Sunday, November 18, 2012

Diabetes and the Devil of low blood sugars

I have always felt that people with diabetes have to work a little harder each day to preserve their good health while being forced to walk a narrow path between 2 devils .  The Devils of high and the Devils of low blood sugars .The devil of high high glucose comes with known long term risk and the devil of low glucose levels , on the other side of the path , comes with immediate often severe consequences. This is the beginning of a 4 part discussion of hypoglycemia. Today, I will lay the ground work with a few definitions and  a little physiology .


 The American Diabetes Association's discussion of hypoglycemia. Position statement 2012
"Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes.

Mild hypoglycemia - plasma glucose below 70 mg/dl

Severe hypoglycemia -
  ( where the individual requires the assistance of another person and cannot be treated with oral
    carbohydrate due to confusion or unconsciousness) should be treated using emergency glucagon kits)
       
Hypoglycemia unawareness
  (In type 1 diabetes and severely insulin deficient type 2 )
  These people of lost their awareness of the early warning signals of hypoglycemia

Joslin's Diabetes Mellitus thirteenth edition has a good chart on page 495 . It matches our bodies response and symptoms to decreasing blood glucose levels. I have adjusted the medical terminology slightly to meet the needs of this discussion.

 Counter regulatory hormones .
 These are hormones our body releases in an attempt to correct a falling  blood glucose  level.  Some of these hormones produce the early warning symptoms that we associate with hypoglycemia.

    Glucose level               Increase counter regulatory hormone         Effects and symptoms 
    
      < 70 mg/dl                         increase glucagon                                   increase in glucose from liver
      < 70  mg/d/                        increase Epinephrine                               increase glucose, feeling of 
                                                                                                                anxiety, sweating , shaking,
                                                                                                                pallor
     < 65 mg/dl                          increase cortisol and growth hormone     increase glucose levels

     < 60 mg/dl                                                                                           neurological symptoms
                                                                                                                     confusion, dizzy
                                                                                                                     headache,weakness
                                                                                                                     irritability , sleepy
                                                                                                                     belligerent behavior
      < 40                                                                                                        lethargy , Coma
                                                                                                                     seizures

Take home message
    Epinephrine produces the early warning symptoms of a dropping blood sugar. The loss of the
    epinephrine response to a falling glucose results in " hypoglycemia unawareness " and the 
    progression to the more severe stages of hypoglycemia.

Have Fun , Be Smart and avoid hypoglycemia
David Calder,MD

Questions
     Does lowering A1c result in increased risk of hypoglycemia in type 1 and type 2 diabetes ?
     Does age effect a persons awareness of hypoglycemia ?

      74% of unrecognized hypoglycemia occurs at night .       True or false

                                                                                             
                                                                             



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Your comments and questions are appreciated. David Calder,MD