If you experience any of the symptoms of hypoglycemia detailed earlier , especially hunger , measure blood sugar.If blood sugar is 10 mg/dl or more below target, chew enough glucose tablets to bring blood sugar back to your target.
If you have no symptoms but dis covera lowblood sugar upon routine testing, again,take enough glu cose tablets to bring blood sugar back to your target.
Having no symptoms is not a valid reason for not taking tablets.
A low blood sugar without symptoms carries more risk than one with symptoms.
If you weigh about 140pounds and your blood sugar is 60 mg/dl but your target is 90 mg/dl, then you might eat 4 Dextrotabs.
This would raise your blood sugar,accordingto Table20-2, by 32 mg/dl, bringing you to 92 mg/dl.
If you are using Dextro-Energen, you'd take 1V4 tablets.
With B-D tablets,you'd take 1.Simple.
HowtoPrevent andCorrectLow Blood Sugars 327
If your lowblood sugar resulted from taking too much insulin or OHA, it may continue to drop after taking glucose if the insulin or OHA hasn't finished working.
You should therefore recheck your blood sugar about 45 minutes aftertakingthe tablets, to rule out this possibility and to see ifyou're back where youbelong.
Ifbloodsugaris still low, take additional tablets.
Ifyou have delayed stomach-emptying, you may have to wait as much as 2 or more hours for full effect.* What if you'reout of your home or workplace and don't have your blood sugar meter? (A major crime, as noted earlier.) If you think you'rehypoglycemic, playit safeand take enough tablets to raiseyour blood sugar about 60 mg/dl (7 Dextrotabs, for example, or 2 B-D tablets).
You may worry that this will bring you too high.
If you take insulin, this poses no problem.
Simply checkyour blood sugar when you getbackto your meter.
If it'sabove your target, takeenough lispro (or aspart or glulisine) to bring you backto target,but be sure to wait 5 hours after your last dose of rapid-acting insulin.
If you don't take insulin, your blood sugar should eventuallycome back on its own, be cause your pancreas is still making some insulin.
It may take several hours, or even a day, depending upon how rapidly you can produce insulin.
In any event,you may havesaved yourselfan embarrassing or even disastrous situation.
WHAT IF BLOOD SUGAR IS LOW JUST BEFORE A MEAL?
Take your glucose tablets anyway. If you don't, you may become very hungry, overeat, and be too high many hours later. The medication you take for a meal is intended to keep your blood sugar level. So if it wastoo lowbefore a meal,it willbe too lowafter if you don't takeyour glucose but eat properly.
This time frame can be gready reduced by drinking a glucose solution (see page 377).
328 Treatment
WHAT IF YOUR SYMPTOMS PERSIST AFTER YOU HAVE CORRECTED THE HYPOGLYCEMIA?
Many ofthesymptoms ofhypoglycemia are actually effects of thehor moneepinephrine (which youmay know asadrenaline).
If youdo not have the problems listed in the section "Hypoglycemia Unawareness" on page 340, your adrenal glands will respond to hypoglycemia by producingepinephrine.
Epinephrine, like glucagon, signals the liver to convertstored glycogen to glucose.
It is epinephrine that brings about such symptoms as rapid heart rate, tremors, pallor, and so on. (Beta blocker medications can interfere with the ability of epinephrine to cause these symptoms.) Epinephrine has a half-life in the blood of about 1 hour.
This means that an hour after your blood sugar comes back to target, about half the epinephrine you made is still in the bloodstream.
This can cause a persistence of symptoms, even if your blood sugar is normal.
Thus, if you took some glucose tablets an hour ago and stillfeel symptomatic, check your blood sugaragain.
If it's on target,try to controlthe temptationto eat more.If your blood sugaris still low, more tablets are warranted.
COPING WITH THE SEVERE HUNGER OFTEN CAUSED BY HYPOGLYCEMIA
Mild to moderate hypoglycemia can cause severehunger and an asso ciated panic.
The drive to eat or drink large amounts of sweet foods can be almost uncontrollable.
Newpatients, before starting our regi men, have told me storiesof eating an entire pie, a jar of peanut but ter, a quart of ice cream, or drinking a quart of orange juice in response to hypoglycemia.
Before I stumbled onto blood sugar self- monitoring and learned how to use glucose tablets, I did much the same.
The eventual outcome, of course, was extremely high blood sugar several hours later.
Since the effects of glucose tablets are so predictable, the panic ele ment has vanished for me and for most of my patients.
Unfortunately, rapid correction of blood sugar does not always correct the hunger.This maybe somehowrelated to the long half-life of epinephrine and the persistence of symptomsevenafter restoration of normal blood sugars.
My patients and I have successfully coped
Howto Prevent and Correct LowBlood Sugars 329
with this problem in a very simple fashion. You can try thesame trick we use.
First, consume the appropriate number of glucose tablets.
If overwhelming hunger persists, consider what might satisfy it.
Typical options include a full meal (such as another lunch or supper), half a meal, or a quarter of a meal.
A full meal means exactly the amounts of carbohydrates and protein that you would ordinarily eat at that meal.
Halfa meal means exactly halfthe protein and halfthe carbohydrate.
Even ifyour blood sugar has notyet come back to target, since you know you have consumed the proper amount ofglucose toeventually bringit back, you canconfidentiy inject theamount of insulinor swal low the dose of the OHA that you normally use to cover that meal.
Forhalfa meal, take halfthe dose; for a quarter of a meal, take one- quarter the dose.
Don'tfrustrate yourself bywaiting the usual 45 minutes or so after injecting regular insulin, or the20 minutes after injecting lispro (oras part or glulisine), or the 60-120 minutes after taking an OHA.
Just in ject and eat.
An extra meal now and then won't make you fatter or cause harm.
Since you're eating within the controlled boundaries of your meal plan and not gorging on sugars or unlimited amounts of food, you'restillabidingby the Laws of Small Numbers.
Ifyou know how much insulin or OHA you usually take to cover a certain snack, you might have the snack instead of the meal.
HOW FAMILY AND FRIENDS CAN HELP YOU CATCH A HYPOGLYCEMIC EPISODE WITHOUT MUTUAL ANTAGONISM
Two ofthemost common effects ofhypoglycemia can make thejobof helping you difficult and unpleasant.
These effects are irritable, nasty behavior and failure to recognize your own symptoms.
Atmyfirst in terview with many new patients and their families, instances of vio lence during hypoglycemic episodes are commonly reported.
The most common scenario I hear goes likethis:"WheneverI see that he's low, I hand him a glass of orange juice and tell him to drink it, but he throws the juice at me.
Sometimes he throws the glass too." Such sto ries comeas no surprise to me because as a teenager I used to throw the orange juice at my mother, and when I wasfirst married, I did the
330 Treatment
same to mywife.
Whydoes this happen, and how can we prevent such situations?
First, it's important to try to understand what's going on in the minds of you and the family member or partner during a bout with hypoglycemia.
The cognitive difficulties that accompany severe hypo glycemia can make the slightest frustration or irritation overwhelm ing.
Your low blood sugar may cause you to act bizarrely, as if intoxicated , andin asense, youare intoxicated.
Because yourthink ing is impaired, you may betotally unaware that your blood sugar is low.
The similarity to drunkenness is not a coincidence, since the higher cognitive centers ofthebrain, which control rational behavior, are impairedin both cases.
You probably have learned that high blood sugars are to beavoided, andat somelevel, youremember this, perhaps even cling to it, despite your hypoglycemia.
If someone tries to cajole you into eating some thing sweet, you may decide that it's theother person who's irrational.
This is especially true if the other person has done the same thing in the past, when blood sugars were actually normal or even high.
In "self-protection" against the supposed irrational attemptto get you to eat something sweet, you instinctively may become violent.
Most commonly, this occurs if an attempt is made to put food or drink in your mouth.
You might view this as an"attack." In less rational mo ments, you may even decide, since you know that high blood sugars are harmful,that yourspouse or relative is trying to kill you.
The helping relative, usually a spouse or parent, maybe terrified to see such strange behavior.
If your loved one has been through many such encounters, he or she may, for self-protection, keep candies or other sweets aroundthe housein the hopesthat you will eatthem and thus avoid such situations.
The fear can be exacerbated if your loved one has seen you unconscious from hypoglycemia, or is merely aware that hypoglycemia can cause dire consequences.
On otheroccasions, whenyour blood sugar wasn't really low, your loved onemayhave er roneously asked you to eat something sweet.
Such erroneous diag noses are especially common during family squabbles.
The spouse or parent mayfeel that"his blood sugar islow, and that's whyhe's yelling at me."Your loved one would rather play it safe and give you some thing sweet, evenif yourbloodsugar isn'tlow.
There is a solution to this apparent dilemma.
First of all, both par tiesmust recognize that, as a rule, about halfthe time that the relative
How to Preventand Correct LowBloodSugars 331
suspects hypoglycemia, you do not havea low blood sugar; the other half of the time, blood sugar is indeed low.
No one hasevercontradicted me when I've made this point.
Encouraging a diabetic to eat sweets when hypoglycemia is sus pected, despite conventional teaching, does as much harm as it does good.A better approach would be for the loved one to say, "I'm wor riedthat your blood sugar may be low.
Please check it and let me know the result so that I'll feel less anxious." As a patient, you should realize that living with a diabetic can often be as much or more of a strain than having diabetes.
You, the diabetic, owe some consideration to the needsof your loved ones.
Try to look upon the request to check your blood sugar not asan intrusionbut as yourobligation to relieve some one else's fear.
With this obUgation in mind, you should automatically checkyour blood sugar if asked, justto make the other person feel bet ter.
It doesn't matter whether your blood sugar is low or normal.
If your blood sugar is low, you can correct it and find out why.
If it's normal, then you probably will have diffused the tension of the situa tion, and now you'll be able to get back to whatever you were doing, unworriedthat blood sugar is offtarget.
When you look at blood sugar as something like a clock that you can set , and reset, you take some ofthe mystery out of it, and can diminish the emotion involved.
If you're without your meter, take enough glucose tablets to raise your blood sugar about 60 mg/dl , again to make the other person feel better.
This is the least you can do for someone who may worry about you every day.
Believe it or not, this simple approach has worked for me and for many of my patients.
As I've said previously, I went through this with my parents and have gone through it with my wife.
Spouses report that it relieves them of a great burden.
Some wives have even cried when expressing their gratitude.
HOW FAMILY AND FRIENDS CAN HELP WHEN YOU ARE CONSCIOUS BUT UNABLE TO HELP YOURSELF