Hypoglycemia: Going Lower Is Not Always Good

July 8, 2016

How can we facilitate fewer hypoglycemic episodes and better equip patients to handle those that do occur?

Patient (describing what he did after finding he had a low fingerstick glucose): “I had a candy bar.”

Me: “Did you recheck your sugar about 15 minutes later?”

Patient: “No, I felt fine.”

Exchanges like this scare me. One of my patients recently related the above. I’m sure you’ve heard something similar, or that some patients aren’t testing at all if they feel low. Or, if not a candy bar, they’ll quaff a regular soda if they experience hypoglycemia.

Hypoglycemia continues to bedevil patients living with diabetes. Low glucose can  potentially lead to an ER visit or hospital admission, a car accident, or even death. They can hamper patients’ quest for glycemic control and a good quality of life. Just as you have, I’ve seen fear of future episodes get so deeply planted that, sometimes to the degree that one patient of mine put it: “I’d rather run a little high than drop that low. I don’t ever want to feel that awful again.”

So what do we do?

1. Head off hypoglycemia as much as possible.

As with diabetes complications, it’s about avoiding the development of the problem in the first place. We must do our very best to ensure that patients and their caregivers optimize their medication regimens as well as their lifestyle, are as well-educated as possible about hypoglycemia, and know their potential triggers. Talk with them about avoiding skipping meals, understanding their medications, and avoiding stacking insulin doses.

2. Discuss what to do (and keep the conversation going).

As I’m sure you all do, remind patients and their caregivers what to look for, and what steps to take, despite all of their best efforts at prevention. Review the 15/15 rule, urge them to eschew candy bars in favor of glucose tablets, and explain why.

Emphasize that this is an ongoing process – it’s certainly not a “one and done” learning experience with, say, the CDE only. I discuss with my patients that everyone is different, and it takes time to be in tune with symptoms of hypoglycemia, and even the subtler cognitive changes that could herald early, mild hypoglycemia.

3. Diabetes care takes a village – enlist help.

Besides the crucial support and assistance of family, friends, colleagues, I urge you to involve your teammates in diabetes care: nurses, CDEs, dietitians, pharmacists, peer coaches. 

I’d love to hear your pearls, experiences, and strategies that have worked for your patients. Please feel free to post a comment.