation. To protect the integrity of the brain, several physiological mechanisms have evolved to respond to and limit the effects of hypoglycemia (3–6). In humans, the initial response to a decline in blood glucose is suppression of endogenous insulin secretio Continue reading >>
Hyperglycemia And Hypoglycemia In Type 2 Diabetes
Hyperglycemia can occur when blood sugar levels are too high. People develop hyperglycemia if their diabetes is not treated properly. Hypoglycemia sets in when blood sugar levels are too low. It is usually a side effect of treatment with blood-sugar-lowering medication. Diabetes is a metabolic disease with far-reaching health consequences. In type 2 diabetes, not enough insulin is released into the bloodstream, or the insulin cannot be used properly. In type 1 diabetes, the body only produces very little insulin, or none at all. We need insulin to live. Without it, sugar (glucose) builds up in the blood because it cannot be taken out and used by the body. Very high blood sugar, known as hyperglycemia, leads to a number of symptoms. If blood sugar levels are too low, it is called hypoglycemia. When is blood sugar considered to be too high or too low? Slight fluctuations in blood sugar levels are completely normal and also happen on a daily basis in people who do not have diabetes. Between around 60 and 140 milligrams of sugar per deciliter of blood (mg/dL) is considered to be healthy. This is equivalent to between 3.3 and 7.8 mmol/L. “Millimole per liter” (mmol/L) is the international unit for measuring blood sugar. It indicates the concentration of a certain substance per liter. If type 1 diabetes is left untreated, people’s blood sugar levels can get very high, even exceeding 27.8 mmol/L (500 mg/dL). Such high levels are rather uncommon for type 2 diabetes. Blood sugar concentrations below 3.3 mmol/L (60 mg/dL) are considered to be too low. As you can see in the illustration below, there are no clear-cut borders between the normal range of blood sugar and high and low blood sugar. Signs of hyperglycemia People with type 2 diabetes do not always realize that their Continue reading >>
Diabetic Hypoglycemia
Print Overview For people with diabetes, low blood sugar (hypoglycemia) occurs when there's too much insulin and not enough sugar (glucose) in the blood. Hypoglycemia is defined as blood sugar below 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L). Several factors can cause hypoglycemia in people with diabetes, including taking too much insulin or other diabetes medications, skipping a meal, or exercising harder than usual. Pay attention to early warning signs, so you can treat low blood sugar promptly. Treatment involves short-term solutions — such as taking glucose tablets — to raise your blood sugar into a normal range. Untreated, diabetic hypoglycemia can lead to seizures and loss of consciousness — a medical emergency. Rarely, it can be deadly. Tell family and friends what symptoms to look for and what to do in case you're not able to treat the condition yourself. Symptoms Early warning signs and symptoms Early signs and symptoms of diabetic hypoglycemia include: Shakiness Dizziness Sweating Hunger Irritability or moodiness Anxiety or nervousness Headache Nighttime symptoms Diabetic hypoglycemia can also occur while you sleep. Signs and symptoms, which can awaken you, include: Damp sheets or bedclothes due to perspiration Nightmares Tiredness, irritability or confusion upon waking Severe symptoms If diabetic hypoglycemia goes untreated, signs and symptoms of severe hypoglycemia can occur. These include: Clumsiness or jerky movements Muscle weakness Difficulty speaking or slurred speech Blurry or double vision Drowsiness Confusion Convulsions or seizures Unconsciousness Death Take your symptoms seriously. Diabetic hypoglycemia can increase the risk of serious — even deadly — accidents. Identifying and correcting the factors contrib Continue reading >>
Low Blood Sugars In Type 2 Diabetes
I’ve spoken to far too many people with type 2 diabetes who start to explain to me these moments of severe dizziness and shaking, and the desperate urge to eat food that they experience sometimes every day, sometimes just once a week. The problem is that no one ever explained to them what a low blood sugar feels like, how to treat a low blood sugar properly, and why it’s happening. It seems as though many busy physicians short on time assume that a person with type 2 diabetes whose A1C is higher than ideal couldn’t possibly be experiencing low blood sugars. Unfortunately, that assumption simply isn’t true. Simple guide to low blood sugars in type 2 diabetes: What is hypoglycemia (low blood sugar): the American Diabetes Association defines hypoglycemia as an event that occurs when your blood sugar drops below 70 mg/dL. If you don’t currently own a glucose meter to actually check your blood sugar level, you can a) ask your doctor for a prescription and b) stay alert to the signs and symptoms of a low blood sugar described below. You may experience some or all of the following symptoms during a low blood sugar: lightheaded, dizzy, trembling, shaking, weakness, headache, sweating, numbness in your lips, tingling in your numbs, a jello-like feeling in your limbs. To see a full list, visit Diabetes.org. Severe hypoglycemia under 30 mg/dL can lead to seizures or comas. It’s important to catch the signs and symptoms sooner than later. The cause of these low blood sugars can be: Oral medications: Most oral diabetes medications (except for Metformin) are known to cause low blood sugars. This means the dosage is possibly too high, and you should explain your low blood sugars to your doctor so she/he can adjust your dosage. Fast-Acting Insulin: Too often, when type 2 di Continue reading >>
Diabetes And Hypoglycemia
Tweet Hypoglycemia occurs when blood glucose levels fall below 4 mmol/L (72mg/dL). Whilst many of us think of diabetes as being a problem of high blood sugar levels, the medication some people with diabetes take medication that can also cause their sugar levels to go too low and this can become dangerous. What is hypoglycemia? Hypoglycemia occurs when the level of glucose present in the blood falls below a set point: Below 4 mmol/L (72mg/dL) Being aware of the early signs of hypoglycemia will allow you to treat your low blood glucose levels quickly - in order to bring them back into the normal range. It is also recommended to make close friends and family aware of the signs of hypoglycemia in case you fail to recognise the symptoms. What are the symptoms of hypoglycemia? The main symptoms associated with hypoglycemia are: Sweating Feeling dizzy Symptoms of hypoglycemia can also include: Being pale Feeling weak Feeling hungry A higher heart rate than usual Blurred vision Confusion Convulsions Loss of consciousness And in extreme cases, coma Who is at risk of hypos? Whilst low blood sugar can happen to anyone, dangerously low blood sugar can occur in people who take the following medication: Sulphopnylureas (such as glibenclamide, gliclazide, glipizide, glimepiride, tolbutamide) Prandial glucose regulators (such as repaglinide, nateglinide) If you are not sure whether your diabetes medication can cause hypos, read the patient information leaflet that comes with each of your medications or ask your doctor. It is important to know whether your diabetes medication puts you at risk of hypos. What are the causes of hypoglycemia? Whilst medication is the main factor involved in hypoglycemia within people with diabetes, a number of other factors can increase the risk of hypos oc Continue reading >>
Can You Have Low Blood Sugar With Type 2 Diabetes?
back to Overview Know-how Type 2 A tag-team approach on low blood sugar with type 2 diabetes. Markus recently wrote an article on our German language blog talking about low blood sugar with type 2 diabetes. The question (“can I have low blood sugar with type 2 diabetes?”) is very common, and it’s easy to see why it’s of concern. So I’ve helped Markus bring his German post to life here in English. I hope it helps! Here’s Markus: Low blood sugar In 2014, results from the DAWN2 study were announced. It was the largest study of its kind (15,000 participants) on the “fears & needs of people with diabetes and their families.” One result stood out: The gravest fears are related to low blood sugars, especially at night. Up to 69% of the participants share this fear! So! Can you have low blood sugar with type 2 diabetes? Yes! Of course! But let’s think about who exactly is at risk – and why. It’s common to think: Type 1 diabetes = at risk for lows Type 2 diabetes = not at risk for lows But that isn’t correct at all, so we should wipe it from our mind. So… what do I need to know? Maybe it’s more accurate to say that people with type 2 diabetes who take certain types of medication are more at risk for lows. We’re getting closer! But to get to the truth, we should take a look at someone without diabetes. Is it possible for them to have lows, too? Theoretically yes, especially if doing long-lasting physical activities without proper food intake. Additionally, extreme stress and binge drinking are also common causes of low blood sugar for people without diabetes. However, it’s pretty rare because as soon as BG’s drop below 80 mg/dl (4.4 mmol/L), the natural counterregulatory system kicks in, raising blood sugar back to normal levels. I’ve never exp Continue reading >>
Hypoglycemia
Blood sugar too low to fuel the body’s activities. The normal range for blood sugar is about 60 mg/dl (milligrams of glucose per deciliter of blood) to 120 mg/dl, depending on when a person last ate. If a person has not eaten for many hours, blood sugar can occasionally fall below 60 mg/dl or even below 50 mg/dl without indicating a serious abnormality or disease. Individuals who take insulin, which includes all people with Type 1 (insulin-dependent) diabetes and some people with Type 2 (non-insulin-dependent) diabetes, are prone to hypoglycemia. People with Type 2 diabetes who take sulfonylureas are also vulnerable to episodes of low blood sugar. Hypoglycemia can occur when a person takes too much medicine, skips or delays a meal, eats too little food for the amount of insulin he injected, exercises too strenuously, or drinks too much alcohol. Common symptoms of hypoglycemia include weakness, drowsiness, confusion, hunger, dizziness, paleness, headache, irritability, trembling, sweating, rapid heartbeat, and a cold, clammy feeling. In severe cases, hypoglycemia can cause a person to lose consciousness or even lapse into a coma. Most people with diabetes can recognize these symptoms and treat them by quickly eating or drinking something with sugar, such as candy, juice, or a regular (not diet) soft drink, or by taking special glucose tablets or gel, available over the counter in pharmacies. However, some people with long-standing diabetes develop a condition known as hypoglycemia unawareness or hypoglycemia without warning, in which they no longer develop the usual symptoms that herald the onset of hypoglycemia. This condition can be reversed by maintaining higher blood sugar levels for a short period of time (about two weeks) and scrupulously avoiding low blood sugar Continue reading >>
Dealing With Hypoglycemia
If you have diabetes, your concern isn’t always that your blood sugar is too high. Your blood sugar can also dip too low, a condition known as hypoglycemia. This occurs when your blood sugar levels fall below 70 milligrams per deciliter (mg/dl). The only clinical way to detect hypoglycemia is to test your blood sugar. However, without blood tests it’s still possible to identify low blood sugar by its symptoms. Early recognition of these symptoms is critical because hypoglycemia can cause seizures or induce a coma if left untreated. If you have a history of low blood sugar episodes, you may not feel symptoms. This is known as hypoglycemic unawareness. By learning to control your blood sugar, you can prevent hypoglycemic episodes. You also should take steps to ensure you and others know how to treat low blood sugar. Managing your blood sugar is a constant balancing of: diet exercise medications A number of diabetes medications are associated with causing hypoglycemia. Only those medications that increase insulin production increase the risk for hypoglycemia. Medications that can cause hypoglycemia include: Combination pills that contain one of the medications above may also cause hypoglycemic episodes. This is a reason why it’s so important to test your blood sugar, especially when making changes to your treatment plan. Some of the most common causes of low blood sugar are: skipping a meal or eating less than usual exercising more than usual taking more medication than usual drinking alcohol, especially without food People with diabetes aren’t the only ones who experience low blood sugar. If you have any of the following conditions, you may also experience hypoglycemia: weight-loss surgery severe infection thyroid or cortisol hormone deficiency Hypoglycemia affect Continue reading >>
Nocturnal Hypoglycemia
Thanks to the Diabetes Control and Complications Trial (DCCT), it is now well recognized that intensive glycemic control can reduce the risk of diabetes complications. Despite this knowledge, one of the biggest barriers in reaching glycemic targets is the increased risk of hypoglycemia that comes with tighter blood glucose control. Hypoglycemia is often reported to be one of the most feared complications of diabetes. With nocturnal hypoglycemia being especially worrisome for those who live alone or travel alone. It can also be concerning (not to mention disruptive) for a significant other that you share a bed with. What is nocturnal hypoglycemia? Nocturnal hypoglycemia is a low blood sugar that occurs overnight while you are asleep. It is common to sleep through a low blood sugar when it occurs during sleep. How common is nocturnal hypoglycemia? According to a journal article from Medscape General Medicine: During the DCCT 43 percent of all hypoglycemia episodes and 55 percent of severe [hypoglycemic] episodes reported occurred during sleep. Incidence rates vary from 12 to 56 percent, however because 49 to 100 percent of episodes occur without symptoms the actual incidence may be much higher.1 Why is nocturnal hypoglycemia concerning? Nocturnal hypoglycemia can be especially dangerous because an individual is unlikely to recognize symptoms or wake up during an episode. Undetected nocturnal hypoglycemia is a risk factor for hypoglycemia unawareness: Hypoglycemia unawareness is a low blood glucose that occurs without symptoms therefore the person is unaware of the drop in their blood glucose, ultimately delaying treatment. Nocturnal hypoglycemia may also result in physical injury, poor quality of life and possibly impairment in cognitive function. Severe hypoglycemia can Continue reading >>
Hypoglycemia In Type 2 Diabetes: Current Controversies And Changing Practices
Attempts to determine whether intensive glycemic treatment would be associated with reduction in adverse cardiovascular outcomes led to three large recent randomized controlled trials: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial, and the Veteran’s Administration Diabetes Trial (VADT). A widely held, but inaccurate interpretation has been that none of these studies suggested benefit from intensive glycemic control. In ADVANCE, the combination of intensive glycemic treatment along with blood pressure-lowering with a diuretic and angiotensin-directed therapy reduced mortality (Zoungas et al., 2009), and an epidemiologic analysis of different levels of on-trial glycemia showed optimal outcome with normal to near-normal A1c levels (Zoungas et al., 2012). In ACCORD there was consistent evidence of reduction in microvascular endpoints, with the intensively treated subgroup showing 30% reduction in retinopathy, while the likelihood of non-fatal myocardial infarction was significantly reduced by 21% (Boussageon et al., 2011; Hemmingsen et al., 2011). There was, however, a significant 26% increase in mortality in this study, which has been a major source of concern. Over the past few years, there has been increasing recognition of the importance of hypoglycemia as an adverse consequence of treatment of type 2 diabetes. Previously, severe hypoglycemia was thought to be relatively rare in type 2 diabetes and perhaps not as important as in type 1 diabetes. The ACCORD, VADT, and ADVANCE trials have, however, underscored the concern with hypoglycemia-related adverse outcomes. Furthermore, hypoglycemia in type 2 diabetes is associated with longer leng Continue reading >>
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 >>
10 Warning Signs Of Low Blood Sugar
Hypoglycemia, or low blood sugar, is common among people with diabetes and can occur even when you're carefully managing the condition. "Hypoglycemia happens when the amount of blood glucose (sugar in the blood) drops to a level that's too low to sustain normal functioning," says Erin Palinski-Wade, RD, CDE, author of 2 Day Diabetes Diet. "In most people, this is defined as a blood-sugar level below 70 milligrams per deciliter." A review published in June 2015 in the journal PLoS One found that among people with type 2 diabetes, this is a far too common occurrence. Individuals with the condition had an average of 19 mild episodes of hypoglycemia per year, and nearly one severe episode per year on average. Low blood sugar was particularly common among those taking insulin. This decrease in blood sugar levels can cause both short-term complications, like confusion and dizziness, as well as more serious, long-term complications. Left untreated, it can lead to a coma and even death. To prevent hypoglycemia and its dangerous side effects, it's crucial to monitor your glucose levels and treat low blood sugar as soon as you become aware of it. Pay attention to these telltale signs of dipping blood sugar levels to make sure yours stays under control: 1. Ravenous Hunger If you've already eaten but still aren't satisfied, or if you suddenly, inexplicably feel as if you're starving, your body is signaling that it needs more glucose. Work with your healthcare team to determine the exact amount of sugar your body needs. A good starting point is the American Diabetes Association's recommendation to eat between 15 and 20 grams (g) of sugar or carbohydrates with each snack, and between 40 and 65 g at each meal. Some good options include 2 tablespoons of raisins, 4 ounces of fruit juice Continue reading >>
Diabetes - Low Blood Sugar - Self-care
Low blood sugar is called hypoglycemia. A blood sugar level below 70 mg/dL (3.9 mmol/L) is low and can harm you. A blood sugar level below 54 mg/dL (3.0 mmol/L) is cause for immediate action. You are at risk for low blood sugar if you have diabetes and are taking any of the following diabetes medicines: Insulin Glyburide (Micronase), glipizide (Glucotrol), glimepiride (Amaryl), repaglinide (Prandin), or nateglinide (Starlix) Chlorpropamide (Diabinese), tolazamide (Tolinase), acetohexamide (Dymelor), or tolbutamide (Orinase) Know how to tell when your blood sugar is getting low. Symptoms include: Weakness or feeling tired Shaking Sweating Headache Hunger Feeling uneasy, nervous, or anxious Feeling cranky Trouble thinking clearly Double or blurry vision Fast or pounding heartbeat Sometimes your blood sugar may be too low even if you do not have symptoms. If it gets too low, you may: Faint Have a seizure Go into a coma Talk with your health care provider about when you should check your blood sugar every day. People who have low blood sugar need to check their blood sugar more often. The most common causes of low blood sugar are: Taking your insulin or diabetes medicine at the wrong time Taking too much insulin or diabetes medicine Not eating enough during meals or snacks after you have taken insulin or diabetes medicine Skipping meals Waiting too long after taking your medicine to eat your meals Exercising a lot or at a time that is unusual for you Not checking your blood sugar or not adjusting your insulin dose before exercising Drinking alcohol Preventing low blood sugar is better than having to treat it. Always have a source of fast-acting sugar with you. When you exercise, check your blood sugar levels. Make sure you have snacks with you. Talk to your provider about r Continue reading >>
