Fear of the low: What you need to know about

hypoglycemia
Publication Date: August 2014 Vol. 9 No. 8

Author: Stacey A. Seggelke, MS, RN, ACNS-BC, BC-ADM, CDE

Approximately 25.8 million children and adults in the United States have diabetes.
Especially with the diabetes rate rising yearly, youre likely to care for many patients
with this disorder.
Of those diagnosed with diabetes, 80% take diabetes medication (oral drugs, insulin, or
both). Hypoglycemia is one of the most feared complications of such diabetes
treatmentsfeared by both patients and healthcare providers alike. Common in hospital
patients, its linked to poor outcomes, including increased mortality. Hypoglycemia
occurs in about 12% to 18% of patients with diabetes, with even higher rates when more
aggressive antihyperglycemic therapy is used.
Did you know? Direct medical costs linked to hypoglycemia in the United States totaled
$1.84 billion in 200
Blood glucose regulation
To understand hypoglycemia, you need to understand normal blood glucose regulation.
Glucose levels are regulated by glucagon and insulinendocrine glands of the pancreas.
When the glucose level rises, as from carbohydrate metabolism or the stress response,
beta cells in the pancreas release insulin. In turn, insulin lowers glucose levels by driving
cellular uptake of glucose to use for energy, and initiates conversion of glucose to
glycogen for storage in the liver and muscle. When the glucose level decreases, as from
lack of carbohydrate intake or increased activity, alpha cells in the pancreas release
glucagon. Glucagon promotes conversion of liver and muscle glycogen to glucose, which
is released in the bloodstream to raise the blood glucose level (glycogenesis).
Defining hypoglycemia
Hypoglycemia generally is defined as a blood glucose level of 70 mg/dL or lower. But
due to variances in individual patients and limitations of current glucose testing, the
American Diabetes Association divides hypoglycemia into several types, described
below.
Severe hypoglycemia occurs when a patient isnt able to treat a hypoglycemic reaction
on his or her own (generally due to decreased neurologic function) and instead must rely

on others to take action to raise the glucose level. In the hospital, for instance, the nurse
may administer glucose to a patient who becomes unconscious.
In documented symptomatic hypoglycemia, the patient has typical hypoglycemia signs
and symptoms, and hypoglycemia is confirmed by a blood glucose level below 70
mg/dL.
With symptomatic hypoglycemia, the patient doesnt experience hypoglycemia signs
and symptoms despite a blood glucose level below 70 mg/dL.
A patient with probable symptomatic hypoglycemia feels hypoglycemia symptoms and
treats them without verifying the blood glucose level with a blood glucose test.
In pseudohypoglycemia, hypoglycemia signs and symptoms develop at a blood glucose
level above 70 mg/dL. This can occur in someone with uncontrolled diabetes who isnt
accustomed to a normal glucose level.
Risk factors
Diabetes and glucose-lowering medications are the most common risk factors for
hypoglycemia. Others include septic shock, renal failure, severe critical illness, heart
failure, liver failure, and cancer. Hypoglycemia risk also rises with altered nutritional
intake and changes in medication dosages or timing.
Causes
Hypoglycemia can result from any of the following:
Adrenal insufficiency: The adrenal glands secrete cortisol and epinephrine, which help
regulate the glucose level. Low cortisol and epinephrine levels may impede glucose
regulation.
Alcohol ingestion: Metabolism of alcohol can prevent the liver from releasing glycogen
to maintain a normal blood glucose level.
Beta blockers: Some beta blockers antagonize the beta1-receptor blockade, which can
impede adrenergic warning signs of hypoglycemia.
Depression: One study found a positive relationship between depression and increased
hypoglycemic effects.
Liver failure: This condition may impair the livers ability to store glucose as glycogen
and to release glucose (glycogenolysis).
Certain medications: Insulin and insulin secretagogues (sulfonylureas and meglitinides)
increase circulating insulin levels.
Poor nutrition: Nausea, vomiting, and appetite loss can lead to reduced carbohydrate

intake.
Pregnancy: Severe hypoglycemia is more common during early pregnancy. Incidence
peaks at gestational weeks 8 to 16, and falls during the second half of pregnancy.
Women with a history of severe hypoglycemic reactions and those with
hypoglycemic unawareness have a threefold higher risk for severe hypoglycemia
during pregnancy. In early pregnancy, a combination of nausea, vomiting, and
hormone fluctuations contributes to hypoglycemia.
Renal insufficiency: This condition stems from a combination of decreased
gluconeogenesis and delayed renal metabolism of insulin.
As a nurse, you need to be aware of comorbidites that may affect glucose control and, as
appropriate, advocate for medication changes to reduce the threat of hypoglycemia in
high-risk patients.
Hypoglycemia signs and symptoms
As the blood glucose level decreases, initial signs and symptoms result from activation of
the autonomic nervous system. Also called neurogenic symptoms, these manifestations
result from acetylcholine release (causing cholinergic symptoms) and
epinephrine/norepinephrine release (causing adrenergic symptoms).
Cholinergic symptoms include sweating, hunger, and paresthesia.
Adrenergic symptoms include palpitations, anxiety, and tremors.
If blood glucose continues to fall, cerebral neurons become glucose-deprived, resulting in
neuroglycopenic symptoms, including fatigue, weakness, confusion, and behavior
changes. If blood glucose keeps falling, loss of consciousness and seizures may occur.
Prolonged severe hypoglycemia can lead to brain damage and death.
During sleep, hypoglycemia symptoms may be masked. However, nocturnal
hypoglycemia may cause increased perspiration, restlessness, and nightmares.
Keep in mind that hypoglycemic symptoms are idiosyncratic. Warning signs vary from
one person to the next.
Hypoglycemic unawarenessPatients who experience severe hypoglycemia episodes may
have a reduced counterregulatory response (especially by epinephrine) to subsequent
hypoglycemic episodes. This can suppress adrenergic symptoms until the glucose level
drops much lower. Those with type 1 diabetes may develop a blunted glucagon response
to low glucose levels, making the body unable to aid in glucose elevation. Some patients
lose all ability to sense hypoglycemia and must rely on others to notice signs and
symptoms for them. Studies show that preventing hypoglycemia by raising the patients
blood glucose target level can reestablish the counterregulatory response in about 3
months.

Did you know?

Hypoglycemia is linked to about 6% of deaths in persons with diabetes who are younger
than age 40.
Hypoglycemia treatmentGlucose is used to treat hypoglycemia. Its given either as an
oral supplement or through a glucose-elevating agent. If the patient is alert and can take
oral treatment safely, a quick-acting carbohydrate is preferred. To help you remember
administration guidelines, think of the rule of 15. (See the box below.)
Rule of 15
If you encounter a patient you suspect has hypoglycemia, administer 15 g of a fast-acting
carbohydrate. Wait 15 minutes, then recheck the blood glucose level. If its still low,
repeat treatment with 15 g of a fast-acting carbohydrate and recheck again in 15 minutes.
Examples of 15 g of a fast-acting carbohydrate are one tube of glucose gel, three or four
glucose tablets, candy containing dextrose (such as three rolls of Smarties), and 4 oz of
juice. For severe hypoglycemia, give 30 g of dextrose.
If the patient isnt fully conscious and cant take oral carbohydrates safely, never force
juice or glucose gel, because this may contribute to choking and aspiration. If the patient
cant take oral treatment and doesnt have I.V. access, inject glucagon intramuscularly or
subcutaneously to raise the glucose level. Glucagon for injection is a synthetic form of
the glucagon hormone, which promotes glycogenesis and increases the glucose level. Be
aware that administering glucagon can deplete liver glycogen stores for up to 24 hours,
making repeat glucagon injections ineffective.
If the patient cant tolerate oral administration but has I.V. access, dextrose is the
preferred treatment; its given as dextrose 50% solution by I.V. push. One ampule of
dextrose 50% in water contains 50 g of dextrose. In most cases, the entire amp should be
administered.
Know that because hypoglycemia causes unpleasant symptoms, most patients with
diabetes consume more carbohydrates than needed to raise their blood glucose levels.
This overtreatment can cause wide fluctuations in glucose levels.
Did you know?
The average person with type 1 diabetes has two hypoglycemia episodes per week and
one episode of severe hypoglycemia per year.
Preventing hypoglycemia
Multiple effective approaches can help prevent hypoglycemia in patients with diabetes.
The most important step is patient education. Instruct patients about hypoglycemia signs
and symptoms so they can recognize a hypoglycemic reaction and quickly administer an

oral carbohydrate or glucagon. Advise them to always carry a fast-acting carbohydrate

with them. Recommend they check their blood glucose level before driving or operating
other dangerous equipment. Instruct all patients with diabetes to wear a medical alert
bracelet or necklace that identifies them as diabetic or to carry a medical identification
card attached to their drivers license. Include family members, significant others, and
friends in diabetes education, including how to recognize and treat hypoglycema signs
and symptoms.
Teach patients about medicationsExplain how diabetes medications work, including
their onset, peak, and duration, so patients can better understand their treatment regimen.
For instance, if the patients glucose level drops 2 hours after injecting rapid-acting
insulin, explain that approximately 2 hours of insulin action time is left. This means the
patient should increase the amount of carbohydrate treatment to avoid another
hypoglycemic episode. Instruct patients to withhold rapid-acting insulin or decrease the
amount administered if theyve had nausea or vomiting or have reduced their food intake
due to a poor appetite.
Review exercise effectsTeach patients how exercise affects blood glucose levels. Explain
that physical activity increases the bodys glucose use, possibly leading to hypoglycemia.
With exercise, the body uses two types of fuel to power the activity. Initially, it uses
glucose for fuel. Glucose comes both from glucose circulating in the blood and from
stored glucose in the form of glycogen in the liver and muscle. After about 30 minutes of
activity, glucose and glycogen stores may become depleted, causing the body to break
down free fatty acids for energy. The body may require up to 24 hours to replenish
glycogen stores in the liver and muscle, raising the hypoglycemia risk after the activity
termed the lag effect of exercise.
To help prevent hypoglycemia during exercise, advise patients to check their blood
glucose level before exercising and frequently afterward to assess for hypoglycemia. For
patients who inject insulin, insulin doses may need to be altered to help avoid
hypoglycemia. Patients on oral diabetes medications may need an additional snack of 15
to 30 g of carbohyderates after exercise to prevent hypoglycemia. Remind patients that
everyday activities, such as shopping and cleaning, also can induce hypoglycemia.
Collaborate on blood glucose goalsUsing a patient-centered approach, help develop
blood glucose goals in collaboration with the patient. Consider individual factors, such as
age, comorbidities, and life expectancy, to help direct the treatment plan and establish
glycemic targets. For example, patients with hypoglycemic unawareness may benefit
from higher blood glucose goals. Elderly patients, on the other hand, may need less
stringent blood glucose goals to avoid hypoglycemia, which could lead to such problems
as fractures from falls. Teach patients how to adjust diabetes medications to meet their

blood glucose goals.

Eradicate fear of the lowFear of hypoglycemia can significantly affect patients and
families. As mentioned earlier, a causal relationship exists between frequent
hypoglycemia and depression. Whats more, a severe hypoglycemia episode can cause
extreme fatigue, disrupting daily activities. In one study, 80% of patients with type 2
diabetes whod experienced severe hypoglycemic reactions answered sometimes or
always when asked if they feared recurrent hypoglycemic episodes. This fear may lead
to medication nonadherence.
In addition, hypoglycemia may strain relationships. Personality changes can occur during
a hypoglycemic event. For instance, neuroglycopenic symptoms can lead to bizarre or
violent behavior; those witnessing this behavior may not understand that the patient cant
control it and may not even realize whats happening. Meanwhile, patients may become
frustrated if family members assume all emotional changes are related to hypoglycemia
and thus insist that the patient get frequent glucose testing.
As healthcare providers, our role is to educate, encourage discussion, and provide support
to patients. Approximately 85% of patients who experience hypoglycemia episodes dont
tell their healthcare providers about these incidents. To help ease their fears of
hypoglycemia, initiate the dialogue, including recommendations for treatment, and
provide support. In the immortal words of Marie Curie, Nothing in life is to be feared; it
is only to be understood. Now is the time to understand more, so that we may fear less.
Stacey A. Seggelke is a clinical nurse specialist in the adult diabetes program at the
University of Colorado Denver School of Medicine.