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Hypoglycemia and hypo unawareness

Hypoglycemia is not only one of the most dangerous challenges we face as people with diabetes (PWD), but it is also one of the scariest.

Hypos can be caused by many things; exercise, excess insulin, alcohol, or a sulfonylurea (glipizide, glimepiride, etc.) just to name a few. These lows make us feel shaky, dizzy, irritable, sweaty, and weak. Our brains depend solely on glucose for fuel!

When there is an inadequate amount of glucose available, the body reacts! This reaction acts not only as a physical warning, but also helps to stimulate physiologic mechanisms that raise blood glucose levels. Due to these mechanisms, people without diabetes rarely get hypoglycemia. The pancreas and the liver work together to balance the release of insulin and glucose depending on the body’s needs. When PWD take drugs such as insulin or sulfonylureas to help lower the BG or if they have a history of frequent hypos, neurohormonal responses can be impaired causing hypoglycemia unawareness.

Why is this dangerous? Because if a PWD is unaware of a low BG, then they may not treat it!

In people without diabetes, their first defense mechanism against hypoglycemia is a decrease in the secretion of insulin. This mechanism is completely impaired in people with type 1 diabetes and becomes impaired over time in people with type 2. The second response is a release glucagon from the liver. This response, although usually normal at onset of DM, decreases over time. Lastly, epinephrine increases delivery of glucose and inhibits its use in the periphery. This allows for the little glucose that is available to be used by the more vital organs.

These mechanisms are impaired in people with diabetes and even more so in people who experience hypoglycemia frequently. In fact, the lower the average BG, the higher the risk of hypoglycemia unawareness. This can be very dangerous, especially overnight! If a person’s body does not warn them of a severe hypo, they may not wake up to treat it. Therefore, a continuous glucose monitor (CGM) in someone with hypoglycemia unawareness is especially important!

What can we do?

People who experience this can regain some awareness by avoiding lows. Alcohol ingestion can also contribute to hypo unawareness by decreasing the liver’s ability to release glucose (it is too busy processing alcohol). Alcohol avoidance is important in someone suffering from hypoglycemia unawareness or trying to regain some of that awareness. Most importantly, for someone with hypoglycemia unawareness, a CGM is a MUST! With a CGM, the person can be alerted before severe lows occur.

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