Candis M. Morello, Pharm D, CDE, FCSHP , Associate Professor of Clinical Pharmacy at UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, Clinical Pharmacist at VASDHS Christine Luu, First Year Student Pharmacist at UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences.
TCOYD Newsletter, Vol. 30, 2009

Have you ever felt irritable, confused, sweaty, weak, or overly tired? You may have been experiencing symptoms of mild to moderate hypoglycemia, or low blood glucose. Many people are unaware of symptoms and experience hypoglycemia without even realizing it. However, unawareness of symptoms can be extremely dangerous. Untreated mild to moderate hypoglycemia may lead to severe lows in blood glucose, unconsciousness, diabetic coma, and, in rare situations, death. The good news is that you can be prepared. Education is key—by arming yourself with tools to prevent and treat hypoglycemia, you can take control.

What is Hypoglycemia?

Normal blood glucose concentrations, even during fasting, are usually greater than 70 mg/dL.

Low blood glucose can be caused by skipping meals, leaving too much time between meals, not eating enough, over or incorrect medication use (especially with insulin), vomiting, diarrhea, vigorous exercise, and excessive alcohol intake. Hypoglycemia can occur at any time, day or night. By regularly monitoring blood glucose, eating nutritious meals, taking the correct doses of medications, and most importantly, by being aware of the symptoms, hypoglycemic episodes can be minimized.

How Do You Know if You Are Too Low?

Symptoms of mild to moderate hypoglycemia may include hunger, irritability, confusion, sweating, palpitations, tiredness, weakness, increased heart rate, nausea, tremors or shakiness, and anxiety. Since catching hypoglycemia early is important, being aware of symptoms is crucial. If ever in doubt about whether or not you are too low, test your blood glucose to confirm hypoglycemia. If you experience hypoglycemic unawareness, testing your blood glucose at regular intervals, and especially before driving is very important.

How Do You Treat Mild to Moderate Hypoglycemia?

Treating hypoglycemia means restoring the glucose in your blood. You can raise glucose to treat mild to moderate hypoglycemia with an approach called the “Rule of 15.” 1. Test to determine blood glucose is below 70 mg/dL. 2. Eat 15 grams of simple, concentrated carbohydrates (for fast-acting sources, refer to the Table on the next page). 3. Wait 15 minutes. 4. Check blood glucose again. 5. If blood glucose is still below 70 mg/dL, consume an additional 15 grams of carbohydrates. 6. Follow up with a light snack (or with a meal if it is mealtime). Mild to moderate hypoglycemia can usually be reversed rapidly, within 5-10 minutes. Using the “Rule of 15,” blood glucose concentrations increase quickly and you can avoid over-treating by overeating, which could lead to elevated glucose concentrations and an undesired blood glucose roller coaster. The table below lists 15-gram amounts of effective fast acting carbohydrates including glucose tablets, milk, fruit juice, regular soda, sugar, raisins, hard candies, and glucose gels. Avoid foods that are high in fat, such as pizza, candy bars, or doughnuts, because fatty foods slow the absorption of carbohydrates, making the blood sugar rise take longer. However, if the only sugary food you have nearby is a candy bar or a doughnut, it is much better than nothing at all. If you experience a ‘low’ right before mealtime, go ahead and eat your meal without applying the “Rule of 15” as long as the meal you are eating has sufficient carbohydrate to get your blood glucose back up. Contact your healthcare provider if you frequently experience low blood glucose as your medication may need adjusting.

How Do You Treat Severe Hypoglycemia?

Untreated mild to moderate hypoglycemia can lead to severe hypoglycemia and unconsciousness, a situation that cannot be selftreated. It is important to remember that the person experiencing severe hypoglycemia cannot swallow. Force-feeding food or liquid to an unconscious person can lead to choking. Treatment of severe hypoglycemia requires a glucagon emergency kit, which is available only by prescription. Glucagon is a natural hormone that works quickly to increase blood glucose concentrations. The glucagon mixing and administration instructions may be confusing during an emergency. To prevent confusion in a stressful situation, it is vital to educate people around you (close friends, family, teachers, caregivers) how to prepare and administer glucagon before an actual emergency arises. Annual reeducation is recommended. Remember to check expiration dates regularly since you do not want to be caught in an emergency with an expired kit. Although some people go years without needing to use their glucagon emergency kits, it is very important for all patients on insulin therapy to have these kits available and to keep them easily accessible. Store them in several places such as in the bedroom, a purse, briefcase or backpack, and let the people around you know where the kits are located.

Bottom Line: Prevent and Prepare

To take control of hypoglycemia and avoid severe episodes, prevention and being prepared are essential. Be aware of early warning symptoms of hypoglycemia and recognize when you are more likely to go low. Keep fast-acting sources of carbohydrates such as glucose tablets or hard candies in the car or with you when traveling. Mini 4-ounce juice boxes are the perfect size and contain 15 grams of carbohydrates— keep some by the bed as a quick source of glucose at bedtime or in the middle of the night when you are more likely to be both low and groggy.

It is important to know when a low is coming on. Over time, many people tend to get used to their early symptoms, making it easier for those symptoms to go undetected. Some people even lose the sensations completely. Educate your family or close friends about the symptoms of hypoglycemia so they can help identify low blood glucose in the event that you are unaware of the symptoms or are experiencing confusion. Educate them about the treatment of mild to moderate hypoglycemia and teach them to use emergency glucagon kits in severe situations.

Knowledge is power! Know your blood glucose values by monitoring frequently, be aware of early warning symptoms of hypoglycemia, know how to treat low blood glucose, prepare yourself with fast-acting carbohydrate sources, and teach others about hypoglycemia! By knowing how to prevent lows and by being prepared if they occur, you can definitely be in control of hypoglycemia!

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