Hypoglycemia – Lower is Not Always Better

shutterstock_88080298~Dr Edward Chao


Patient (describing what he did after discovering he had a low fingerstick glucose): “I had a candy bar.”

Me: “Did you recheck your sugar about 15 minutes later?”

Patient: “No, I felt fine.”

Exchanges like this scare me. One of my patients recently related the above. I’m sure you’ve had similar conversations, or have worked with some patients who aren’t testing at all if they feel low, or have some patients who have a candy bar if they experience hypoglycemia.

Hypoglycemia continues to bedevil patients living with diabetes. Low glucose can  potentially lead to a seizure, loss of consciousness, that may result in a car accident, or even death. They can hamper patients’ quest for glycemic control and a good quality of life. Just as you have, I’ve seen fear of future episodes get so deeply planted that, sometimes to the degree that one patient of mine put it: “I’d rather run a little high than drop that low. I don’t ever want to feel that awful again.”

So what can we do to prevent or reduce hypoglycemic episodes, and better guide patients to optimally address those that do occur?

1. Dig deeper, and by doing this, help cultivate curiosity. 

One of my patients used to bring in meticulous log books, with readings from 4 (yes, four!) glucometers. His reason? “I was a instrument engineer, and I like to see how accurate the meters are.” An insulin pump patient, he was fastidious about recording his SMBGs, as well as his insulin doses. Yet, he would continue to have multiple hypos. But the kicker was that he steadfastly declined adjusting his rates. Why? “Because my A1c’s been good, and I’d rather run a little low than be out of control.”

As with complications of diabetes it’s about avoiding the development of the problem in the first place. Probe for any underlying reasons for hypos. For many patients, it may be very simple – skipping meals, not adjusting fast-acting insulin if eating less, exercising more. Even more importantly, by asking questions, get the patient to develop this mindset of being curious – to be, if you will, a diabetes detective – so that s/he can develop awareness, and potentially, limit, or eliminate hypoglycemic episodes.

Talk with them about avoiding skipping meals, understanding their medications, and avoiding stacking insulin doses.

2. Discuss what to do (and keep the conversation going).

Hypoglycemia can be as mentally distressing as it can be physically unpleasant. Some patients and their caregivers may be unsure of what to look for, and what steps to take, despite all of their best efforts at prevention. Review the 15/15 rule, urge them to eschew candy bars in favor of glucose tablets, and explain why.

(The first 15 of the 15/15 rule is the patient should consume 15 g of carbohydrate if s/he has a hypoglycemic event. The second 15 means s/he should recheck the glucose 15 minutes after correcting, since sometimes patients may remain low, and need more correction.  Re: candy bars vs glucose tablets – the fat in candy bars slows the absorption of sugar, so patients should avoid those, but take glucose tablets, glucose gel, hard candy, grapes, and the like.)

Emphasize that this is an ongoing process – it’s certainly not a “one and done” learning experience with, say, the CDE only. I discuss with my patients that everyone is different, and it takes time to be in tune with symptoms of hypoglycemia, and even the subtler cognitive changes that could herald early, mild hypoglycemia.

3. Diabetes care takes a village – enlist help.

Besides the crucial support and assistance can be family, friends, colleagues, I urge you to involve your teammates in diabetes care: nurses, CDEs, dietitians, pharmacists, peer coaches. I feel it’s like the old saying about each of us needing more than one mentor for our careers – you can learn different items from a diverse group of individuals with their unique perspectives.

I’d love to hear your pearls, your experiences, and strategies that have worked for your patients. Log in to SERMO and share your experiences and thoughts.


BioEdward Chao Photo

Dr. Chao practices at the VA San Diego Healthcare System and is Associate Clinical Professor of Medicine at the University of California, San Diego. He received his medical degree from the University of New England College of Osteopathic Medicine. He completed residency in internal medicine at Loma Linda University Medical Center and fellowship in endocrinology and metabolism at the University of California, San Diego. Dr. Chao’s interests include diabetes research and medical education. He was recently elected to the UCSD Academy of Clinician Scholars.

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