For people with diabetes, keeping their blood sugar from rising too high is a major concern. However, the opposite problem can also occur. Having a blood sugar that’s too low is known as hypoglycemia. It can cause serious health problems, and can even be fatal if left untreated.

Hypoglycemia is a potential side effect of treatment for diabetes. Although it can be dangerous, there are ways for people with diabetes to minimize the risk of hypoglycemia.

Takeaways

• Hypoglycemia occurs when a person’s blood sugar level drops too low. This can cause problems with the function of the brain, heart, and other organs.

• Insulin and other medications used for diabetes can cause hypoglycemia. The purpose of these treatments is to lower blood sugar, and they can sometimes lower it too much.

• Hypoglycemia is treated by consuming carbohydrates in order to get your blood sugar back into the normal range.

• Adjusting your doses of insulin and other medications for diabetes can help to prevent hypoglycemia. Using a continuous glucose monitor can help to detect hypoglycemia early, and makes it easier to adjust your treatment plan to avoid it.

What is hypoglycemia?

Hypoglycemia, sometimes known simply as “hypo,” occurs when a person’s blood sugar drops too low. The specific blood sugar reading that indicates hypoglycemia can differ somewhat from person to person, because everyone’s body responds a little differently to low blood sugar. Hypoglycemia is most commonly defined as a blood sugar reading below 70 mg/dl (3.9 mmol/L), but your number may be slightly different.

Because many tissues in the body require sugar in order to function properly, hypoglycemia can be dangerous. It’s important to take hypoglycemia seriously, and to address it quickly.

Signs and symptoms of hypoglycemia

Many people with diabetes develop a sense for when they’re experiencing hypoglycemia, because they learn how their body reacts to it. Some of the possible symptoms of hypoglycemia include:

• Shakiness

• Sweating

• Nausea

• Pounding heart or rapid heartbeat

• Fatigue

• Anxiety or irritability

• Difficulty concentrating

• Feeling dizzy or lightheaded

• Confusion

• Difficulty completing routine tasks

• Loss of coordination

• Slurred speech

• Blurred vision or double vision

If hypoglycemia is severe, it can cause seizures, an irregular heartbeat, and loss of consciousness. If the problem is not addressed, then it can even be fatal.

If you’re feeling symptoms that may indicate hypoglycemia, it’s best to check your blood sugar. If it’s below 70 mg/dl (or below the target that your care team has set for you), then you’re experiencing hypoglycemia.

Hypoglycemia causes

Your body’s cells use glucose, which is a type of sugar, for energy. When your blood glucose rises or is high, insulin is secreted. This tells your cells to take up glucose from the blood, and either use it for energy or store it. Insulin keeps your blood sugar from rising too high, because your cells remove it from circulation.

In people with diabetes, the body either doesn’t produce enough insulin, or the body’s cells don’t have a strong enough response to insulin. In order to keep the blood sugar from rising too high and causing damage, people with diabetes may need to take insulin and/or other medications that lower blood sugar. This helps to prevent the serious long-term complications that untreated diabetes can cause. However, these medications also carry a risk of lowering the blood sugar too much. In fact, treatment for diabetes is the most common cause of hypoglycemia.

A dose of insulin that’s too high can lead to hypoglycemia. The need for insulin depends on a number of factors, including how many carbs you’ve recently eaten, your activity level, and even the time of day. When you take too much insulin relative to these factors, then you may experience hypoglycemia.

This can occur in many different ways. For example, if you take your regular dose of insulin, but then you decide to do a workout, your body will use up the sugar in your blood more quickly than expected, which can lead to hypoglycemia. If you plan to eat a meal and program your pump to deliver bolus insulin, but then you don’t eat as much as you’d planned, then you could also experience hypoglycemia.

It’s not just insulin that can cause hypoglycemia. Some people with diabetes use other types of medications, either oral or injectable, to treat their diabetes. When the dose of these medications is too high, this can also lead to hypoglycemia.

Hypoglycemia is unfortunately a common problem for people with diabetes. In a large study of over 27,000 people with diabetes, about half of the people with type 2 diabetes, and more than 80% of those with type 1 diabetes, experienced hypoglycemia at least once over a four-week period.

Hypoglycemia treatment

When you’re experiencing hypoglycemia, it’s important to get your blood sugar up. This involves eating or drinking some sugar, which will quickly enter your bloodstream and raise your blood sugar. Many people with diabetes keep some glucose tablets or glucose gel with them, to use if their blood sugar drops too low. 

Drinking or eating something with sugar (such as fruit juice, non-diet soda, or candy) is another option. However, if you’re taking a medication that slows your digestion (e.g. GLP1-RA class of medications such as Ozempic, Trulicity, Rybelsus, and Victoza semaglutide), then it may be difficult to raise your blood sugar quickly enough through food.

When you’re treating hypoglycemia, you don’t want to overcorrect and cause high blood sugar. The general recommendation is to consume 15 to 20 grams of carbohydrates, which equates to three to four glucose tablets, half a can of soda, or half a cup of juice. Wait 15 minutes, and then check your blood sugar. If it’s still low, consume another 15 to 20 grams of carbohydrates.

Besides using sugar, another option is treatment with glucagon. Glucagon is a hormone that has opposite actions to insulin. It causes blood sugar to rise, by stimulating the release of stored glucose and causing cells to synthesize glucose. Glucagon can be injected or given as a nasal spray.

Once your blood sugar has gotten back up into the normal range, the next step is to try to determine why it dropped, so you can prevent future episodes of hypoglycemia.

Prevention of hypoglycemia

To prevent hypoglycemia, it’s important to match your dose of insulin to your body’s need for blood sugar. For example, if you exercise or skip a meal, then you’ll need to reduce your dose of insulin to account for this. If you find that you’re experiencing frequent episodes of hypoglycemia, this could mean that your basal (background) insulin dose is too high, or that your dose of oral diabetes medications needs to be reduced.

The use of continuous glucose monitoring (CGM) can help to reduce the risk of hypoglycemia. By monitoring a person’s blood sugar continuously, hypoglycemia can be detected and treated quickly, and diabetes treatment can more easily be adjusted to help keep blood sugar in the normal range. Studies have shown that people with diabetes who use CGM have fewer episodes of hypoglycemia than those who monitor their blood sugar by fingerstick.

For those who use insulin to manage their diabetes, an insulin pump may also help to reduce the risk of hypoglycemia. This method of giving insulin allows for more precise doses, and allows the dose of insulin to be adjusted frequently in order to reduce the risk of hypoglycemia. Some insulin pumps can integrate with a continuous glucose monitor, allowing the pump to continually adjust the dose of insulin based on blood sugar levels. This reduces the risk of getting too much insulin and developing hypoglycemia.

Nocturnal hypoglycemia (hypo at night)

Nocturnal hypoglycemia, or episodes of low blood sugar at night, are relatively common. Research has found that over half of all episodes of severe hypoglycemia occur at night. However, many people with diabetes may not even be aware of these episodes. Some signs that you might be experiencing nocturnal hypoglycemia include:

• Having a headache when you wake up

• Intense nightmares

• Disturbed sleep

• Heavy sweating during sleep (so that you wake up to damp bedsheets)

If you use a continuous glucose monitor, this allows you to check in the morning to see what your blood sugar levels were like overnight. If you’re experiencing any of the possible symptoms of nocturnal hypoglycemia, then it’s a good idea to look at what your blood sugar levels were like during the night.

There are a few different reasons why people may experience hypo at night. A basal (background) insulin level that’s too high can lead to hypoglycemia at night. Adjusting your basal insulin dose can help to keep your blood sugar from dipping too low while you sleep. 

Changes to your routine may also lead to experiencing hypoglycemia during the night. If you exercise more intensely than usual, particularly in the evening, then you may also find yourself experiencing nocturnal hypoglycemia, because exercise increases the body’s insulin sensitivity. Skipping an evening meal or snack that you usually eat can also cause hypoglycemia to occur at night. Drinking alcohol in the evening is another potential cause of this issue.

Hypoglycemia in the morning

Many people may not realize that they have experienced hypoglycemia overnight. However, when they check their blood sugar in the morning, then they may find that they’re experiencing hypoglycemia. If you’re experiencing hypoglycemia in the morning, this very often means that you experienced hypoglycemia during the night. You may also notice some of the symptoms listed above, which indicate nocturnal hypoglycemia.

If you’re experiencing low blood sugar in the morning, then your basal insulin dose may need to be adjusted. It’s also important to pay attention to your dietary and exercise routines, and to adjust your insulin dose when you deviate from your routine.

Frequent or persistent hypoglycemia

People who experience frequent episodes of hypoglycemia may start to experience a phenomenon called hypoglycemia unawareness. This means that the body no longer reacts as strongly to low blood sugar, and so it’s difficult for the person to tell that their blood sugar has dropped until it’s at a very low level. 

Using a continuous glucose monitor can be very helpful in this situation, because it allows you to detect and treat hypoglycemia before it becomes severe. The more often you experience hypoglycemia, the less your body will show signs of it when it happens. With a CGM, you’ll be able to see that your blood sugar is starting to drop, and take actions to correct it early.

If you use insulin to help control your diabetes, and you’re experiencing frequent episodes of hypoglycemia, then your basal insulin dose may be too high. An insulin pump makes it easier to adjust your insulin dose to keep your blood sugar in the normal range. If you’re taking any other medications for diabetes, the doses of these medications may also need to be adjusted to prevent hypoglycemia.

Improving blood sugar control in diabetes

For people who have diabetes, it’s important to try to achieve the best possible blood sugar control. When a person’s blood sugar is frequently too high, this can cause damage throughout the body, eventually leading to problems like blindness and kidney failure. However, when blood sugar drops too low, it can affect brain and heart function.

Diabetes is best managed with a combination of medical therapy, nutrition, and exercise. To successfully manage your blood sugar and maximise your health, you’ll need the advice of an expert diabetes doctor. It can also be helpful to have a team of other experts, such as a dietitian and a health coach, to support you in managing your diabetes and protecting your long-term health.

If you’re looking for a team-based approach to diabetes management in Singapore, we invite you to check out NOVI Magnum, our comprehensive program for people with diabetes.