Hypoglycemia

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Diabetes Home Care and Monitoring: Blood Sugar (Glucose): Hypoglycemia

Definition

Hypoglycemia (also spelled hypoglycaemia or hypoglycæmia, not to be confused with hyperglycemia) is a medical emergencythat involves an abnormally diminished content of glucose in the blood. The term literally means low blood sugar (Gr.ὑπογλυκαιμία, from hypo-glykyshaima). Such blood sugar levels can produce a variety of symptoms and effects, but the principal problems arise from an inadequate supply of glucose to the brain, resulting in impairment of function (neuroglycopenia). Effects can range from mild dysphoria to more serious issues such as seizures, unconsciousness, and (rarely) permanent brain damage ordeath. 

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The most common forms of hypoglycemia occur as a complication of treatment of diabetes mellitus with insulin or oral medications. Hypoglycemia is less common in non-diabetic persons, but can occur at any age. Among the causes are excessive insulin produced in the body (hyperinsulinemia), inborn error of metabolism, medications and poisons, alcohol, hormone deficiencies, prolongedstarvation, alterations of metabolism associated with infection, and organ failure.

Hypoglycemia is treated by restoring the blood glucose level to normal by the ingestion or administration of dextrose or carbohydrate foods. It is often self-diagnosed and self-medicated orally by the ingestion of balanced meals. In more severe circumstances, it is treated by injection or infusion of glucagon. Recurrent hypoglycemia may be prevented by reversing or removing the underlying cause, by increasing the frequency of meals, with medications like diazoxide, octreotide, or glucocorticoids, or by surgical removal of much of the pancreas.

The level of blood glucose low enough to define hypoglycemia may be different for different people, in different circumstances, and for different purposes, and occasionally has been a matter of controversy. Most healthy adults maintain fasting glucose levels above 4.0 mmol/L (72 mg/dl), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L. It can sometimes be difficult to determine whether a person’s symptoms are due to hypoglycemia. Criteria referred to as Whipple’s triad are used to determine a diagnosis of hypoglycemia:

  1. Symptoms known to be caused by hypoglycemia
  2. Low glucose at the time the symptoms occur
  3. Reversal or improvement of symptoms or problems when the glucose is restored to normal

Hypoglycemia (common usage) is also a term in popular culture and alternative medicine for a common condition characterized by shakiness and altered mood and thinking, but without measured low glucose or risk of severe harm. It is treated by changing eating patterns, i.e. eating regular balanced meals with reasonable portions and avoiding excessive sugar.

Causes 

Hypoglycemia occurs when your blood sugar (glucose) level falls too low. There are several reasons why this may happen, the most common being a side effect of drugs used for the treatment of diabetes. But to understand how hypoglycemia happens, it helps to know how your body normally regulates blood sugar production, absorption and storage.

Blood sugar regulation

During digestion, your body breaks down carbohydrates from foods — such as bread, rice, pasta, vegetables, fruit and milk products — into various sugar molecules. One of these sugar molecules is glucose, the main energy source for your body. Glucose is absorbed into your bloodstream after you eat, but it can’t enter the cells of most of your tissues without the help of insulin — a hormone secreted by your pancreas.

When the level of glucose in your blood rises, it signals certain cells (beta cells) in your pancreas, located behind your stomach, to release insulin. The insulin, in turn, unlocks your cells so that glucose can enter and provide the fuel your cells need to function properly. Any extra glucose is stored in your liver and muscles in the form of glycogen.

This process lowers the level of glucose in your bloodstream and prevents it from reaching dangerously high levels. As your blood sugar level returns to normal, so does the secretion of insulin from your pancreas.

If you haven’t eaten for several hours and your blood sugar level drops, another hormone from your pancreas called glucagon signals your liver to break down the stored glycogen and release glucose back into your bloodstream. This keeps your blood sugar level within a normal range until you eat again.

Aside from your liver breaking down glycogen into glucose, your body also has the ability to manufacture glucose in a process called gluconeogenesis. This process occurs primarily in your liver, but also in your kidneys, and makes use of various substances that are precursors to glucose.

Possible causes, with diabetes

If you have diabetes, the effects of insulin on your body are drastically diminished, either because your pancreas doesn’t produce enough of it (type 1 diabetes) or because your cells are less responsive to it (type 2 diabetes). As a result, glucose tends to build up in your bloodstream and may reach dangerously high levels. To correct this problem, you likely take insulin or other drugs designed to lower blood sugar levels.

If you take too much insulin relative to the amount of glucose in your bloodstream, it can cause your blood sugar level to drop too low, resulting in hypoglycemia. Hypoglycemia may also result if, after taking your diabetes medication, you don’t eat as much as usual (ingesting less glucose) or you exercise more (using up more glucose) than you normally would. To prevent this from happening, it’s likely that your doctor will work with you to find the optimum dosage that fits your regular eating and activity habits.

Possible causes, without diabetes

Hypoglycemia in people without diabetes is much less common. Causes may include the following:

  • Medications. Taking someone else’s oral diabetes medication accidentally is a possible cause of hypoglycemia. Other medications may cause hypoglycemia, especially in children or in people with kidney failure. One example is quinine (Qualaquin), which is used to treat malaria.
  • Excessive alcohol consumption. Drinking heavily without eating can block your liver from releasing stored glucose into your bloodstream, causing hypoglycemia.
  • Some critical illnesses. Severe illnesses of the liver, such as severe hepatitis, can cause hypoglycemia. Disorders of the kidney, which can keep your body from properly excreting medications, can affect glucose levels due to a buildup of those medications. Long-term starvation, as may occur in the eating disorder anorexia nervosa, can result in the depletion of substances your body needs in gluconeogenesis, causing hypoglycemia.
  • Insulin overproduction. A rare tumor of the pancreas (insulinoma) may cause overproduction of insulin, resulting in hypoglycemia. Other tumors may result in excessive production of insulin-like substances.

Enlargement of beta cells of the pancreas that produce insulin (nesidioblastosis) may result in excessive insulin release, causing hypoglycemia.

  • Hormone deficiencies. Certain disorders of the adrenal glands and the pituitary gland can result in a deficiency of key hormones that regulate glucose production. Children with these disorders are more prone to hypoglycemia than are adults.

Hypoglycemia after meals

Hypoglycemia usually occurs when you haven’t eaten (when you’re in a fasting state), but that’s not always the case. Sometimes hypoglycemia occurs after meals because the body produces more insulin than is needed.

This type of hypoglycemia, called reactive or postprandial hypoglycemia, may occur in people who have had stomach surgery. It may also occur in people who haven’t had this surgery.

http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/causes/con-20021103

Diagnostics

Your doctor will use three criteria — often referred to as Whipple’s triad — to diagnose hypoglycemia. Whipple’s triad includes the following factors:

  • Signs and symptoms of hypoglycemia. You may not exhibit signs and symptoms of hypoglycemia during your initial visit with your doctor. In this case, your doctor may have you fast overnight (or for a longer period). This will allow hypoglycemic symptoms to occur so that he or she can make a diagnosis.

It’s also possible that you’ll need to undergo an extended fast in a hospital setting. Or if your symptoms occur after a meal, your doctor will want to test your glucose levels after a meal.

  • Documentation of low blood glucose when the signs and symptoms occur. Your doctor will draw a sample of your blood to be analyzed in the laboratory.
  • Disappearance of the signs and symptoms. The third part of the diagnostic triad involves whether your signs and symptoms go away when blood glucose levels are raised.
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In addition, your doctor will likely conduct a physical examination and review your medical history.

http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/tests-diagnosis/con-20021103

Treatment 

Treatment of hypoglycemia involves:

  • Immediate initial treatment to raise your blood sugar level
  • Treatment of the underlying condition that’s causing your hypoglycemia to prevent it from recurring

Immediate initial treatment

The initial treatment depends on your symptoms. Early symptoms can usually be treated by consuming 15 to 20 grams of a fast-acting carbohydrate. Fast-acting carbohydrates are foods that are easily converted to sugar in the body, such as candy, fruit juice, regular — not diet — soft drinks, or glucose tablets or gel. Foods containing fat or protein aren’t good treatments for hypoglycemia, because protein and fat can slow the body’s absorption of sugar.

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Recheck blood sugar levels 15 minutes after treatment. If blood sugar levels are still under 70 mg/dL (3.9 mmol/L), treat with another 15 to 20 grams of fast-acting carbohydrate, and recheck the blood sugar level again in 15 minutes. Repeat these steps until the blood sugar is above 70 mg/dL (3.9 mmol/L).

Once the blood sugar levels are back to normal, it’s important to have a snack or meal to help stabilize your blood sugar. This also helps the body replenish glycogen stores that may have been depleted during the hypoglycemia.

If your symptoms are more severe, impairing your ability to take sugar by mouth, you may need an injection of glucagon or intravenous glucose. Do not give food or drink to someone who is unconscious, as he or she may aspirate these substances into the lungs.

If you’re prone to severe episodes of hypoglycemia, ask your doctor if a home glucagon kit might be appropriate for you. In general, people with diabetes who are treated with insulin should have a glucagon kit for low blood sugar emergencies. Family and friends need to know where to find the kit, and need to be taught how to use it before an emergency occurs.

Treatment of the underlying condition

Preventing recurrent hypoglycemia requires your doctor to identify the underlying condition and treat it. Depending on the underlying cause, treatment may involve:

  • Medications. If a medication is the cause of your hypoglycemia, your doctor will likely suggest changing the medication or adjusting the dosage.
  • Tumor treatment. A tumor in your pancreas is treated by surgical removal of the tumor. In some cases, partial removal of the pancreas is necessary.

http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/treatment/con-20021103 

Prophylaxis

  • If you have diabetes, carefully follow the diabetes management plan you and your doctor have developed. If you’re taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your doctor about how these changes might affect your diabetes management and your risk of low blood sugar.

A continuous glucose monitor (CGM) is an option for some people, particularly those with hypoglycemia unawareness. These devices insert a tiny wire under the skin that sends blood glucose readings to a receiver every five minutes or so. If blood sugar levels are dropping too low, the CGM alerts you with an alarm.

Be sure to always have a fast-acting carbohydrate with you, such as juice or glucose tablets, so you can treat a falling blood sugar before it dips dangerously low.

  • If you don’t have diabetes but have recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent your blood sugar levels from getting too low. However, this approach isn’t an advisable long-term strategy. Work with your doctor to identity and treat the underlying cause of hypoglycemia.

http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/prevention/con-20021103

Useful advice

Home Remedies Low Blood Sugar

  • The following herbs help to normalize blood sugar: angostura bitters (or any combination of bitters), artichoke leaf, and gentian root.
  • To help your body respond to stress, try astragalus or licorice root.
  • Caution: If overused, licorice can elevate blood pressure. Do not use this herb on a daily basis for more than seven days in a row. Avoid it completely if you have high blood pressure or are pregnant or nursing.
  • Bilberry and wild yam aid in controlling insulin levels.
  • Dandelion root is an excellent source of calcium and supports the pancreas and liver.
  • Gudmar (Gymnema sylvestre), an Ayurvedic herb, suppresses the intestinal absorption of saccharides, which prevents blood sugar fluctuations.
  • Licorice nourishes the adrenal glands.
  • Caution: Do not use this herb on a daily basis for more than seven days in a row. Avoid if you have high blood pressure or are pregnant or nursing.
  • Milk thistle rejuvenates the liver.
  • Other beneficial herbs include echinacea, parsley, pau d’arco, raspberry leaves, and uva ursi.
  • Remove from the diet all alcohol, canned and packaged foods, refined and processed foods, dried fruits, salt, sugar, saturated fats, soft drinks, and white flour. Also avoid foods that contain artificial colors or preservatives.
  • Avoid sweet fruits and juices such as grape and prune. If you drink these, mix the juice with an equal amount of water.
  • Sweeten food with natural sweeteners such as stevia, a South American herb available in liquid form that is 200 times sweeter than sugar. Other acceptable sweeteners include barley malt syrup, molasses, and brown rice syrup.

Outcome 

The prognosis of hypoglycemia depends on the cause of this condition, its severity, and its duration. If the cause of fasting hypoglycemia is identified and treated early, the prognosis is excellent. If the problem is not curable, such as an inoperable malignant tumor, the long-term prognosis is poor. However, note that these tumors may progress rather slowly. Severe and prolonged hypoglycemia can be life threatening and may be associated with increased mortality in patients with diabetes.

If the patient has reactive hypoglycemia, symptoms often spontaneously improve over time, and the long-term prognosis is very good. Reactive hypoglycemia is often treated successfully with dietary changes and is associated with minimal morbidity. Mortality is not observed. Untreated reactive hypoglycemia may cause significant discomfort to the patient, but long-term sequelae are not likely.

A study by Boucai et al found that drug-associated hypoglycemia was not associated with increased mortality risk among patients admitted to general wards. This suggests that hypoglycemia may be a marker of disease burden and not a direct cause of death.

http://emedicine.medscape.com/article/122122-overview#a7

Complications

If you ignore the symptoms of hypoglycemia too long, you may lose consciousness. That’s because your brain needs glucose to function properly.

Recognize the signs and symptoms of hypoglycemia early because untreated hypoglycemia can lead to:

  • Seizure
  • Loss of consciousness
  • Death

Hypoglycemia unawareness

Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats. When this happens, the risk of severe, life-threatening hypoglycemia is increased.

Undertreated diabetes

If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening. Repeated episodes of hypoglycemia may cause you to take less insulin to ensure that your blood sugar level doesn’t go too low. But long-term high blood sugar levels can be dangerous, too, possibly causing damage to your nerves, blood vessels and various organs.

http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/complications/con-20021103 

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