Hypoglycemia in Diabetic Patients

Hypoglycemia refers to low blood glucose levels i.e. less than 70 mg/dl. It is a dangerous and life threatening complication of diabetes. If not recognised and treated promptly, it can be fatal or cause permanent neurological damage.

• Causes
  Hypoglycemia occurs in diabetic patients who are on either tablets or insulin. Blood glucose levels drop when a patient takes his medications but misses/ delays a meal or snack or has less food than usual or has vomiting or diarrhoea. Hypoglycemia also develops when there is excess physical activity than usual or drinking too much alcohol. Some patients take an extra tablet when eating sweets. This is a wrong habit as it can cause delayed hypoglycaemia.
• Symptoms
  At a blood glucose levels of <70mg/dl, the pancreas insulin production stops as a protective mechanism. At <65mg% counter­regulatory hormones like epinephrine, nor­epinephrine, cortisol and growth hormone are released which try to increase blood glucose levels. These hormones produce autonomic symptoms like sweating, palpitations, tremors, increased hunger, dizziness and headaches. If no remedial measures are taken, the blood glucose can fall even lower. At levels <50mg% the glucose supply to brain reduces and this leads to neuroglycopenic symptoms like confusion, falls, seizures, coma or even death. Sometimes in longstanding elderly diabetic patients the initial warning symptoms may not be produced and the patient can suddenly become unconscious or comatose, especially in sleep.
• Treatment
  Any patient with symptoms of hypoglycaemia should check his blood glucose levels with a glucometer if available. Otherwise he/she should be advised to take 15 gm of simple carbohydrates (3 tsp of Glucon D). This should be followed by a complex carbohydrate snack like milk or fruits or rotis or brown bread. If blood glucose levels do not increase to >80mg% or if symptoms persist after 15 mins, please repeat the treatment. Repeat the process every 15 mins till patient is stable or blood glucose is >80mg%. If the patient is unconscious or unable to eat anything orally, glucagon injections (available as lmg/ml- prefilled syringes) can be given subcutaneously at home and rushed to a nearby hospital. Patients with neuroglycopenic symptoms will require N dextrose infusion for correcting hypoglycaemia. This is given as bolus of 25-50% N dextrose over 5-10 min followed by an infusion over a few hours. These patients require close monitoring to titrate their blood glucose levels and hence require to be hospitalised for at least 24 hours for recurrent hypoglycaemia. Protracted or recur rent hypoglycaemia is especially common in patients on oral antidiabetic medicines as their duration ofaction is longer.
• Patient education
  It is very important for every diabetic patient to have meals and snacks on time. Do not keep long gaps between meals. Avoid heavy meals as it causes fullness of stomach and skipping the next snack. Have meals and snacks in regulated portion sizes. Include proteins and complex carbohydrates like jowar, bajra, ragi, wheat, brown rice, fruits and vegetables in diet. Avoid simple carbs like sugary items, maida and white rice/bread/pasta. Cut down intake of fatty foods. Limit intake of alcohol to one drink occasionally. Never exercise on an empty stomach. Patients should eat/ drink something like nuts/fruits or milk before their morning walk. Increase the complex carbohydrate intake if the exercise is heavy. Diabetic medicines need to be readjusted if there are GI symptoms like vomiting or diarrhoea.
• Specific tests
  Uncontrolled hypothyroidism and adrenal insufficiency can cause hypoglycaemia in diabetics as drug metabolism is slowed in these conditions. Similarly, kidney and liver disorders also slow drug metabolism. Hence, in cases of unexplained hypoglycaemia, it is vital to check RIT, LFT, T3T4TSH and Cortisol levels. Finally, periodic HbAlc checks help track the trend of glycemic control and guide to timely dose reductions and prevent a dangerous hypoglycaemia episode.