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Hypoglycemic unawareness emergency care

Hypoglycemic unawareness emergency care

Devore, M. LS: Writing—review Hypoglyceemic editing. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm. Hypoglycemic unawareness emergency care

Hypoglycemic unawareness emergency care -

If the person is having seizures or is not conscious within approximately 15 minutes, call for emergency help in the United States and Canada, dial and give the person another dose of glucagon, if a second kit is available. FOLLOW-UP CARE. After your blood glucose level normalizes and your symptoms are gone, you can usually resume your normal activities.

If you required glucagon, you should call your health care provider right away. They can help you to determine how and why you developed severely low blood glucose and can suggest adjustments to prevent future reactions.

In the first 48 to 72 hours after a low blood glucose episode, you may have difficulty recognizing the symptoms of low blood glucose.

In addition, your body's ability to counteract low blood glucose levels is decreased. Check your blood glucose level before you eat, exercise, or drive to avoid another low blood glucose episode. WHEN TO SEEK HELP. A family member or friend should take you to the hospital or call for emergency assistance immediately if you:.

Once in a hospital or ambulance, you will be given treatment intravenously by IV to raise your blood glucose level immediately. If you require emergency care, you may be observed in the emergency department for a few hours before being released.

In this situation, you will need someone else to drive you home. Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website www. Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below. Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Type 1 diabetes The Basics Patient education: Low blood sugar in people with diabetes The Basics Patient education: Diabetes and diet The Basics Patient education: Should I switch to an insulin pump?

The Basics. Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Type 1 diabetes: Insulin treatment Beyond the Basics Patient education: Type 1 diabetes: Overview Beyond the Basics Patient education: Exercise and medical care for people with type 2 diabetes Beyond the Basics Patient education: Type 2 diabetes: Overview Beyond the Basics Patient education: Type 2 diabetes: Treatment Beyond the Basics Patient education: Preventing complications from diabetes Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings.

These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Hypoglycemia in adults without diabetes mellitus: Determining the etiology Diagnostic dilemmas in hypoglycemia: Illustrative cases Factitious hypoglycemia Management of blood glucose in adults with type 1 diabetes mellitus Insulin therapy in type 2 diabetes mellitus Insulin-induced hypoglycemia test protocol Insulinoma Hypoglycemia in adults with diabetes mellitus Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, causes, and diagnosis Physiologic response to hypoglycemia in healthy individuals and patients with diabetes mellitus Evaluation of postprandial symptoms of hypoglycemia in adults without diabetes.

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View Topic. Font Size Small Normal Large. Patient education: Hypoglycemia low blood glucose in people with diabetes Beyond the Basics.

Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. Author: Kasia J Lipska, MD, MHS Section Editor: David M Nathan, MD Deputy Editor: Katya Rubinow, MD Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan This topic last updated: Aug 23, FOLLOW-UP CARE After your blood glucose level normalizes and your symptoms are gone, you can usually resume your normal activities. The Basics Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

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Chapter Headings Introduction Definition and Frequency of Hypoglycemia Severe Hypoglycemia and Hypoglycemia Unawareness Complications of Severe Hypoglycemia Treatment of Hypoglycemia Other Relevant Guidelines Author Disclosures. Key Messages It is important to prevent, recognize and treat hypoglycemic episodes secondary to the use of insulin or insulin secretagogues.

It is safer and more effective to prevent hypoglycemia than to treat it after it occurs, so people with diabetes who are at high risk for hypoglycemia should be identified and counselled about ways to prevent low blood glucose. It is important to counsel individuals who are at risk of hypoglycemia and their support persons about the recognition and treatment of hypoglycemia.

The goals of treatment for hypoglycemia are to detect and treat a low blood glucose level promptly by using an intervention that provides the fastest rise in blood glucose to a safe level, to eliminate the risk of injury and to relieve symptoms quickly.

Once the hypoglycemia has been reversed, the person should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia.

It is important to avoid overtreatment of hypoglycemia, since this can result in rebound hyperglycemia and weight gain. Key Messages for People with Diabetes Know the signs and symptoms of a low blood glucose level. Some of the more common symptoms of low blood glucose are trembling, sweating, anxiety, confusion, difficulty concentrating or nausea.

Not all symptoms will be present and some individuals may have other or no symptoms. Wear diabetes identification e. a MedicAlert® bracelet Talk with your diabetes health-care team about prevention and emergency treatment of a severe low blood glucose associated with confusion, loss of consciousness or seizure.

Introduction Drug-induced hypoglycemia is a major obstacle for individuals trying to achieve glycemic targets. Complications of Severe Hypoglycemia Short-term risks of hypoglycemia include the dangerous situations that can arise while an individual is hypoglycemic, whether at home or at work e.

Treatment of Hypoglycemia The goals of treatment for hypoglycemia are to detect and treat a low BG level promptly by using an intervention that provides the fastest rise in BG to a safe level, to eliminate the risk of injury and to relieve symptoms quickly.

Recommendations All people with diabetes currently using or starting therapy with insulin or insulin secretagogues and their support persons should be counselled about the risk, prevention, recognition and treatment of hypoglycemia. Risk factors for severe hypoglycemia should be identified and addressed [Grade D, Consensus].

The DHC team should review the person with diabetes' experience with hypoglycemia at each visit, including an estimate of cause, frequency, symptoms, recognition, severity and treatment, as well as the risk of driving with hypoglycemia [Grade D, Consensus].

In people with diabetes at increased risk of hypoglycemia, the following strategies may be used to reduce the risk of hypoglycemia: Avoidance of pharmacotherapies associated with increased risk of recurrent or severe hypoglycemia see Glycemic Management in Adults with Type 1 Diabetes, p.

S88, for further discussion of drug-induced hypoglycemia [Grade D, Consensus] A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control [Grade B, Level 2 83 ] Increased frequency of SMBG, including periodic assessment during sleeping hours [Grade D, Consensus] Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4 37,38 ] A psycho-behavioural intervention program blood glucose awareness training [Grade C, Level 3 40 ] Structured diabetes education and frequent follow up [Grade C, Level 3 42 for type 1 diabetes; Grade D, Consensus for type 2].

In people with diabetes with recurrent or severe hypoglycemia, or impaired awareness of hypoglycemia, the following strategies may be considered to reduce or eliminate the risk of severe hypoglycemia and to attempt to regain hypoglycemia awareness: Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4 37,38 ] CSII or CGM or sensor augmented pump with education and follow up for type 1 diabetes [Grade B, Level 2 42,44,46,47 ] Islet transplantation for type 1 diabetes [Grade C, Level 3 48 ] Pancreas transplantation for type 1 diabetes [Grade D, Level 4 50—53 ].

These are preferable to orange juice and glucose gels [Grade B, Level 2 73 ]. Note : This does not apply to children. See Type 1 Diabetes in Children and Adolescents, p.

S; and Type 2 Diabetes in Children and Adolescents, p. S, for treatment options in children. For people with diabetes at risk of severe hypoglycemia, support persons should be taught how to administer glucagon [Grade D, Consensus]. Abbreviations: A1C , glycated hemoglobin; BG, blood glucose; CVD , cardiovascular disease; CGM , continuous glucose monitoring; CSII , continuous subcutaneous insulin infusion; DHC , diabetes health-care team; SMBG , self-monitoring of blood glucose.

Other Relevant Guidelines Chpater 8. Targets for Glycemic Control Chapter 9. Monitoring Glycemic Control Chapter Glycemic Management in Adults With Type 1 Diabetes Chapter Pharmacologic Glycemic Management of Type 2 Diabetes in Adults Chapter Diabetes and Driving Chapter Type 1 Diabetes in Children and Adolescents Chapter Type 2 Diabetes in Children and Adolescents Chapter Diabetes and Pregnancy Chapter Diabetes in Older People.

Author Disclosures Dr. References Alvarez-Guisasola F, Yin DD, Nocea G, et al. Health Qual Life Outcomes ; Anderbro T, Amsberg S, Adamson U, et al. Fear of hypoglycaemia in adults with Type 1 diabetes. Diabet Med ;—8. Belendez M, Hernandez-Mijares A.

Beliefs about insulin as a predictor of fear of hypoglycaemia. Chronic Illn ;—6. Barnard K, Thomas S, Royle P, et al. Fear of hypoglycaemia in parents of young children with type 1 diabetes: A systematic review. BMC Pediatr ; Di Battista AM, Hart TA, Greco L, et al.

Type 1 diabetes among adolescents: Reduced diabetes self-care caused by social fear and fear of hypoglycemia. Diabetes Educ ;— Haugstvedt A,Wentzel-Larsen T, GraueM, et al. Fear of hypoglycaemia in mothers and fathers of children with type 1 diabetes is associated with poor glycaemic control and parental emotional distress: A population-based study.

Hepburn DA. Symptoms of hypoglycaemia. In: Frier BM, Fisher BM, eds. Hypoglycaemia and diabetes: clinical and physiological aspects. London: Edward Arnold, , pg. The Diabetes Control and Complications Trial Research Group. Adverse events and their association with treatment regimens in the diabetes control and complications trial.

Diabetes Care ;— Hypoglycemia in the diabetes control and complications trial. Diabetes ;— Mühlhauser I, Overmann H, Bender R, et al.

Risk factors of severe hypoglycaemia in adult patients with type I diabetes—a prospective population based study.

Diabetologia ;— The DCCT Research Group. Epidemiology of severe hypoglycemia in the diabetes control and complications trial. Am J Med ;—9. Davis EA, Keating B, Byrne GC, et al.

Hypoglycemia: Incidence and clinical predictors in a large population-based sample of children and adolescents with IDDM.

Diabetes Care ;—5. Egger M, Davey Smith G, Stettler C, et al. Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: A meta-analysis. Diabet Med ;— Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia.

Mokan M, Mitrakou A, Veneman T, et al. Hypoglycemia unawareness in IDDM. Meyer C, Grossmann R, Mitrakou A, et al. Effects of autonomic neuropathy on counterregulation and awareness of hypoglycemia in type 1 diabetic patients. Diabetes Care ;—6.

Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial.

J Pediatr ;— Miller ME, Bonds DE, Gerstein HC, et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: Post hoc epidemiological analysis of the ACCORD study.

BMJ ;b de Galan BE, Zoungas S, Chalmers J, et al. Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation ADVANCE trial.

Sarkar U, Karter AJ, Liu JY, et al. Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: The Diabetes Study of Northern California DISTANCE. J Gen Intern Med ;—8. Seligman HK, Davis TC, Schillinger D, et al.

Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. 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.

If you add in lows without symptoms and the ones that happen overnight, the number would likely be higher. Too much insulin is a definite cause of low blood glucose.

Insulin pumps may also reduce the risk for low blood glucose. Accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle instead of just under the skin , can cause low blood glucose. 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. 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. 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. 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 CGM 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.

If you think you have hypoglycemia unawareness, speak with your health care provider. 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.

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. 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 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.

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With prolonged fasting, the body can break down fat stores and use products of fat breakdown as an alternative fuel. If you have diabetes, you might not make insulin type 1 diabetes or you might be less responsive to it type 2 diabetes. As a result, glucose builds up in the bloodstream and can reach dangerously high levels.

To correct this problem, you might take insulin or other medications to lower blood sugar levels. But too much insulin or other diabetes medications may cause your blood sugar level to drop too much, causing hypoglycemia.

Hypoglycemia can also occur if you eat less than usual after taking your regular dose of diabetes medication, or if you exercise more than you typically do. Hypoglycemia usually occurs when you haven't eaten, but not always.

Sometimes hypoglycemia symptoms occur after certain meals, but exactly why this happens is uncertain. This type of hypoglycemia, called reactive hypoglycemia or postprandial hypoglycemia, can occur in people who have had surgeries that interfere with the usual function of the stomach.

The surgery most commonly associated with this is stomach bypass surgery, but it can also occur in people who have had other surgeries. Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness.

The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats palpitations. When this happens, the risk of severe, life-threatening hypoglycemia increases.

If you have diabetes, recurring episodes of hypoglycemia and hypoglycemia unawareness, your health care provider might modify your treatment, raise your blood sugar level goals and recommend blood glucose awareness training. A continuous glucose monitor CGM is an option for some people with hypoglycemia unawareness.

The device can alert you when your blood sugar is too low. If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening. Fear of hypoglycemia can cause you to take less insulin to ensure that your blood sugar level doesn't go too low.

This can lead to uncontrolled diabetes. Talk to your health care provider about your fear, and don't change your diabetes medication dose without discussing changes with your health care provider. A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin.

An insulin pump, attached to the pocket, is a device that's worn outside of the body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen.

Insulin pumps are programmed to deliver specific amounts of insulin automatically and when you eat. Follow the diabetes management plan you and your health care provider have developed. If you're taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your health care provider about how these changes might affect your diabetes management and your risk of low blood sugar.

Learn the signs and symptoms you experience with low blood sugar. This can help you identify and treat hypoglycemia before it gets too low. Frequently checking your blood sugar level lets you know when your blood sugar is getting low.

A continuous glucose monitor CGM is a good option for some people. A CGM has a tiny wire that's inserted under the skin that can send blood glucose readings to a receiver. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm.

Some insulin pumps are now integrated with CGMs and can shut off insulin delivery when blood sugar levels are dropping too quickly to help prevent hypoglycemia. Be sure to always have a fast-acting carbohydrate with you, such as juice, hard candy or glucose tablets so that you can treat a falling blood sugar level before it dips dangerously low.

For recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent blood sugar levels from getting too low.

However, this approach isn't advised as a long-term strategy. Work with your health care provider to identify and treat the cause of hypoglycemia. Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. This content does not have an English version. This content does not have an Arabic version. Overview Hypoglycemia is a condition in which your blood sugar glucose level is lower than the standard range.

Request an appointment. Thank you for subscribing! Sorry something went wrong with your subscription Please, try again in a couple of minutes Retry. Continuous glucose monitor and insulin pump Enlarge image Close. Continuous glucose monitor and insulin pump A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin.

By Mayo Clinic Staff. Show references AskMayoExpert. Unexplained hypoglycemia in a nondiabetic patient. Mayo Clinic; American Diabetes Association. Standards of medical care in diabetes — Diabetes Care.

Accessed Nov. Hypoglycemia low blood sugar. Low blood glucose hypoglycemia. National Institute of Diabetes and Digestive and Kidney Diseases. Cryer PE. Hypoglycemia in adults with diabetes mellitus. Vella A. Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes.

Merck Manual Professional Version. What is diabetes? Centers for Disease Control and Prevention. Kittah NE, et al. Management of endocrine disease: Pathogenesis and management of hypoglycemia.

: Hypoglycemic unawareness emergency care

Hypoglycemia

As discussed earlier, hypoglycemia encountered in the hospital is often iatrogenic, with a large number of cases related to drug therapy. It is important to assess the BG level of any patient with hypoglycemic signs and symptoms.

However, unavailability of testing equipment should not delay treatment if hypoglycemia is suspected. In the conscious patient, the most practical treatment is the oral administration of a rapid-acting carbohydrate TABLE 4.

If needed, additional g doses of carbohydrate may be administered to resolve symptoms and increase blood sugar above an established threshold e.

Hypoglycemic type 2 diabetes patients taking alpha-glucosidase inhibitors who are treated with oral carbohydrates must receive monosaccharides e. Glucagon, a counterregulatory pancreatic hormone, causes the breakdown and release of glycogen from the liver to increase BG concentrations.

A glucagon kit for emergency treatment of hypoglycemia is recommended for any patient with a history of severe hypoglycemia or who is at risk for it. The kit is particularly useful for patients in the community or in long-term care facilities where IV administration of dextrose is not feasible.

Close contacts of the patient e. Other formulations of glucagon premixed injectable solutions and nasal sprays are being developed to improve ease of administration in the community setting.

Reversal of hypoglycemia relies on sufficient hepatic glycogen stores and other factors. Patients normally respond within 15 minutes; IV glucose must be administered as soon as possible to any patient failing to respond to glucagon.

IV dextrose is the best treatment for inpatients and for patients found by emergency medical services personnel. IV dextrose is available in different concentrations.

It is recommended to administer 10 to 25 g mL over 1 to 3 minutes. Rapid or excessive administration can induce hyperosmolar syndrome, and prolonged use especially when insulin levels are high can lead to hypokalemia. Patients who are given dextrose and sodium chloride solutions are at risk for hypokalemia, fluid overload, and edema.

Once recovered, regardless of the method used to increase serum glucose oral, IV, or liver glycogenolysis due to glucagon , the patient should continue to receive supplementation to prevent recurrence and reestablish glycogen stores as necessary.

If NPO, parenteral supplementation should continue to prevent hypoglycemia. If conscious and oral intake is possible, the patient should consume foods with longer-acting sources of energy complex carbohydrates, fats, proteins in order to prevent recurrence.

Pharmacists are well positioned to directly prevent, recognize, and treat hypoglycemia, and they can successfully develop institutional protocols and procedures and educate patients, caregivers, and other healthcare practitioners to achieve these goals.

Treatment of hypoglycemia depends on the severity and setting, and ranges from self-treatment with oral administration of 15 g of simple carbohydrates to outpatient use of glucagon kits and from oral intake to parenteral dextrose or glucagon administration at an institution.

Pharmacist involvement in the care of patients at risk for hypoglycemia and in education on prevention, recognition, and treatment of hypoglycemia for patients and their close family members and associates is critically important in helping reduce complications and improve outcomes.

Seaquist ER, Anderson J, Childs B, Cryer P, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society.

J Clin Endocrinol Metab. International Hypoglycaemia Study Group. Glucose concentrations of less than 3. Diabetes Care. Minimizing hypoglycemia in diabetes. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med.

American Diabetes Association. Introduction: Standards of Medical Care in Diabetes— Seaquist ER, Miller ME, Bonds DE, et al. The impact of frequent and unrecognized hypoglycemia on mortality in the ACCORD Study. Service FJ, Cryer PE, Vella A. Hypoglycemia in adults: clinical manifestations, definition, and causes.

Waltham, MA: UpToDate; Milligan PE, Bocox MC, Pratt E, et al. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

Am J Health Syst Pharm. Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management.

Endocr Pract. Hypoglycemia low blood glucose. Accessed September 12, Precose acarbose package insert. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc; March Glucagon: drug information.

Accessed June 19, GlucaGen glucagon package insert. Plainsboro, NJ: Novo Nordisk, Inc; July Diabetes Canada Clinical Practice Guidelines Expert Committee.

Severe symptoms of low blood sugar requiring immediate medical attention:. Despite all the safety planning, you still may get a low blood sugar when you are treated with insulin releasing pills sulfonylureas, meglitinides, or nateglinide or insulin.

So always wear your medical alert identification. And if you are taking insulin, have family members or friends trained to use a Glucagon Emergency kit. Sometimes people treated with insulin releasing pills or insulin lose the ability to detect a low blood sugar — a condition known as hypoglycemic unawareness.

Your brain has a trigger point that tells it when to release stress hormones from other organs in the body. When there are frequent low blood sugars, this set point gets reprogrammed to lower and lower blood sugar levels.

Because the symptoms of low blood sugar alert you to the problem, not having any symptoms requires that you be especially vigilant. Remember: Frequent monitoring is the only way to know if you are low and need to take corrective action. Keep in mind, too, that hypoglycemic unawareness is not a permanent condition.

For many people, symptoms of low blood sugar will return and act as your warning signal once you stop having chronic low blood sugars.

Taking control of your bloods sugars means knowing what to do and when. When you are experiencing mild hypoglycemic symptoms, the immediate treatment is:. If you have symptoms of a severe low blood sugar and your sense of confusion grows or you feel that you may pass out:. The glucagon injection should help your liver release sugar and thereby raise the blood sugar level.

Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about Diabetes Complications , take our self assessment quiz when you have completed this section.

Other causes of symptoms

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:. The only sure way to know whether you are experiencing low blood glucose is to check your blood glucose levels, if possible.

If you are experiencing symptoms and you are unable to check your blood glucose for any reason, treat the hypoglycemia. Epinephrine is what can cause the symptoms of hypoglycemia such as thumping heart, sweating, tingling, and anxiety. If the blood sugar glucose 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. The rule—have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes.

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 " Rule" can help you avoid this, preventing high blood glucose levels. 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.

Glucagon is used to treat someone with diabetes when their blood glucose is too low to treat using the rule. Glucagon is available by prescription and is either injected or administered or puffed into the nostril.

For those who are familiar with injectable glucagon, there are now two injectable glucagon products on the market—one that comes in a kit and one that is pre-mixed and ready to use. Speak with your doctor about whether you should buy a glucagon product, 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.

If you have needed glucagon, let your doctor know so you can discuss ways to prevent severe hypoglycemia in the future. If someone is unconscious and glucagon is not available or someone does not know how to use it, call immediately. 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.

If you add in lows without symptoms and the ones that happen overnight, the number would likely be higher. Too much insulin is a definite cause of low blood glucose. Insulin pumps may also reduce the risk for low blood glucose.

Accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle instead of just under the skin , can cause low blood glucose.

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. 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.

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. 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 CGM 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.

If you think you have hypoglycemia unawareness, speak with your health care provider. This helps your body re-learn how to react to low blood glucose levels.

Sometimes hypoglycemia symptoms occur after certain meals, but exactly why this happens is uncertain. This type of hypoglycemia, called reactive hypoglycemia or postprandial hypoglycemia, can occur in people who have had surgeries that interfere with the usual function of the stomach.

The surgery most commonly associated with this is stomach bypass surgery, but it can also occur in people who have had other surgeries. Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats palpitations.

When this happens, the risk of severe, life-threatening hypoglycemia increases. If you have diabetes, recurring episodes of hypoglycemia and hypoglycemia unawareness, your health care provider might modify your treatment, raise your blood sugar level goals and recommend blood glucose awareness training.

A continuous glucose monitor CGM is an option for some people with hypoglycemia unawareness. The device can alert you when your blood sugar is too low. If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening.

Fear of hypoglycemia can cause you to take less insulin to ensure that your blood sugar level doesn't go too low. This can lead to uncontrolled diabetes. Talk to your health care provider about your fear, and don't change your diabetes medication dose without discussing changes with your health care provider.

A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. An insulin pump, attached to the pocket, is a device that's worn outside of the body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen.

Insulin pumps are programmed to deliver specific amounts of insulin automatically and when you eat. Follow the diabetes management plan you and your health care provider have developed.

If you're taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your health care provider about how these changes might affect your diabetes management and your risk of low blood sugar. Learn the signs and symptoms you experience with low blood sugar.

This can help you identify and treat hypoglycemia before it gets too low. Frequently checking your blood sugar level lets you know when your blood sugar is getting low. A continuous glucose monitor CGM is a good option for some people.

A CGM has a tiny wire that's inserted under the skin that can send blood glucose readings to a receiver. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm. Some insulin pumps are now integrated with CGMs and can shut off insulin delivery when blood sugar levels are dropping too quickly to help prevent hypoglycemia.

Be sure to always have a fast-acting carbohydrate with you, such as juice, hard candy or glucose tablets so that you can treat a falling blood sugar level before it dips dangerously low. For recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent blood sugar levels from getting too low.

However, this approach isn't advised as a long-term strategy. Work with your health care provider to identify and treat the cause of hypoglycemia. Mayo Clinic does not endorse companies or products.

Advertising revenue supports our not-for-profit mission. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. This content does not have an English version. This content does not have an Arabic version.

Overview Hypoglycemia is a condition in which your blood sugar glucose level is lower than the standard range.

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Continuous glucose monitor and insulin pump A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. By Mayo Clinic Staff. Show references AskMayoExpert. Unexplained hypoglycemia in a nondiabetic patient.

Mayo Clinic; American Diabetes Association. Standards of medical care in diabetes — Diabetes Care. Accessed Nov. Hypoglycemia low blood sugar.

Low blood glucose hypoglycemia. National Institute of Diabetes and Digestive and Kidney Diseases. Cryer PE. Hypoglycemia in adults with diabetes mellitus. Vella A. Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes.

Merck Manual Professional Version. What is diabetes? Centers for Disease Control and Prevention. Kittah NE, et al. Management of endocrine disease: Pathogenesis and management of hypoglycemia. European Journal of Endocrinology. Vella A expert opinion. Mayo Clinic. Castro MR expert opinion.

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Hypoglycemia means low blood sugar. Symptoms include:

Glucose, the main energy source for your body, enters the cells with the help of insulin — a hormone produced by your pancreas. Insulin allows the glucose to enter the cells and provide the fuel your cells need. Extra glucose is stored in your liver and muscles in the form of glycogen.

When you haven't eaten for several hours and your blood sugar level drops, you will stop producing insulin. Another hormone from your pancreas called glucagon signals your liver to break down the stored glycogen and release glucose into your bloodstream.

This keeps your blood sugar within a standard range until you eat again. Your body also has the ability to make glucose. This process occurs mainly in your liver, but also in your kidneys. With prolonged fasting, the body can break down fat stores and use products of fat breakdown as an alternative fuel.

If you have diabetes, you might not make insulin type 1 diabetes or you might be less responsive to it type 2 diabetes. As a result, glucose builds up in the bloodstream and can reach dangerously high levels. To correct this problem, you might take insulin or other medications to lower blood sugar levels.

But too much insulin or other diabetes medications may cause your blood sugar level to drop too much, causing hypoglycemia. Hypoglycemia can also occur if you eat less than usual after taking your regular dose of diabetes medication, or if you exercise more than you typically do.

Hypoglycemia usually occurs when you haven't eaten, but not always. Sometimes hypoglycemia symptoms occur after certain meals, but exactly why this happens is uncertain. This type of hypoglycemia, called reactive hypoglycemia or postprandial hypoglycemia, can occur in people who have had surgeries that interfere with the usual function of the stomach.

The surgery most commonly associated with this is stomach bypass surgery, but it can also occur in people who have had other surgeries. Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats palpitations.

When this happens, the risk of severe, life-threatening hypoglycemia increases. If you have diabetes, recurring episodes of hypoglycemia and hypoglycemia unawareness, your health care provider might modify your treatment, raise your blood sugar level goals and recommend blood glucose awareness training.

A continuous glucose monitor CGM is an option for some people with hypoglycemia unawareness. The device can alert you when your blood sugar is too low. If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening.

Fear of hypoglycemia can cause you to take less insulin to ensure that your blood sugar level doesn't go too low. This can lead to uncontrolled diabetes. Talk to your health care provider about your fear, and don't change your diabetes medication dose without discussing changes with your health care provider.

A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. An insulin pump, attached to the pocket, is a device that's worn outside of the body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen.

Insulin pumps are programmed to deliver specific amounts of insulin automatically and when you eat. Follow the diabetes management plan you and your health care provider have developed. If you're taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your health care provider about how these changes might affect your diabetes management and your risk of low blood sugar.

Learn the signs and symptoms you experience with low blood sugar. This can help you identify and treat hypoglycemia before it gets too low. Frequently checking your blood sugar level lets you know when your blood sugar is getting low.

A continuous glucose monitor CGM is a good option for some people. A CGM has a tiny wire that's inserted under the skin that can send blood glucose readings to a receiver. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm.

Some insulin pumps are now integrated with CGMs and can shut off insulin delivery when blood sugar levels are dropping too quickly to help prevent hypoglycemia. Be sure to always have a fast-acting carbohydrate with you, such as juice, hard candy or glucose tablets so that you can treat a falling blood sugar level before it dips dangerously low.

For recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent blood sugar levels from getting too low.

However, this approach isn't advised as a long-term strategy. Work with your health care provider to identify and treat the cause of hypoglycemia. Mayo Clinic does not endorse companies or products. In people with diabetes at increased risk of hypoglycemia, the following strategies may be used to reduce the risk of hypoglycemia: Avoidance of pharmacotherapies associated with increased risk of recurrent or severe hypoglycemia see Glycemic Management in Adults with Type 1 Diabetes, p.

S88, for further discussion of drug-induced hypoglycemia [Grade D, Consensus] A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control [Grade B, Level 2 83 ] Increased frequency of SMBG, including periodic assessment during sleeping hours [Grade D, Consensus] Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4 37,38 ] A psycho-behavioural intervention program blood glucose awareness training [Grade C, Level 3 40 ] Structured diabetes education and frequent follow up [Grade C, Level 3 42 for type 1 diabetes; Grade D, Consensus for type 2].

In people with diabetes with recurrent or severe hypoglycemia, or impaired awareness of hypoglycemia, the following strategies may be considered to reduce or eliminate the risk of severe hypoglycemia and to attempt to regain hypoglycemia awareness: Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade D, Level 4 37,38 ] CSII or CGM or sensor augmented pump with education and follow up for type 1 diabetes [Grade B, Level 2 42,44,46,47 ] Islet transplantation for type 1 diabetes [Grade C, Level 3 48 ] Pancreas transplantation for type 1 diabetes [Grade D, Level 4 50—53 ].

These are preferable to orange juice and glucose gels [Grade B, Level 2 73 ]. Note : This does not apply to children. See Type 1 Diabetes in Children and Adolescents, p.

S; and Type 2 Diabetes in Children and Adolescents, p. S, for treatment options in children. For people with diabetes at risk of severe hypoglycemia, support persons should be taught how to administer glucagon [Grade D, Consensus].

Abbreviations: A1C , glycated hemoglobin; BG, blood glucose; CVD , cardiovascular disease; CGM , continuous glucose monitoring; CSII , continuous subcutaneous insulin infusion; DHC , diabetes health-care team; SMBG , self-monitoring of blood glucose. Other Relevant Guidelines Chpater 8.

Targets for Glycemic Control Chapter 9. Monitoring Glycemic Control Chapter Glycemic Management in Adults With Type 1 Diabetes Chapter Pharmacologic Glycemic Management of Type 2 Diabetes in Adults Chapter Diabetes and Driving Chapter Type 1 Diabetes in Children and Adolescents Chapter Type 2 Diabetes in Children and Adolescents Chapter Diabetes and Pregnancy Chapter Diabetes in Older People.

Author Disclosures Dr. References Alvarez-Guisasola F, Yin DD, Nocea G, et al. Health Qual Life Outcomes ; Anderbro T, Amsberg S, Adamson U, et al. Fear of hypoglycaemia in adults with Type 1 diabetes. Diabet Med ;—8.

Belendez M, Hernandez-Mijares A. Beliefs about insulin as a predictor of fear of hypoglycaemia. Chronic Illn ;—6. Barnard K, Thomas S, Royle P, et al. Fear of hypoglycaemia in parents of young children with type 1 diabetes: A systematic review.

BMC Pediatr ; Di Battista AM, Hart TA, Greco L, et al. Type 1 diabetes among adolescents: Reduced diabetes self-care caused by social fear and fear of hypoglycemia.

Diabetes Educ ;— Haugstvedt A,Wentzel-Larsen T, GraueM, et al. Fear of hypoglycaemia in mothers and fathers of children with type 1 diabetes is associated with poor glycaemic control and parental emotional distress: A population-based study.

Hepburn DA. Symptoms of hypoglycaemia. In: Frier BM, Fisher BM, eds. Hypoglycaemia and diabetes: clinical and physiological aspects. London: Edward Arnold, , pg.

The Diabetes Control and Complications Trial Research Group. Adverse events and their association with treatment regimens in the diabetes control and complications trial. Diabetes Care ;— Hypoglycemia in the diabetes control and complications trial. Diabetes ;— Mühlhauser I, Overmann H, Bender R, et al.

Risk factors of severe hypoglycaemia in adult patients with type I diabetes—a prospective population based study. Diabetologia ;— The DCCT Research Group. Epidemiology of severe hypoglycemia in the diabetes control and complications trial. Am J Med ;—9. Davis EA, Keating B, Byrne GC, et al.

Hypoglycemia: Incidence and clinical predictors in a large population-based sample of children and adolescents with IDDM. Diabetes Care ;—5. Egger M, Davey Smith G, Stettler C, et al. Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: A meta-analysis.

Diabet Med ;— Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia. Mokan M, Mitrakou A, Veneman T, et al.

Hypoglycemia unawareness in IDDM. Meyer C, Grossmann R, Mitrakou A, et al. Effects of autonomic neuropathy on counterregulation and awareness of hypoglycemia in type 1 diabetic patients. Diabetes Care ;—6. Diabetes Control and Complications Trial Research Group.

Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial.

J Pediatr ;— Miller ME, Bonds DE, Gerstein HC, et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: Post hoc epidemiological analysis of the ACCORD study.

BMJ ;b de Galan BE, Zoungas S, Chalmers J, et al. Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation ADVANCE trial.

Sarkar U, Karter AJ, Liu JY, et al. Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: The Diabetes Study of Northern California DISTANCE.

J Gen Intern Med ;—8. Seligman HK, Davis TC, Schillinger D, et al. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved ;— Davis TM, Brown SG, Jacobs IG, et al.

Determinants of severe hypoglycemia complicating type 2 diabetes: The Fremantle diabetes study. J Clin Endocrinol Metab ;—7. Schopman JE, Geddes J, Frier BM.

Prevalence of impaired awareness of hypoglycaemia and frequency of hypoglycaemia in insulin-treated type 2 diabetes. Diabetes Res Clin Pract ;—8. Cryer PE.

Banting lecture. Hypoglycemia: The limiting factor in the management of IDDM. Daneman D, Frank M, Perlman K, et al. Severe hypoglycemia in children with insulin-dependent diabetes mellitus: Frequency and predisposing factors.

J Pediatr ;—5. Berlin I, Sachon CI, Grimaldi A. Identification of factors associated with impaired hypoglycaemia awareness in patients with type 1 and type 2 diabetes mellitus. Diabetes Metab ;— Schultes B, Jauch-Chara K, Gais S, et al.

Defective awakening response to nocturnal hypoglycemia in patients with type 1 diabetes mellitus. PLoS Med ;4:e Porter PA, Byrne G, Stick S, et al.

Nocturnal hypoglycaemia and sleep disturbances in young teenagers with insulin dependent diabetes mellitus. Arch Dis Child ;—3. Gale EA, Tattersall RB. Unrecognised nocturnal hypoglycaemia in insulintreated diabetics.

Lancet ;— Beregszàszi M, Tubiana-Rufi N, Benali K, et al. Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus: Prevalence and risk factors.

Vervoort G, Goldschmidt HM, van Doorn LG. Diabet Med ;—9. Ovalle F, Fanelli CG, Paramore DS, et al. With the goal of augmenting the response to hypoglycemia, pharmacological interventions have targeted sites of action that are responsible for blood glucose sensing.

When blood glucose falls, neurons in the brain Thorens, and the periphery Fournel et al. One peripheral glucose sensor that responds to hypoglycemia lies within the portal-mesenteric vein PMV Matveyenko et al.

Recent studies suggest that PMV glucose sensing may be mediated via sodium-dependent glucose transporter 3 SGLT3 receptors. Following antecedent hypoglycemia, miglitol Glyset © , Pfizer, New York, NY, United States a SGLT3 agonist, was shown to restore the counterregulatory response to hypoglycemia in rats Jokiaho et al.

The predominant glucose-sensing apparatus lies within the brain. Early studies identified the ventromedial hypothalamus VMH as a key glucose-sensing region Borg et al.

In terms of testing responses to drug therapy, one study examined the effects of systemic and central VMH administration of a beta 2-adrenergic receptor agonist, formoterol, on the counterregulatory responses following hypoglycemia Szepietowska et al.

Systemic administration improved the glucose infusion rate and hepatic glucose production response to hypoglycemia; however, counterregulatory hormones did not change with formoterol administration Szepietowska et al.

While formoterol and miglitol improved counterregulation and hepatic glucose production of HAAF, awareness was not assessed in those studies and the effects of those drugs on IAH remain unknown.

In rodent models of HAAF, recurrent hypoglycemia consistently blunts the sympathoadrenal response noted by a blunted plasma catecholamine response Powell et al. Unfortunately, the ability to determine hypoglycemia unawareness induced by recurrent hypoglycemia has been understandably more difficult to quantify in animal models Sankar et al.

Of note, Farhat et al. As model of IAH, recurrent antecedent treatment with 2-deoxyglucose 2DG blunted the food intake response to insulin-induced hypoglycemia; yet rodents treated with carvedilol did not develop IAH i.

Another area of the brain that has been implicated in glucose sensing is the perifornical hypothalamus PFH. Researchers focused on the orexin-glucose-inhibited neurons in the PFH responsible for arousal as a target for IAH and explored treatment with the anti-narcolepsy drug, modafinil Teva Pharmaceutical Industries Ltd.

Mice underwent a conditioned place preference test surrogate test for IAH prior to recurrent hypoglycemia and treatment. Compared to saline-treated mice, modafinil-treated mice adjusted their preference for the food-associated chamber after insulin-induced hypoglycemia.

Additionally, researchers showed that modafinil restored glucose sensing by the orexin-glucose-inhibited neurons in the PFH Patel et al. Modafinil is a dopamine reuptake inhibitor thus, it appears that dopamine signaling is potentially involved in the development of IAH.

Consistent with this notion, metoclopramide Teva Pharmaceutical Industries Ltd. Based on these preclinical results, the potential of this drug to restore awareness of hypoglycemia in subjects with T1D and IAH has advanced to a Phase 2 clinical trial NCT Translation of these pre-clinical results to clinical trials remains an important step to validate potential drug therapies for the treatment of IAH.

Drugs that work within the adrenergic system seem like an obvious target that might improve both the counterregulatory response and awareness of hypoglycemia Cooperberg et al.

Consistent with preclinical studies Li et al. Thus, some degree of adrenergic blockage within the CNS may serve to improve hypoglycemia awareness and hypoglycemic counterregulation, at least based on preclinical studies Farhat et al.

Another, similar pharmacological approach to treating IAH is targeting adenosine receptors to increase alertness and enhanced secretion of the counterregulatory hormones De Galan et al.

One study used theophylline, an adenosine-receptor antagonist, to determine its effects on IAH de Galan et al. In response to hypoglycemia, subjects with diabetes and IAH treated with theophylline demonstrated an improved counterregulatory hormone response but theophylline did not improve hypoglycemia symptom scores de Galan et al.

However, another methylxanthine, caffeine, was shown to stimulate more symptomatic hypoglycemic episodes i. The glucagon-like peptide-1 receptor agonist, exenatide, was used in a crossover trial in subjects with T1D and IAH van Meijel et al.

Subjects treated with exenatide for 4-week had no differences in frequency or time spent in hypoglycemia compared to the placebo group. Exenatide-treated subjects had similar symptom scores and counterregulatory hormone responses to that of the placebo group van Meijel et al.

A sodium-glucose cotransporter-2 inhibitor, dapagliflozin, has shown effectiveness van Meijel et al. Dapagliflozin treatment did not improve awareness of hypoglycemia, however, it did reduce the glucose infusion rates during the clamp indicating an improvement in glucoregulatory response to hypoglycemia van Meijel et al.

Using the same drug, another study assessed glucagon response in T1D subjects; however, subjects were on the lower end of the Clarke score median 3, range 1—5 , suggesting that awareness might have been present in some subjects.

Similar to previous results, dapagliflozin treatment did not improve counterregulatory hormone responses, symptom scores, or recovery from hypoglycemia Boeder et al. Treatment with the CNS stimulant, modafinil, resulted in improved autonomic symptom scores, higher heart rates, higher glucagon concentrations during hypoglycemia, and improved scores on cognitive tests; however, the epinephrine response was not altered Klement et al.

Since modafinil was administered in non-diabetic subjects, IAH was not present Klement et al. Conversely, another study also conducted in healthy subjects showed improvements in the norepinephrine response, but no other improvements in hormonal responses epinephrine, growth hormone, and cortisol or symptom scores during a hypoglycemic clamp Smith et al.

Both of these studies attribute the positive improvements seen in healthy subjects to γ-aminobutyric acid GABA signaling.

Modulating GABA signaling as a means to restore counterregulation and hypoglycemia awareness is supported by pre-clinical models Chan et al. Clinically, antecedent GABA-A activation with the benzodiazepine, alprazolam, has been shown to blunt the neuroendocrine and autonomic nervous system responses to subsequent hypoglycemia in healthy humans Hedrington et al.

Consistent with these findings, antagonism of GABA with dehydroepiandrosterone DHEA can prevent the development of HAAF under experimental conditions in healthy humans Mikeladze et al.

Thus, with successful proof of concept studies in healthy humans, more recent studies in people with long-standing diabetes have shown that GABA administration significantly augmented the hormonal counterregulatory response to hypoglycemia Espes et al.

Pre-treatment with opioid receptor agonists can impair the counterregulatory response to hypoglycemia Carey et al. Conversely, pre-treatment with the opioid receptor antagonist naltrexone can prevent the development of an impaired counterregulatory response to hypoglycemia Leu et al.

Based on animal studies that indicate a possible role for selective serotonin reuptake inhibitors SSRIs to augment the counterregulatory response to glucoprivation Baudrie and Chaouloff, , clinical studies have demonstrated that 6-week treatment with SSRIs augmented counterregulatory, but not symptom responses, to hypoglycemia in nondiabetic people Briscoe et al.

It remains to be determined if these beneficial effects of SSRIs are mediated by the inhibition of neuronal serotonin uptake or via inhibition of norepinephrine transport in the CNS Chaouloff et al. It also remains to be determined why hypoglycemia awareness was not improved with SSRI therapy.

IAH continues to be a complication in people with both T1D and T2D who seek optimal glycemic control with insulin therapy. Providers who care for patients with diabetes should inquire about hypoglycemia and IAH with a view towards considering treatment options.

This review shows that there are several advances in technology and educational approaches that can improve hypoglycemia awareness. With regards to pharmacological treatments, basic science research in animal models is continuing to elucidate the mechanism s responsible and these novel treatments for IAH are being advanced into clinical trials.

Future studies should focus on these possible mechanisms to develop more targeted therapies for patients who suffer from IAH. EM: Writing—original draft. MD: Writing—original draft.

YL: Writing—review and editing. MM: Writing—review and editing. MW: Writing—review and editing. CM: Writing—review and editing. AW: Writing—review and editing. AM: Writing—review and editing. ZB: Writing—review and editing.

BP: Writing—review and editing. LS: Writing—review and editing. AI: Writing—review and editing. SF: Writing—original draft. NIH support DK, DK to SF, DK to YL, TL1TR to MD, as well as support from the University of Kentucky Barnstable Brown Diabetes Center and the Diabetes and Obesity Research Priority Area.

The authors would like to thank and acknowledge NIH support DK, DK to SF, DK to YL, TL1TR to MD, as well as support from the University of Kentucky Barnstable Brown Diabetes Center and the Diabetes and Obesity Research Priority Area. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Adachi, A. Convergence of hepatoportal glucose-sensitive afferent signals to glucose-sensitive units within the nucleus of the solitary tract.

PubMed Abstract CrossRef Full Text Google Scholar. Advani, A. Positioning time in range in diabetes management. Diabetologia 63 2 , — Aggarwal, S. Augmenting engraftment of beta cell replacement therapies for T1DM.

CrossRef Full Text Google Scholar. Agiostratidou, G. Standardizing clinically meaningful outcome measures beyond HbA1c for type 1 diabetes: a consensus report of the American association of clinical endocrinologists, the American association of diabetes educators, the American diabetes association, the endocrine society, JDRF international, the leona M.

And harry B. Helmsley charitable trust, the pediatric endocrine society, and the T1D exchange. Diabetes care 40 12 , — Akturk, S. Technological advances shaping diabetes care. Alcantara-Aragon, V.

Improving patient self care using diabetes technologies. Ali, N. Fall in prevalence of impaired awareness of hypoglycaemia in individuals with type 1 diabetes. Alkhatatbeh, M. Impaired awareness of hypoglycemia in children and adolescents with type 1 diabetes mellitus in north of Jordan.

BMC Endocr. Amiel, S. Impaired awareness of hypoglycaemia. Diabetes 22 1 , S26—S A parallel randomised controlled trial of the Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised self-care HARPdoc.

Ang, L. New insights into the currently available questionnaire for assessing impaired awareness of hypoglycaemia IAH among insulin-treated type 2 diabetes- A key risk factor for hypoglycaemia.

Diabetes Epidemiol. Bahrami, J. Impaired awareness of hypoglycaemia in women with type 1 diabetes in pregnancy: hypoglycaemia fear, glycaemic and pregnancy outcomes. Banarer, S. Sleep-related hypoglycemia-associated autonomic failure in type 1 diabetes: reduced awakening from sleep during hypoglycemia.

Diabetes 52 5 , — Barnard, K. Impact of chronic sleep disturbance for people living with T1 diabetes. Diabetes Sci.

Battelino, T. Continuous glucose monitoring—derived data report—simply a better management tool. Diabetes Care 43 10 , — Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care 42 8 , — Baudrie, V. Beall, C.

The physiology and pathophysiology of the neural control of the counterregulatory response. Bellary, H. Clinical evaluation of a novel test strip technology for blood glucose monitoring: accuracy at hypoglycaemic glucose levels.

Diabetes Res. Bergenstal, R. Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes. Jama 13 , — Boeder, S. SGLT2 inhibition increases fasting glucagon but does not restore the counterregulatory hormone response to hypoglycemia in participants with type 1 diabetes.

Diabetes 71 3 , — Borg, M. Local ventromedial hypothalamus glucose perfusion blocks counterregulation during systemic hypoglycemia in awake rats.

Bosi, E. Efficacy and safety of suspend-before-low insulin pump technology in hypoglycaemia-prone adults with type 1 diabetes SMILE : an open-label randomised controlled trial.

Lancet Diabetes and Endocrinol. Briscoe, V. Effects of the selective serotonin reuptake inhibitor fluoxetine on counterregulatory responses to hypoglycemia in individuals with type 1 diabetes.

Diabetes 57 12 , — Effects of a selective serotonin reuptake inhibitor, fluoxetine, on counterregulatory responses to hypoglycemia in healthy individuals. Diabetes 57 9 , — Burckhardt, M.

Impact of hybrid closed loop therapy on hypoglycemia awareness in individuals with type 1 diabetes and impaired hypoglycemia awareness. Diabetes Technol. Carey, M. Opioid receptor activation impairs hypoglycemic counterregulation in humans. Diabetes 66 11 , — Cengiz, E.

Severe hypoglycemia and diabetic ketoacidosis among youth with type 1 diabetes in the T1D Exchange clinic registry. diabetes 14 6 , — Chan, O. Increased GABAergic tone in the ventromedial hypothalamus contributes to suppression of counterregulatory responses after antecedent hypoglycemia.

Diabetes 57 5 , — Influence of VMH fuel sensing on hypoglycemic responses. Trends Endocrinol. metabolism TEM 24 12 , — Chaouloff, F.

Influence of 5-HT1 and 5-HT2 receptor antagonists on insulin-induced adrenomedullary catecholamine release. Neuroendocrinology 54 6 , — Chittineni, C.

Incidence and causes of iatrogenic hypoglycemia in the emergency department. West J. Choudhary, P. Real-time continuous glucose monitoring significantly reduces severe hypoglycemia in hypoglycemia-unaware patients with type 1 diabetes.

Diabetes Care 36 12 , — Clarke, J. A history of blood glucose meters and their role in self-monitoring of diabetes mellitus.

Clarke, W. Reduced awareness of hypoglycemia in adults with IDDM. A prospective study of hypoglycemic frequency and associated symptoms. Diabetes Care 18 4 , — Cobry, E. Friend or foe: a narrative review of the impact of diabetes technology on sleep.

diabetes Rep. Cook, A. Cognitions associated with hypoglycemia awareness status and severe hypoglycemia experience in adults with type 1 diabetes. Diabetes Care 42 10 , — Cooperberg, B. Terbutaline and the prevention of nocturnal hypoglycemia in type 1 diabetes.

Diabetes Care 31 12 , — Cox, D. A multicenter evaluation of blood glucose awareness training-II. Blood glucose awareness training BGAT-2 - long-term benefits. Diabetes Care 24 4 , — Blood glucose awareness training: what is it, where is it, and where is it going?

Diabetes Spectr. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care 10 5 , — Hypoglycemia anticipation, awareness and treatment training HAATT reduces occurrence of severe hypoglycemia among adults with type 1 diabetes mellitus.

Cranston, I. Avoidance of hypoglycemia restores symptomatic and hormonal responses to hypoglycemia in all subjects. Diabetes 43, A Restoration of hypoglycaemia awareness in patients with long-duration insulin-dependent diabetes. Lancet , — Cryer, P.

Glycemic goals in diabetes: trade-off between glycemic control and iatrogenic hypoglycemia. Diabetes 63 7 , — Hypoglycemia begets hypoglycemia in IDDM. Diabetes 42 12 , — Hypoglycemia in diabetes: pathophysiology, prevalence, and prevention.

United States: American Diabetes Association. Google Scholar. Mechanisms of hypoglycemia-associated autonomic failure in diabetes.

Dagogo-Jack, S. Reversal of hypoglycemia unawareness, but not defective glucose counterregulation, in IDDM. Diabetes 43 12 , — Davis, H.

Feingold, B. Anawalt, M. Blackman, A. Boyce, G. Chrousos, and E. Corpas Editors South Dartmouth MA : MDText, Inc. De Galan, B. Pathophysiology and management of recurrent hypoglycaemia and hypoglycaemia unawareness in diabetes.

PubMed Abstract Google Scholar. de Galan, B. Theophylline improves hypoglycemia unawareness in type 1 diabetes. Diabetes 51, — de Zoysa, N. A psychoeducational program to restore hypoglycemia awareness: the DAFNE-HART pilot study. Diabetes Care 37 3 , — Deary, I.

Severe hypoglycemia and intelligence in adult patients with insulin-treated diabetes. Diabetes 42 2 , — Deininger, E. Losartan attenuates symptomatic and hormonal responses to hypoglycemia in humans. DeSalvo, D. Patient demographics and clinical outcomes among type 1 diabetes patients using continuous glucose monitors: data from T1D Exchange real-world observational study.

diabetes Sci. Devore, M. Diabetes 71 1. Diabetes, C. Diabetes Care 39 5 , — Dovc, K. Continuous and intermittent glucose monitoring in Ebekozien, O. The promise of diabetes technologies. Espes, D.

GABA induces a hormonal counter-regulatory response in subjects with long-standing type 1 diabetes. BMJ Open Diabetes Res. Care 9 1 , e Fanelli, C.

ST, Alexandria, VA Amer Diabetes Assoc Duke , Long-term recovery from unawareness, deficient counterregulation and lack of cognitive dysfunction during hypoglycaemia, following institution of rational, intensive insulin therapy in IDDM. Diabetologia 37 12 , — Farhat, R. Carvedilol prevents impairment of the counterregulatory response in recurrently hypoglycaemic diabetic rats.

Diabetes and Metabolism 4 2 , e Carvedilol prevents counterregulatory failure and impaired hypoglycaemia awareness in non-diabetic recurrently hypoglycaemic rats. Diabetologia 62 4 , — Farrell, C. Clinical approaches to treat impaired awareness of hypoglycaemia.

Unawarebess is a Hypoglycemic unawareness emergency care in which your Insulin and hypoglycemia management sugar glucose level is lower than the standard range. BMR and weight maintenance is your body's main cwre source. Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don't have diabetes. Hypoglycemia needs immediate treatment. But your numbers might be different. Ask your health care provider.

Author: Sasar

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