From the Guidelines
Nocturnal hypoglycemia is primarily caused by an imbalance between insulin levels and glucose availability at night, and its management should focus on prevention through adjusting insulin doses and consuming a bedtime snack. The causes of nocturnal hypoglycemia include excessive insulin doses, delayed meals, inadequate evening snacks, alcohol consumption, or increased physical activity during the day 1.
Key Factors
- Excessive insulin doses, particularly long-acting insulins like glargine or detemir, can increase the risk of nocturnal hypoglycemia 1.
- Alcohol consumption, especially in the evening, can also contribute to the risk of nocturnal hypoglycemia 1.
- Inadequate evening snacks or delayed meals can lead to an imbalance between insulin levels and glucose availability at night.
Management
- Adjusting insulin doses, particularly long-acting insulins, is crucial in preventing nocturnal hypoglycemia 1.
- Consuming a bedtime snack containing complex carbohydrates and protein can help maintain glucose levels during sleep.
- Regular blood glucose monitoring before bedtime and using continuous glucose monitoring systems can provide alerts before levels drop too low.
- Treatment of an episode involves consuming 15-20 grams of fast-acting carbohydrates like glucose tablets or juice, followed by a more substantial snack if the next meal is not imminent.
- Avoiding alcohol before bed and maintaining consistent meal and exercise schedules also helps reduce the risk of nocturnal hypoglycemia 1.
Prevention
- Regular communication with healthcare providers to adjust medication regimens is essential, as recurrent episodes may indicate the need for insulin dose reduction or timing adjustments 1.
- Understanding how to convert individuals from one basal insulin to another and being aware of the potential for overbasalization with insulin therapy can help prevent nocturnal hypoglycemia 1.
From the FDA Drug Label
The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal Other factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to concomitantly administered medication Patients with renal or hepatic impairment may be at higher risk of hypoglycemia
The causes of nocturnal hypoglycemia include:
- Changes in meal pattern: Changes in the timing or content of meals can increase the risk of hypoglycemia
- Changes in physical activity: Increased physical activity can lower blood glucose levels and increase the risk of hypoglycemia
- Changes in concomitantly administered medication: Certain medications can increase the risk of hypoglycemia
- Renal or hepatic impairment: Patients with kidney or liver disease may be at higher risk of hypoglycemia
- Duration of action of insulin: The risk of hypoglycemia is highest when the glucose-lowering effect of insulin is maximal 2
Management of nocturnal hypoglycemia includes:
- Self-monitoring of blood glucose: Regular monitoring of blood glucose levels can help identify hypoglycemia
- Adjustments in drug dosage or meal patterns: Changes to insulin dosage or meal patterns may be needed to prevent hypoglycemia
- Treatment with oral glucose or glucagon: Mild episodes of hypoglycemia can be treated with oral glucose, while more severe episodes may require treatment with glucagon or intravenous glucose 2
From the Research
Causes of Nocturnal Hypoglycemia
- Nocturnal hypoglycemia is often a consequence of inappropriate basal insulin therapy in type 1 diabetes (T1D) 3
- The inability to control glucose levels during sleep, the impact of external factors such as exercise or alcohol, and the influence of hormones are main causes of nocturnal hypoglycemia 4
- Nocturnal hyperinsulinemia frequently occurs with insulin therapy, and although blood glucose levels are often low during sleep, they are seldom measured routinely 5
Management of Nocturnal Hypoglycemia
- Various strategies can be used to minimize the nocturnal hyperinsulinemia that is associated with many insulin replacement regimens, such as regular blood glucose monitoring, ingestion of appropriate bedtime snacks, and utilization of short- and long-acting insulin analogues 5
- Continuous glucose monitoring (CGM) can reduce the number of nocturnal hypoglycemic events with the help of alarms, trend arrows, and evaluation routines 4
- Automatic glucose adjustment (AID) systems have their particular strength in nocturnal glucose regulation and the prevention of nocturnal hypoglycemia 4
- Long-acting insulin analogs, such as insulin detemir or insulin glargine, may be the best option to provide basal insulin coverage in patients who do not choose or require continuous subcutaneous insulin infusion 6
- Sensor-augmented pumps with predictive low glucose suspend technology can predict and stop hypoglycemia before it develops 7
Prevention of Nocturnal Hypoglycemia
- Prevention of nocturnal hypoglycemia includes behavioral, dietary, and pharmacologic interventions 7
- Treatment with insulin degludec compared with insulin glargine U100 significantly reduces nocturnal CGM-recorded hypoglycemia in people with T1D prone to nocturnal severe hypoglycemia 3
- Patients with type 1 and type 2 diabetes mellitus have a lower risk for nocturnal hypoglycemia when receiving long-acting insulin analogs, provided that glycemic control is comparable to that provided by traditional human basal insulin 6