Hypoglycemia: The Curse of Good Control?
Hypoglycemia is the biggest problem facing the implementation of intensive diabetes management today. The DCCT results show a 3-fold increase in people who are following an intensive diabetes regimen.
Most people think of hypoglycemia as having the classic symptoms of shakiness, sweating and hunger. When keeping blood sugars in the normal range, these symptoms often disappear or only occur occasionally. They are replaced by numb lips, numb tongue, confusion (repeating the same task or inability to perform familiar tasks such as dialing a phone), blurry vision or double vision. Many times these symptoms go unnoticed until it's too late and someone else needs to treat the reaction. In retrospect, most people can remember something about how they felt before it became impossible to self-treat. It is important to try to remember what it was, so that treatment will be instituted immediately the next time it occurs. It will also inspire you to have something readily available at all times to immediately treat these reactions. (See: Glucagon: Insulin "Antidote" Not in All Pumpers' Homes)
One of our patients was a competitive runner. He was training for an upcoming race and fell when running down a hill. He realized he was probably low, but had only one tube of Insta-Glucose. He was still several miles from home and knew this was not enough to get him there. He passed a police station on the way and requested a ride home. He was told that they were not a taxi service and he was incapable of arguing though he did show his ID bracelet.
He did make it home on his own somehow, but was extremely frightened by the experience. He now carries enough Insta-Glucose to get him home from any distance!
Another patient had anticipated having a large dinner so increased her pre-dinner bolus. She didn't really eat more and then proceeded to go out with friends. When driving home at 2 AM she realized she was in trouble when she couldn't keep her car between the lines. She had nothing in her pockets, purse or car to treat her reaction. She knew she needed to get off of the highway but was unable to find the exit ramp. Another driver saw her weaving and motioned for her to follow him off the exit ramp, which she did. Luckily he was a good Samaritan and flagged a policeman who fortunately had a relative with diabetes. She was still able to communicate at this point and told him she needed sugar. He bought her two candy bars and she recovered but was terribly frightened. She now never goes anywhere without some form of glucose on her person.
Brian was a college student who received a ski trip to Colorado for his 21st birthday. On his way out for a night at the bar he checked his glucose and discovered it was 35 mg/dl. He ate 3 glucose tabs and was on his way. He had a good time drinking with his buddies and came home around 2AM and flopped into bed. At 5:30AM, his roommates were awakened by him having a seizure. They called 911, but in the meantime, one of his friends gave him an injection of insulin since he thought this would help! He was brought to the ER, given glucose, but was not discharged. He was admitted for 24 hours of observation due to his insulin injection of unknown amount.
He lost a day of his skiing time, but luckily no more than that. He is now careful to always check his glucose before going to sleep, especially if he's been out drinking. Also, his friends now know about glucagon.
Close to 3/4 of severe hypoglycemic episodes occur during sleep. It is particularly important to be aware of this.
You don't need to experience a reaction like any of those described if you simply follow these guidelines:
- Always carry fast-acting glucose on your person (glucose tabs, insta-glucose, Dextrose).
- Always check your glucose level before driving unless you've just completed a meal.
- Wait 15 minutes after treatment before driving.
- Never miss a bedtime glucose test.
- If you usually eat a bedtime snack, DON'T MISS IT!
- Don't complete "one last thing" before treating a reaction -- otherwise, it may be too late.
When you strive for tight control of glucose, there is less time to treat reactions, but the end results are well worth the effort: healthy eyes, kidneys and nerves and a longer life expectancy!
JoAnn Ahern, RN, MSN, CDE
JoAnn is a DCCT Trial Coordinator from Yale University. She followed many pump patients in the DCCT and at Yale where the first U.S. research paper on pumps was published in the late 1970's. JoAnn's comments in this article are not specific to pump patients, but to anyone using insulin.
