Low Blood Glucose (Hypoglycemia)

What is hypoglycemia?

Hypoglycemia, also called low blood glucose or low blood sugar, occurs when the level of glucose in
your blood drops below normal. For many people with diabetes, that means a level of 70 milligrams
per deciliter (mg/dL) or less. Your numbers might be different, so check with your health care
provider to find out what level is too low for you.

What are the symptoms of hypoglycemia?

Symptoms of hypoglycemia tend to come on quickly and can vary from person to person. You may
have one or more mild-to-moderate symptoms listed in the table below. Sometimes people don’t feel
any symptoms.

Severe hypoglycemia is when your blood glucose level becomes so low that you’re unable to
treat yourself and need help from another person. Severe hypoglycemia is dangerous and needs
to be treated right away. This condition is more common in people with type 1 diabetes.

Hypoglycemia Symptoms
Mild-to-Moderate Severe
 Shaky or jittery  Uncoordinated  Unable to eat or drink
 Sweaty  Irritable or nervous  Seizures or convulsions
 Hungry  Argumentative or (jerky movements)
 Headachy combative  Unconsciousness
 Blurred vision  Changed behavior
or personality
 Sleepy or tired
 Trouble
 Dizzy or
concentrating
lightheaded
 Weak
 Confused or
disoriented  Fast or irregular
heart beat
 Pale

Some symptoms of hypoglycemia during sleep are

 crying out or having nightmares

 sweating enough to make your pajamas or sheets damp
 feeling tired, irritable, or confused after waking up
What causes hypoglycemia in diabetes?

Hypoglycemia can be a side effect of insulin or other types of diabetes medicines that help your body
make more insulin. Two types of diabetes pills can cause hypoglycemia: sulfonylureas and
meglitinides. Ask your health care team if your diabetes medicine can cause hypoglycemia.

Although other diabetes medicines don’t cause

1 hypoglycemia by themselves, they can increase the
chances of hypoglycemia if you also take insulin, a sulfonylurea, or a meglitinide.
 If you take insulin or some other diabetes
medicines, your blood glucose level can drop too low.
What other factors contribute to hypoglycemia in diabetes?

If you take insulin or diabetes medicines that increase the amount of insulin your body
makes—but don’t match your medications with your food or physical activity—you
could develop hypoglycemia. The following factors can make hypoglycemia more likely:

Not eating enough carbohydrates (carbs)

When you eat foods containing carbohydrates, your digestive system breaks down the sugars and
starches into glucose. Glucose then enters your bloodstream and raises your blood glucose level. If
you don’t eat enough carbohydrates to match your medication, your blood glucose could drop too
low.

Skipping or delaying a meal

If you skip or delay a meal, your blood glucose could drop too low. Hypoglycemia also can occur
when you are asleep and haven’t eaten for several hours.

Increasing physical activity

Increasing your physical activity level beyond your normal routine can lower your blood glucose level
for up to 24 hours after the activity.

Drinking too much alcohol without enough food

Alcohol makes it harder for your body to keep your blood glucose level steady, especially if you
haven’t eaten in a while. The effects of alcohol can also keep you from feeling the symptoms of
hypoglycemia, which may lead to severe hypoglycemia.

Being sick

When you’re sick, you may not be able to eat as much or keep food down, which can cause low blood
glucose. Learn more about taking care of your diabetes when you’re sick.
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 How can I prevent hypoglycemia if I have diabetes?

If you are taking insulin, a sulfonylurea, or a meglitinide, using your diabetes management plan and
working with your health care team to adjust your plan as needed can help you prevent
hypoglycemia. The following actions can also help prevent hypoglycemia:

Check blood glucose levels

Knowing your blood glucose level can help you decide how much medicine to take, what food to eat,
and how physically active to be. To find out your blood glucose level, check yourself with a blood
glucose meter as often as your doctor advises.

Hypoglycemia unawareness. Sometimes people with diabetes don’t feel or recognize the
symptoms of hypoglycemia, a problem called hypoglycemia unawareness. If you have had
hypoglycemia without feeling any symptoms, you may need to check your blood glucose more often
so you know when you need to treat your hypoglycemia or take steps to prevent it. Be sure to check
your blood glucose before you drive.

If you have hypoglycemia unawareness or have hypoglycemia often, ask your health care provider
about a continuous glucose monitor (CGM). A CGM checks your blood glucose level at regular times
throughout the day and night. CGMs can tell you if your blood glucose is falling quickly and sound an
alarm if your blood glucose falls too low. CGM alarms can wake you up if you have hypoglycemia
during sleep.

Eat regular meals and snacks

Your meal plan is key to preventing hypoglycemia. Eat regular meals and snacks with the correct
amount of carbohydrates to help keep your blood glucose level from going too low. Also, if you drink
alcoholic beverages, it’s best to eat some food at the same time.

Be physically active safely

Physical activity can lower your blood glucose during the activity and for hours afterward. To help
prevent hypoglycemia, you may need to check your blood glucose before, during, and after physical
activity and adjust your medicine or carbohydrate intake. For example, you might eat a snack before
being physically active or decrease your insulin dose as directed by your health care provider to keep
your blood glucose from dropping too low.

Work with your health care team

Tell your health care team if you have had hypoglycemia. Your health care team may adjust your
diabetes medicines or other aspects of your management plan. Learn about balancing your
medicines, eating plan, and physical activity to prevent hypoglycemia. Ask if you should have
a glucagon emergency kit to carry with you at all times.

3
 You can help prevent hypoglycemia by working
with your health care team.
How do I treat hypoglycemia?

If you begin to feel one or more hypoglycemia symptoms, check your blood glucose. If your blood
glucose level is below your target or less than 70, eat or drink 15 grams of carbohydrates right away.
Examples include

 four glucose tablets or one tube of glucose gel

 1/2 cup (4 ounces) of fruit juice—not low-calorie or reduced sugar*
 1/2 can (4 to 6 ounces) of soda—not low-calorie or reduced sugar
 1 tablespoon of sugar, honey, or corn syrup
 2 tablespoons of raisins

Wait 15 minutes and check your blood glucose again. If your glucose level is still low, eat or drink
another 15 grams of glucose or carbohydrates. Check your blood glucose again after another 15
minutes. Repeat these steps until your glucose level is back to normal.

If your next meal is more than 1 hour away, have a snack to keep your blood glucose level in your
target range. Try crackers or a piece of fruit.

*People who have kidney disease shouldn’t drink orange juice for their 15 grams of carbohydrates
because it contains a lot of potassium. Apple, grape, or cranberry juice are good options.

4 If your blood glucose is below your target, take

15 grams of glucose or carbohydrates right away.

Treating hypoglycemia if you take acarbose or miglitol

If you take acarbose or miglitol along with diabetes medicines that can cause hypoglycemia, you will
need to take glucose tablets or glucose gel if your blood glucose level is too low. Eating or drinking
other sources of carbohydrates won’t raise your blood glucose level quickly enough.

What if I have severe hypoglycemia and can’t treat myself?

Someone will need to give you a glucagon injection if you have severe hypoglycemia. An injection of
glucagon will quickly raise your blood glucose level. Talk with your health care provider about when
and how to use a glucagon emergency kit. If you have an emergency kit, check the date on the
package to make sure it hasn’t expired.

If you are likely to have severe hypoglycemia, teach your family, friends, and coworkers when and
how to give you a glucagon injection. Also, tell your family, friends, and coworkers to call 911 right
away after giving you a glucagon injection or if you don’t have a glucagon emergency kit with you.

If you have hypoglycemia often or have had severe hypoglycemia, you should wear a medical alert
bracelet or pendant. A medical alert ID tells other people that you have diabetes and need care right
away. Getting prompt care can help prevent the serious problems that hypoglycemia can cause.

August 2016

Hypoglycemia (Low Blood Glucose)

Throughout the day, depending on multiple different factors, blood
glucose (also called blood sugar) levels will vary – up or down. This is
normal. If it varies within a certain range, you probably won’t be able to tell.
But if it goes below the healthy range and is not treated, it can get
dangerous.

Low blood glucose (hypoglycemia) is when your blood glucose levels have
fallen low enough that you need to take action to bring them back to
your target range. This is usually when your blood glucose is less than
70 mg/dL. However, talk to your diabetes care team about your own
blood glucose targets, and what level is too low for you.

Low blood glucose may also be referred to as an insulin reaction,

or insulin shock.

Signs and Symptoms of Low

Blood Glucose
5
(happen quickly)
Each person's reaction to low blood glucose is different. Learn your own
signs and symptoms of when your blood glucose is low. Taking time to write
these symptoms down may help you learn your own symptoms of when your
blood glucose is low. From milder, more common indicators to most severe,
signs and symptoms of low blood glucose include:

 Feeling shaky
 Being nervous or anxious
 Sweating, chills and clamminess
 Irritability or impatience
 Confusion
 Fast heartbeat
 Feeling lightheaded or dizzy
 Hunger
 Nausea
 Color draining from the skin (pallor)
 Feeling Sleepy
 Feeling weak or having no energy
 Blurred/impaired vision
 Tingling or numbness in the lips, tongue, or cheeks
 Headaches
 Coordination problems, clumsiness
 Nightmares or crying out during sleep
 Seizures

The only sure way to know whether you are experiencing low blood
glucose is to check your blood glucose, if possible. If you are
experiencing symptoms and you are unable to check your blood
glucose for any reason, treat the hypoglycemia.

A low blood glucose level triggers the release of epinephrine (adrenaline),

the “fight-or-flight” hormone. Epinephrine is what can cause the symptoms
of hypoglycemia such as thumping heart, sweating, tingling, and anxiety.

If the blood glucose level continues to drop, the brain does not get enough
glucose and stops functioning as it should. This can lead to blurred vision,
difficulty concentrating, confused thinking, slurred speech, numbness, and
drowsiness. If blood glucose stays low for too long, starving the brain of
glucose, it may lead to seizures, coma, and very rarely death.

Treatment - The "15-15 Rule"

The 15-15 rule—have 15 grams of carbohydrate to raise your blood
glucose and check it after 15 minutes. If it’s still below 70 mg/dL,
have another serving. 6
Repeat these steps until your blood glucose is at least 70 mg/dL. Once your
blood glucose is back to normal, eat a meal or snack to make sure it doesn’t
lower again.

This may be:

 Glucose tablets (see instructions)

 Gel tube (see instructions)
 4 ounces (1/2 cup) of juice or regular soda (not diet)
 1 tablespoon of sugar, honey, or corn syrup
 Hard candies, jellybeans, or gumdrops—see food label for how many to
consume

Make a note about any episodes of low blood glucose and talk with your
health care team about why it happened. They can suggest ways to avoid
low blood glucose in the future.

Many people tend to want to eat as much as they can until they feel better.
This can cause blood glucose levels to shoot way up. Using the step-wise
approach of the "15-15 Rule" can help you avoid this, preventing high blood
glucose levels.

Note:

 Young children usually need less than 15 grams of carbs to fix a low blood
glucose level: Infants may need 6 grams, toddlers may need 8 grams, and
small children may need 10 grams. This needs to be individualized for the
patient, so discuss the amount needed with your diabetes team.
 When treating a low, the choice of carbohydrate source is important.
Complex carbohydrates, or foods that contain fats along with carbs (like
chocolate) can slow the absorption of glucose and should not be used to treat
an emergency low.

Severe Hypoglycemia
When low blood glucose isn’t treated and you need someone to help you
recover, it is considered a severe event.

Treating Severe Hypoglycemia

Glucagon is a hormone produced in the pancreas that stimulates
your liver to release stored glucose into your bloodstream when your blood
glucose levels are too low. Injectable glucagon is used to treat someone with
diabetes when their blood glucose7 is too low to treat using the 15-15 rule.
Glucagon kits are available by prescription. Speak with your doctor about
whether you should buy a glucagon kit and how and when to use it.

The people you are in frequent contact with (for example, friends, family
members, and coworkers) should be instructed on how to give you glucagon
to treat severe hypoglycemia.

Steps for treating a person with symptoms

keeping them from being able to treat
themselves.
1. Inject glucagon into the buttock, arm, or thigh, following the instructions
in the kit.
2. When the person regains consciousness (usually in 5-15 minutes), they
may experience nausea and vomiting.
3. If you have needed glucagon, let your doctor know so you can discuss
ways to prevent severe hypoglycemia in the future.

Don’t hesitate to call 911. If someone is unconscious and glucagon is not

available or someone does not know how to use it, call 911 immediately.

Do NOT:

 Inject insulin (it will lower their blood glucose even more)
 Provide food or fluids (they can choke)

Causes of Low Blood Glucose

Low blood glucose is common for people with type 1 diabetes and can occur
in people with type 2 diabetes taking insulin or certain medications. The
average person with type 1 diabetes may experience up to two episodes of
mild low blood glucose each week, and that’s only counting episodes with
symptoms. If you add in lows without symptoms and the ones that happen
overnight, the number would likely be higher.

Insulin
Too much insulin is a definite cause of low blood glucose. One reason newer
insulins are preferred over NPH and regular insulin is that they’re less likely
to cause blood glucose lows, particularly overnight. Insulin pumps may also
reduce the risk for low blood glucose. Accidentally injecting the wrong insulin
type, too much insulin, or injecting
8 directly into the muscle (instead of the
just under the skin), can cause low blood glucose.
Food
What you eat can cause blood glucose, including:

 Not enough carbohydrates

 Eating foods with less carbohydrate than usual without reducing the amount
of insulin taken.
 Timing of insulin based on whether your carbs are from liquids versus solids
can affect blood glucose levels. Liquids are absorbed much faster than solids,
so timing the insulin dose to the absorption of glucose from foods can be
tricky.
 The composition of the meal—how much fat, protein, and fiber are present—
can also affect the absorption of carbohydrates.

Physical Activity
Exercise has many benefits. The tricky thing for people with type 1 diabetes
is that it can lower blood glucose in both the short- and long-term. Nearly
half of children in a type 1 diabetes study who exercised an hour during the
day experienced a low blood glucose reaction overnight. The intensity,
duration, and timing of exercise can all affect the risk for going low.

Medical IDs
Many people with diabetes, particularly those who use insulin, should have a
medical ID with them at all times.

In the event of a severe hypoglycemic episode, a car accident, or other

emergency, the medical ID can provide critical information about the
person's health status, such as the fact that they have diabetes, whether or
not they use insulin, whether they have any allergies, etc. Emergency
medical personnel are trained to look for a medical ID when they are caring
for someone who can't speak for themselves.

Medical IDs are usually worn as a bracelet or a necklace. Traditional IDs are
etched with basic, key health information about the person, and some IDs
now include compact USB drives that can carry a person's full medical record
for use in an emergency.

Hypoglycemia Unawareness
Very often, hypoglycemia symptoms
9 occur when blood glucose levels fall
below 70 mg/dL. As unpleasant as they may be, the symptoms of low blood
glucose are useful. These symptoms tell you that you your blood glucose is
low and you need to take action to bring it back into a safe range. But, many
people have blood glucose readings below this level and feel no symptoms.
This is called hypoglycemia unawareness.

People with hypoglycemia unawareness can't tell when their blood glucose
gets low so they don’t know they need to treat it. Hypoglycemia
unawareness puts the person at increased risk for severe low blood glucose
reactions (when they need someone to help them recover). People with
hypoglycemia unawareness are also less likely to be awakened from sleep
when hypoglycemia occurs at night. People with hypoglycemia unawareness
need to take extra care to check blood glucose frequently. This is especially
important prior to and during critical tasks such as driving. A continuous
glucose monitor can sound an alarm when blood glucose levels are low or
start to fall. This can be a big help for people with hypoglycemia
unawareness.

Hypoglycemia unawareness occurs more frequently in those who:

 Frequently have low blood glucose episodes (which can cause you to stop
sensing the early warning signs of hypoglycemia)
 Have had diabetes for a long time
 Tightly control their diabetes (which increases your chances of having low
blood glucose reactions)

If you think you have hypoglycemia unawareness, speak with your health
care provider. Your health care provider may adjust/raise your blood glucose
targets to avoid further hypoglycemia and risk of future episodes.

Regaining Hypoglycemia Awareness

It’s possible to get your early warning symptoms back by avoiding any, even
mild, hypoglycemia for several weeks. This helps your body re-learn how to
react to low blood glucose levels. This may mean increasing your target
blood glucose level (a new target that needs to be worked out with your
diabetes care team). It may even result in a higher A1C level, but regaining
the ability to feel symptoms of lows is worth the temporary rise in blood
glucose levels.

Other Causes of Symptoms

Other people may start to have symptoms of hypoglycemia when their blood
glucose levels are higher than 70
10mg/dL. This can happen when your blood
glucose levels are very high and start to go down quickly. If this is
happening, discuss treatment with your diabetes care team.

How Can I Prevent Low Blood

Glucose?
Your best bet is to practice good diabetes management and learn to detect
hypoglycemia so you can treat it early—before it gets worse.

Monitoring blood glucose, with either a meter or a continuous glucose

monitor (CGM), is the tried and true method for preventing hypoglycemia.
Studies consistently show that the more a person checks blood glucose, the
lower his or her risk of hypoglycemia. This is because you can see when
blood glucose levels are dropping and can treat it before it gets too low.

If you can, check often!

 Check before and after meals

 Check before and after exercise (or during, if it’s a long or intense session)
 Check before bed
 After intense exercise, also check in the middle of the night
 Check more if things around you change such as, a new insulin routine, a
different work schedule, an increase in physical activity, or travel across time
zones

Why Am I Having Lows?

If you are experiencing low blood glucose and you’re not sure why, bring a
record of blood glucose, insulin, exercise, and food data to a health care
provider. Together, you can review all your data to figure out the cause of
the lows.

The more information you can give your health care provider, the better
they can work with you to understand what's causing the lows. Your provider
may be able to help prevent low blood glucose by adjusting the timing of
insulin dosing, exercise, and meals or snacks. Changing insulin doses or the
types of food you eat may also do the trick.

If you or your child has recently been diagnosed with type 1 diabetes, order
our FREE Courage-Wisdom-Hope Kit for children and their families.

If you're new to type 2 diabetes, join our free Living With Type 2 Diabetes
11
program to get help and support during your first year.
 Personal Stories from The Type
1 Diabetes Self-Care Manualby
Jamie Wood, MD and Anne
Peters, MD

Rush and Fog

There are the slow lows, where blood sugars drop ever so slightly over time
until you are symptomatic. There are the crashing lows, where due to insulin
or exercise (or both), I’m crashing down at a rapid pace and feel terrible.
These are the ones that make me feel weak, shaky, nervous, not want to
talk to anyone, and give me a ravenous need to eat everything around me
until I feel better. It’s like an adrenaline rush and brain fog mixed into one. I
hate this feeling. My husband knows to leave me alone when I’m low (it’s
the only time I don’t like to be touched or talked to), unless I ask for help. I
12
do like that he will bring me a juice box or something to treat at night. It
helps to have a little bit of the burden shared by someone else.

—Natalie H. Strand, MD, is a pain management specialist, a mother of two,

and was a member of the first two-woman team to win The Amazing Race.

Clouded Bravery
Many people say that I’m brave because I poke myself multiple times in a
day with fingersticks or syringes. But many don’t understand that the
hardest, scariest, and most paralyzing moments have nothing to do with a
needle.

Usually I notice it with a shift of my head. It will feel like things move
slightly slower than they should. I’ll mentally calculate, “When did I last eat?
How much insulin did I take?” And even though neither of these things
matter because they could have nothing to do with my low blood sugar, I try
to rationalize that I’m fine.

I can feel my heart beating out of my chest, and it becomes difficult to hear
and see. Check blood sugar level, get sugar. Except I forgot to replace the
sugar in my purse the last time I used it, so now I’m a fool without the one
thing I need. I start rummaging through my purse, hoping for some random
piece of candy, something, anything, that can bring my levels up. I can go
get a soda from the machine, but I don’t have any cash.

I need someone to help me, but in this intense moment of fear, my brain
becomes incapacitated and all logical ideas are gone. Everything is so blurry,
I can hardly make out what I’m even looking at now.

The only way to move past the fear is to robot-like move forward. Get up
and go find something or someone to help. Saying to someone “I have low
blood sugar and need juice” becomes the hardest sentence I’ve ever said;
shame overwhelms me and the effects of the low make it difficult for me to
even move my mouth, let alone say something that makes sense...

When I finally obtain the sugar I need, I can’t turn off the panic coursing
through my veins. I’ll inhale the food and guzzle the soda quicker than I can
even realize. Often I’ll try to drink the soda again, confused why the bottle is
empty. The world is still spinning for me, my heart still feels like it’s beating
so quickly that it’ll explode. It can take me 30 minutes to convince myself
that I’m not dying, that I have pulled through this again.
13
This experience never gets easier. Knowing that I’ve survived it a million
times before doesn’t help me believe I’ll get through in again. After 16 years
of this, I still struggle to hold back the tears and shame and to fight for
myself in that moment. It all seems so simple: If it’s an emergency, ask
someone to help and very likely, they will! But it’s hard to remember in that
moment...

Every diabetic has their story (or stories)... These are the moments that
make us brave. These are the moments where we must have a stronger
sense in us to live and fight for it than to let go and let the dizzying wheel
take us away. These are the moments that no matter how much you love a
diabetic, you will never truly understand.

...No one sees the chemical, hormonal, emotional scars. So brave, yes, but
for so many reasons others may never understand.

—DeAnna Wendland, 33, teaches middle school history, English, and

religion, and plans her road trips around craft beer and delicious wine.

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