Low Blood Sugar, Everything You Need to Know!

What number is low blood sugar (glucose)?

Most endocrinologists/diabetes doctors believe that below 70 mg/dl, blood sugar is an alert level. Yet, clinically important biochemical low blood sugar ( hypoglycemia) is blood sugar below 54mg/dl. American Diabetes Association (ADA) has defined hypoglycemia (low blood sugar/glucose) in patients with diabetes as all episodes of an abnormally low plasma glucose concentration (with or without symptoms) that can potentially be harmful.

On the other hand, in some cases, a diabetic person with diabetes reports typical symptoms of hypoglycemia but has a measured glucose level >70 mg/dL. This category reflects the fact that patients with chronically poorly controlled diabetes can experience symptoms of hypoglycemia as glucose levels fall into the more normal range.

How do you feel when blood sugar is low and what is a hypoglycemia attack?

Low blood sugar causes neurological or adrenergic (adrenal hormone-induced) symptoms such as: 1. The adrenergic symptoms include tremors, palpitations, and anxiety/arousal and sweating, hunger. 2. The neurological symptoms include confusion, dizziness, weakness, drowsiness. Also, at very low glucose concentrations seizures and coma may occur.

Although profound, prolonged hypoglycemia can cause brain death in the unobserved patient with diabetes. In patients with diabetes, the start of symptoms can occur at glucose levels less than 65 mg/dL (3.6 mmol/L), although the specific glucose value depends on and within individuals over time.

The lower limit of the normal fasting plasma glucose value is typically 70 mg/dL (3.9 mmol/L). Patients who most of the time run high blood sugars tend to feel low blood glucose symptoms at relatively normal glucose levels. For example, a diabetic patient who typically runs in the 200 mg/dL to 300 mg/dL may feel low blood sugar symptoms and 100 mg/dL which is totally normal blood sugar levels otherwise.

On the other hand, some patients especially type I diabetic patients who have repeated episodes of low blood sugar may stop having symptoms of low sugar or may have very mild symptoms even at low levels of blood sugar such as down to 50 or 60 mg/dL blood sugar levels.

Can you have low blood sugar without being diabetic?

The answer is yes. Reactive hypoglycemia is the type of low sugar that happens in patients without diabetes. This can happen in certain individuals after high carbohydrate/sugar-containing foods or beverages.

It can happen 1 to 3 hours after a high carbohydrate or high sugar food or beverage. The patient who has a history of gastric bypass surgery is particularly susceptible to this problem. Occasionally patients with insulin resistance can also experience the same problem.

Is hypoglycemia harmful?

Low blood sugar can definitely be harmful. A large majority of episodes will go away after the glucose level is up. The rare fatal episodes can be due to severe heart rhythm problems. The younger the patient and the healthcare the patient’s risk of low blood sugar is less. The frequency of serious, clinically important hypoglycemia in type 2 diabetes patients is not certain.

The extent to which recurrent hypoglycemia causes cognitive impairment is also uncertain. What we know is that in middle-aged adults (mean age 50), mild to moderate hypoglycemia can increase the time away from work. Also, in frail, older adults, mild episodes of hypoglycemia may cause episodes of dizziness or weakness. As a result, the chances of falls and fractures can be higher.

Severe hypoglycemia

Severe hypoglycemia is a low blood sugar needing assistance from another person to fix it. It can be more problematic. Some endocrinologists believe that severe hypoglycemia may also be associated with an increased risk of cardiovascular disease in patients with type 2 diabetes, although whether hypoglycemia is the main reason is not clear.

In our practice, we try to prevent low sugar( glucose) at all costs as symptoms are not pleasant and can cause many unwanted side effects such as feeling down and tired for a while after the event. A typical type I diabetic patient can report an average of up to three episodes of severe hypoglycemia (episodes requiring the assistance of another person) per year.

Some studies using continuous glucose monitoring (CGM) such as Dexcom G6 or Freestyle libre show much more frequent episodes of clinically important hypoglycemia (<54 mg/dL [3 mmol/L]), ranging from every two to three days to every six days. Hypoglycemia is much less frequent in type 2 diabetes.

Although patients with type 2 diabetes who are on any insulin, a sulfonylurea(glipizide, glyburide, glimepiride) or a meglitinide(repaglinide, nateglinide) are generally at higher risk than those treated with diet or other medications. On the other hand, a lot of other diabetic medications do not cause hypoglycemia.

List of diabetic drugs that do not cause hypoglycemia

• Metformin

• Alpha-glucosidase inhibitors such as acarbose

• Thiazolidinediones such as pioglitazone (Actos)

• Glucagon-like peptide-1 (GLP-1) receptor agonists such as rybelsus, Ozempic, Bydureon, Trulicity 

• Dipeptidyl peptidase-4 (DPP-4) inhibitors such as Januvia, Tradjenta

• Sodium-glucose co-transporter 2 (SGLT2) inhibitors such as Jardiance, Invokana, Farxiga, Steglatro

What causes low blood sugar?

Some diabetic medications, longer duration of diabetes, being old and being diabetic, eating erratically and missing meals, exercise, alcohol, chronic kidney disease, liver failure, malnutrition.

●Longer duration of diabetes

As the duration of diabetes increases the number of glucagon-producing cells also goes down. This is more prominent in type I diabetics. Glucagon is a hormone that protects against low blood sugar.

●Older age

Symptoms of low blood sugar may not be as prominent in older individuals. As a result, the risk of low blood sugar is much higher in older type I and type II diabetic patients.

●Lower levels of glycemia, when achieved with medications

When patients and doctors try to achieve very normal blood sugar levels by using certain medications that can potentially increase the risk of low blood sugar. As we discussed certain medications such as sulfonylureas and insulins increase the risk of low blood sugar drastically.

●Erratic timing of meals, including missed meals and low carbohydrate content of meals

This is very important in patients taking insulin at mealtimes. That is also true for patients taking sulfonylureas or repaglinide or nateglinide. When patients take insulin or take 1 of these pills the risk of low blood sugar increases dramatically if they do not eat.

●History of recent severe hypoglycemia

If the patient had low blood sugar one time before unless there is a dramatic change in the regimen or lifestyle risk of low blood sugar happening again is very high as well.

●Exercise

Exercise can increase the risk of low blood sugar, especially in the setting of insulin and sulfonylureas (see above)

●Alcohol ingestion

Drinking alcohol can prevent the liver from producing glucose in response to the glucagon stimulation. The liver is the ultimate glucose for storing organs. Especially in times of need obtaining glucose from the liver is vitally important. Alcohol suppresses the liver from releasing glucose.

●Chronic kidney disease

Patients with chronic kidney disease also are susceptible to low blood sugar. This is because kidneys also contribute to gluconeogenesis (making glucose similar to the liver although to a lesser extent). In addition to that patients with chronic kidney disease tend to accumulate insulin and some other medications such as sulfonylureas. As a result of low blood sugar increases in type I and type 2 diabetes patients with chronic kidney disease.

●Malnutrition with glycogen depletion

If the patient is not eating well the glycogen and glucose stores in the liver and kidneys will be depleted very quickly. If the patient is on medications that can increase the risk of low blood sugar malnutrition definitely will significantly increase the risk of low blood sugars.

Hypoglycemia-associated autonomic failure (including the syndromes of impaired awareness of hypoglycemia and of defective glucose counter-regulation):

This happens mostly in patients with type 1 diabetes. It happens as a result of frequent hypoglycemia. But sometimes diabetic patients stop responding to recurrent low blood sugar episodes after a while. This can be dangerous as a person may not realize that they have very low blood sugar. This happens as a result of the down-regulation of the autonomous nervous system that causes the symptoms of shaking, sweating, heart racing, etc.

How to reduce the risk of low blood sugar or prevent low blood sugar (hypoglycemia)

The prevention of hypoglycemia involves assessing risk factors and tailoring treatment regimens to individual patients to reduce the risk. As we discussed every patient is different and risk factors, medications, and lifestyle should all be taken into consideration.

In our practice, we assess the patient holistically to ensure that the medications we provide are not going to be high risk for our patients. Our diabetes doctors/endocrinologists do everything in their power to reduce the risk of low blood sugar in diabetic patients we treat.

We monitor patients either through continuous glucose monitoring systems such as Dexcom G6 or freestyle libre or freestyle libre 2. For patients who may not be able to obtain these devices, we still use finger prick glucose monitoring.

We offer cellular technology that allows data to be transferred to our diabetes center directly and immediately so we can monitor patients continuously and intervene as soon as possible. In most cases, patients are on their own to monitor their blood sugars.

Even if they do not have a service like us, patients should monitor as frequently as possible if they are on a sulfonylurea agent or insulin. The frequency of monitoring should be determined by an endocrinologist/diabetes doctor. If the patient is having frequent low blood sugars the diabetes medication regimen should be changed.

The patient also needs to go through lifestyle change classes to improve the dietary and exercise regimen and schedule. Diabetes doctors should individualize the goals for every single patient.

Elderly patients who have chronic kidney disease and other health problems should have a more relaxed glucose goal to avoid severe low blood sugars that can cause more harm than benefit. Endocrinologists and diabetes doctors should continue to find flexible and adjustable medication and lifestyle changes.

Patient education

Patient education is a critical part of preventing low blood sugar. If patients know how the medications work and why they can be at risk for low blood sugar, they are more likely to find ways to prevent it.

Exercise-induced low blood sugar (hypoglycemia)

Exercise-induced hypoglycemia can occur during, shortly after, or many hours after exercise, and therefore, patients should remain vigilant for its occurrence, including frequent SMBG or CGM such as Dexcom G6, Dexcom G7, freestyle libre, freestyle libre 2.

A patient’s endocrinologist can take measures to reduce early post-exercise hypoglycemia. These measures may include interchanging brief episodes of intense exercise (which tends to raise glucose concentrations), adding carbohydrate snacks such as 0.5 g/pound per hour and reducing insulin doses.

Exercise increases glucose utilization by muscle. Therefore, exercise can cause hypoglycemia in patients who have near-normal or moderately elevated plasma glucose levels at the start of the exercise.

Fear of hypoglycemia

Hypoglycemia can be a scary, unpleasant, and potentially lethal complication of diabetes, and therefore, we understand the patient’s fears of low blood sugar. As a result, we always encourage diabetic patients to be aware of early symptoms and to ingest carbohydrates before symptoms progress.

In some cases, however, fear of hypoglycemia can become a major barrier to lowering blood glucose concentrations substantially. In those patients, we try to change medications if they are on medications that can drastically increase the risk of low blood sugar.

A good endocrinologist or diabetes doctor will definitely pay attention to low blood sugar while treating diabetes.1 study found that patients who had a frightening episode of severe hypoglycemia in the previous year often became so fearful that they kept their blood glucose excessively high for several months afterward.

How to reverse/treat low blood sugars (hypoglycemia)?

The goal of the treatment of low blood sugar is to raise the plasma glucose concentration to normal. Diabetic patients or doctors can do that by getting glucose orally or IV. In cases of severe hypoglycemia outside of a medical center, patients should take glucagon.

What is the best thing to eat when your blood sugar is low?

Both type I and type II diabetic patients also should be able to treat early symptoms of low blood sugar by fast-acting carbohydrates such as glucose tablets, hard candy, or sweetened fruit juice. These items should be available at all times, although treatment with glucose tablets is more consistently effective.

What I do if my blood sugar is below 70 but I do not have symptoms?

For a person with drug-treated diabetes, we suggest defensive actions when self-monitoring reveals a glucose level of ≤70 mg/dL (3.9 mmol/L). Defensive options include repeating the measurement within 15 to 60 minutes, avoiding critical tasks such as driving, ingesting carbohydrates, and adjusting the treatment regimen.

What widely my blood sugars below 70 and I have symptoms? Patients with symptomatic hypoglycemia should ingest 15 to 20 grams of fast-acting carbohydrate, check blood sugars again in 15 to 20 minutes. If blood sugars are about 70 they can monitor again in 15 minutes.

If blood sugars are not above 70 they can eat another 15 to 20 g of carbs and check blood sugars again in 15 to 20 minutes and repeat the protocol until blood sugars are consistently staying above 70 mg/dL.

Do I need a glucagon?

Every patient who is on insulin or sulfonylurea should have glucagon available. Diabetic patients should make sure that their glucagon is not expired. They should also make their family members and friends family here of how to use glucagon correctly. Glucagon is available as the traditional injectable form.

Glucagon is also available as a premixed syringe (Gvoke) that is ready to inject. Nasal glucagon (Baqsimi) also came to the market recently in early 2020. At Sugar MDs diabetes care center operating mainly from West Palm Beach Florida in Jupiter

Florida as well as throughout the entire Florida New York State, our goal is to provide the best diabetes care possible for every patient we care for. Dr. Ergin and his staff are talented in monitoring patients remotely and intervening as soon as a dangerous blood sugar level is noted. AHMET ERGIN, MD, FACE, CDCES, ECNU ENDOCRINOLOGIST 2260 Palm Beach Lakes Blvd. Ste 212 Unit #7 West Palm Beach, Florida 33409 Phone: 561-462-5053