From the Guidelines
When a body adapted to hyperglycemia starts using insulin to normalize blood sugars, it can experience symptoms of hypoglycemia, including shakiness, irritability, confusion, tachycardia, and hunger, due to the body's adaptation to high blood sugar levels. These symptoms occur because the body has physiologically adapted to high blood sugar levels, so normal levels feel low by comparison, as noted in the 2017 American Diabetes Association standards of medical care in diabetes 1. The brain and nervous system, accustomed to functioning with excess glucose, interpret the normalized levels as insufficient.
Symptoms and Management
- Patients may experience shakiness, sweating, anxiety, confusion, irritability, hunger, headaches, weakness, fatigue, and heart palpitations even when blood glucose levels are technically normal or only slightly low.
- This adaptation typically resolves within 2-3 weeks as the body adjusts to healthier glucose levels.
- During this transition period, patients should monitor blood glucose closely, make gradual rather than rapid insulin adjustments, ensure regular meals with consistent carbohydrate intake, and keep fast-acting carbohydrates available, as recommended by the International Hypoglycaemia Study Group 1.
- Medical supervision is important during this adjustment phase, especially for those with diabetes complications or on multiple medications.
Prevention and Education
- Patients should be educated about times when they may be at increased risk for hypoglycemia, such as while fasting for tests, with delayed meals, during or after exercise, and during sleep, as outlined in the 2017 American Diabetes Association standards of medical care in diabetes 1.
- Self-monitoring of blood glucose and, for some patients, continuous glucose monitoring (CGM) are important tools to monitor glucose levels and prevent hypoglycemia.
- Glucagon should be prescribed for all patients at increased risk for clinically significant hypoglycemia, and caregivers, school personnel, and family members should know where the glucagon is stored and when and how to administer it 1.
From the FDA Drug Label
Insulin Initiation and Intensification of Glucose Control Intensification or rapid improvement in glucose control has been associated with a transitory, reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy. However, long-term glycemic control decreases the risk of diabetic retinopathy and neuropathy.
When a body adapted to hyperglycemia starts using insulin to normalize blood sugars, symptoms that can occur include:
- Transitory, reversible ophthalmologic refraction disorder
- Worsening of diabetic retinopathy
- Acute painful peripheral neuropathy These symptoms are associated with the intensification or rapid improvement in glucose control. 2 3
From the Research
Symptoms of Hypoglycemia
When a body adapted to hyperglycemia starts using insulin to normalize blood sugars, several symptoms can occur due to hypoglycemia. These symptoms can be categorized into two main types: sympathetic and neuroglucopenic.
- Sympathetic symptoms include:
- Sweating
- Tremor
- Palpitations
- Sensation of hunger
- Restlessness
- Anxiety 4
- Neuroglucopenic symptoms include:
- Blurred vision
- Weakness
- Slurred speech
- Vertigo
- Difficulties in concentration 4
Common Symptoms Reported in Studies
According to the ACCORD clinical trial data, the most frequently reported symptoms of hypoglycemia were:
- Weakness/fatigue (29% in the intensive group and 30% in the standard group)
- Sweating (26% in the intensive group and 27% in the standard group)
- Confusion/disorientation (22% in the intensive group and 29% in the standard group)
- Shakiness (21% in the intensive group and 19% in the standard group) 5
Risk of Hypoglycemia with Insulin Therapy
The use of insulin to normalize blood sugars can increase the risk of hypoglycemia. Studies have shown that the highest rates of hypoglycemia were found among patients treated with insulin only 5. However, the risk of hypoglycemia can be reduced with the use of certain types of insulin, such as insulin glargine, which has been shown to reduce the risk of hypoglycemia compared to NPH insulin 6.
Prevention and Treatment of Hypoglycemia
Prevention and treatment of hypoglycemia are crucial to minimize its risks. This can be achieved through:
- Flexible and individualized drug regimens
- Addressing the issue of hypoglycemia
- Applying the principles of aggressive glycemic therapy
- Considering the risk factors for iatrogenic hypoglycemia 7
- Treatment of mild episodes of hypoglycemia with fast-absorbing carbohydrates, and severe episodes with i.v. dextrose or glucagon injected i.m. or i.v. 4