Self-care for Diabetes: Low/High blood sugar

A proactive attitude towards your diabetes treatment is crucial in preventing complications. Diabetics can't just delegate their care to their health care provider.

1. Low blood sugar - self-care

Low blood sugar is a condition that occurs when your blood sugar (glucose) is lower than normal. Low blood sugar may occur in people with diabetes who are taking insulin or certain other medicines to control their diabetes. Low blood sugar can cause dangerous symptoms. Learn how to recognize the symptoms of low blood sugar and how to prevent them.

What is Low Blood Sugar?

Low blood sugar is called hypoglycemia. A blood sugar level below 70 mg/dL (3.9 mmol/L) is low and can harm you. A blood sugar level below 54 mg/dL (3.0 mmol/L) is a cause for immediate action.

You are at risk for low blood sugar if you have diabetes and are taking any of the following diabetes medicines:

• Insulin
• Glyburide (Micronase), glipizide (Glucotrol), glimepiride (Amaryl), repaglinide (Prandin), or nateglinide (Starlix)
• Chlorpropamide (Diabinese), tolazamide (Tolinase), acetohexamide (Dymelor), or tolbutamide (Orinase)

You are also at increased risk of having low blood sugar if you have had previous low blood sugar levels.

Recognizing Low Blood Sugar

Know how to tell when your blood sugar is getting low. Symptoms include:

• Weakness or feeling tired
• Shaking
• Sweating
• Headache
• Hunger
• Feeling uneasy, nervous, or anxious
• Feeling cranky
• Trouble thinking clearly
• Double or blurry vision
• Fast or pounding heartbeat

Sometimes your blood sugar may be too low even if you do not have symptoms. If it gets too low, you may:

• Faint
• Have a seizure
• Go into a coma

Some people who have had diabetes for a long time stop being able to sense low blood sugar. This is called hypoglycemic unawareness. Ask your health care provider if wearing a continuous glucose monitor and sensor can help you detect when your blood sugar is getting too low in order to help prevent symptoms.

Check Your Blood Sugar Often

Talk with your provider about when you should check your blood sugar every day. People who have low blood sugar need to check their blood sugar more often.

The most common causes of low blood sugar are:

• Taking your insulin or diabetes medicine at the wrong time
• Taking too much insulin or diabetes medicine
• Not eating enough during meals or snacks after you have taken insulin or diabetes medicine
• Skipping meals
• Waiting too long after taking your medicine to eat your meals
• Exercising a lot or at a time that is unusual for you
• Not checking your blood sugar or not adjusting your insulin dose before exercising
• Drinking alcohol

Preventing Low Blood Sugar

Preventing low blood sugar is better than having to treat it. Always have a source of fast-acting sugar with you.

• When you exercise, check your blood sugar levels. Make sure you have snacks with you.
• Talk to your provider about reducing insulin doses on days that you exercise.
• Ask your provider if you need a bedtime snack to prevent low blood sugar overnight. Protein snacks may be best.

DO NOT drink alcohol without eating food. Women should limit alcohol to 1 drink a day and men should limit alcohol to 2 drinks a day. Family and friends should know how to help. They should know:

• The symptoms of low blood sugar and how to tell if you have them.
• How much and what kind of food they should give you.
• When to call for emergency help.
• How to inject glucagon, a hormone that increases your blood sugar. Your doctor or nurse will tell you when to use this medicine.

If you have diabetes, always wear a medical alert bracelet or necklace. This helps emergency medical workers know you have diabetes.

When Your Blood Sugar Gets Low

Check your blood sugar whenever you have symptoms of low blood sugar. If your blood sugar is below 70 mg/dL, treat yourself right away.

1. Eat something that has about 15 grams (g) of carbohydrates. Examples are 3 glucose tablets, one half cup (4 ounces or 237 mL) of fruit juice or regular, non-diet soda, 5 or 6 hard candies, 1 tablespoon (tbsp) or 15 mL of sugar, plain or dissolved in water, or 1 tbsp (15 mL) of honey or syrup.

2. Wait about 15 minutes before eating any more. Be careful not to eat too much. This can cause high blood sugar and weight gain.

3. Check your blood sugar again.

4. If you do not feel better in 15 minutes and your blood sugar is still lower than 70 mg/dL (3.9 mmol/L), eat something with 15 g of carbohydrate again.

You may need to eat a snack with carbohydrates and protein if your blood sugar is in a safer range -- over 70 mg/dL (3.9 mmol/L) -- and your next meal is more than an hour away.

Ask your provider how to manage this situation. If these steps for raising your blood sugar do not work, call your doctor right away.

Talk to Your Doctor or Nurse

If you use insulin and your blood sugar is frequently or consistently low, ask your doctor or nurse if you:

• Are injecting your insulin the right way
• Need a different type of needle
• Should change how much insulin you take
• Should change the kind of insulin you take

DO NOT make any changes without talking to your doctor or nurse first.

Sometimes hypoglycemia can be due to taking the wrong medicines. Check your medicines with your pharmacist.

When to Call the Doctor

If signs of low blood sugar DO NOT improve after you have eaten a snack that contains sugar, have someone drive you to the emergency room or call your local emergency number (such as 911). DO NOT drive when your blood sugar is low.

Get medical help right away for a person with low blood sugar if the person is not alert or cannot be awakened.

2. High Blood Sugar Emergencies

Blood sugar levels that are too high (hyperglycemia) can quickly turn into a diabetic emergency without quick and appropriate treatment. The best way to avoid dangerously high blood sugar levels is to self-test to stay in tune with your body, and to stay attuned to the symptoms and risk factors for hyperglycemia.

Extremely high blood sugar levels can lead to one of two conditions—diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS; also called hyperglycemic hyperosmolar nonketotic coma). Although both syndromes can occur in either type 1 or type 2 diabetes, DKA is more common in type 1, and HHNS is more common in type 2.

Diabetic Ketoacidosis (DKA)

Ketoacidosis (or DKA) occurs when blood sugars become elevated (over 249 mg/dl, or 13.9 mmol/l) over a period of time and the body begins to burn fat for energy, resulting in ketone bodies in the blood or urine (a phenomenon called ketosis). A variety of factors can cause hyperglycemia (high blood glucose), including failure to take medication or insulin, stress, dietary changes without medication adjustments, eating disorders, and illness or injury. This last cause is important, because if illness brings on DKA, it may slip by unnoticed, since its symptoms can mimic the flu (aches, vomiting, etc.). In fact, people with type 1 diabetes are often seeking help for the flu-like symptoms of DKA when they first receive their diagnosis.

Symptoms of diabetic ketoacidosis may include:

• fruity (acetone) breath
• nausea and/or vomiting
• abdominal pain
• dry, warm skin
• confusion
• fatigue
• breathing problems
• excessive thirst
• frequent urination
• in extreme cases, loss of consciousness

DKA is a medical emergency, and requires prompt and immediate treatment. A simple over-the-counter urine dipstick test (e.g., Ketostix) can check for ketones; anyone who has blood glucose levels above 240 mg/dl (13.3 mmol/l) should test their urine for ketones. There is also at least one glucose meter on the market that tests blood ketone levels. It’s normal to occasionally have trace amounts of ketones in the urine, but you should call your healthcare provider immediately if you experience moderate to heavy ketones. Treatment for DKA involves administering insulin to lower blood glucose levels, and restoring fluid balance to the bloodstream with an intravenous (IV) saline drip. Electrolytes may also be given via IV.

Hyperglycemic Hyperosmolar Syndrome (HHS)

Hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes that can occur when blood glucose levels exceed 600 mg/dl (33.3 mmol/l), but ketosis (ketone bodies in the blood) is low or not present. With such high blood sugar, the body becomes severely dehydrated. HHS occurs most often in the elderly (who are either newly diagnosed with diabetes or unaware of having high blood glucose levels) and those who are not able to tell they are thirsty (impaired thirst mechanism). If you or a loved one are elderly or have a decreased thirst mechanism, it is important to always have water within reach, and to drink plenty of fluids. Impaired kidney function and infections are also risk factors.

HHS is a life-threatening condition. If you experience any of the following symptoms of the syndrome, seek emergency medical care immediately:

• excessive thirst
• dehydration
• disorientation and confusion
• sudden hypotension or low blood pressure (as evidenced by faintness or dizziness when changing positions, especially lying or sitting to standing up)
• visual problems
• extreme, unexplained fatigue
• fever
• in advanced cases, coma, seizure, and/or hemiplegia (paralysis on one side of the body)

Treatment for HHS involves administering intravenous fluids (i.e., saline and sometimes electrolyte solutions) to restore fluid balance. Insulin therapy may also be required.

It’s ideal to avoid these blood sugar emergencies altogether by self-testing regularly and managing your blood sugar with diet, exercise, and any medications prescribed to you. But what if your blood sugar levels do become elevated? Here are some simple tips for handling a high:

You can often lower your blood sugar by exercising. If your levels are elevated, try doing some light exercise, such as going for a walk. If you have ketones in your urine, do not exercise, as this can cause blood sugar levels to rise even more.

Be sure to drink plenty of water. Elevated blood sugar levels are often associated with being dehydrated.

If you’re on insulin, your doctor may be able to give you a “correction dose” of insulin. This will temporarily correct a blood sugar high, and is not a permanent adjustment to your daily insulin injection.

Make sure you are taking the correct amount of medication at the right time. If you’re not, medications may be less effective at controlling blood sugar levels. Discuss your medications with your doctor to see if you need to adjust the dose or timing of your meds.

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References:

American Diabetes Association. 6. Glycemic targets: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S55-S64. PMID: 29222377 www.ncbi.nlm.nih.gov/pubmed/29222377.

Davis SN, Lamos EM, Younk LM. Hypoglycemia and hypoglycemic syndromes. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 47

American Diabetes Association. “Standards of Medical Care in Diabetes—2016.” Diabetes Care. January 2016. http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf.

Gosmanov, A. R., Gosmanova, E. O., and Kitabchi, A. E. “Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), and Hyperglycemic Hyperosmolar State (HHS).” May 19, 2015.  https://www.ncbi.nlm.nih.gov/books/NBK279052/

U.S. National Library of Medicine and National Institutes of Health. “Hyperglycemia.” MedlinePlus. https://medlineplus.gov/hyperglycemia.html.