What is the best way to manage frequent hypoglycemia (low blood sugar)?

Managing Frequent Hypoglycemia in Diabetes

To effectively manage frequent hypoglycemia, implement a structured approach focusing on consistent carbohydrate intake, medication adjustments, and regular glucose monitoring while always carrying fast-acting glucose sources for immediate treatment.

Understanding Hypoglycemia Risk

Hypoglycemia (blood glucose ≤70 mg/dL) is a significant barrier to optimal diabetes management and can lead to serious complications including confusion, loss of consciousness, and potentially death. It's particularly common in:

• People using insulin therapy
• Those taking insulin secretagogues (sulfonylureas)
• Individuals with impaired hypoglycemia awareness
• Those with a history of severe hypoglycemic episodes

Immediate Treatment of Hypoglycemia

When hypoglycemia occurs, prompt treatment is essential:

• For blood glucose ≤70 mg/dL, consume 15-20g of fast-acting carbohydrates 1
  • Pure glucose is preferred (glucose tablets)
  • Alternatives: fruit juice, regular soda, or hard candy
• Recheck blood glucose after 15 minutes
• If still low, repeat the treatment
• Once glucose normalizes, consume a meal or snack to prevent recurrence

Note: For those using automated insulin delivery systems, 5-10g carbohydrates may be sufficient unless hypoglycemia occurs with exercise or after insulin overestimation 1

Prevention Strategies for Frequent Hypoglycemia

1. Nutrition-Based Approaches

• Maintain consistent carbohydrate intake with respect to timing and amount 1
  • This is especially important for those on fixed insulin regimens
  • Do not skip meals
• Consume moderate amounts of carbohydrates at each meal and snack
• Consider low-glycemic index foods to help maintain steadier blood glucose levels 2
• When consuming alcohol:
  • Limit to one drink for women and two for men per day
  • Always consume alcohol with food to reduce hypoglycemia risk 1

2. Medication Management

• Review and adjust medications that increase hypoglycemia risk 1

  • Consider reducing doses of insulin or insulin secretagogues
  • Discontinue sulfonylureas when initiating insulin therapy
  • Consider medication de-intensification if HbA1c is below target

• For insulin users:

  • Match prandial insulin to carbohydrate intake, pre-meal glucose levels, and anticipated activity 1
  • Reduce insulin doses before planned exercise
  • Consider sensor-augmented insulin pump therapy with threshold suspend features for those with nocturnal hypoglycemia 1

3. Glucose Monitoring and Awareness

• Implement regular glucose monitoring, especially before and after exercise, before driving, and at bedtime
• Consider continuous glucose monitoring (CGM) systems, particularly for those with hypoglycemia unawareness
• Screen for impaired hypoglycemia awareness at least yearly 1
• For those with hypoglycemia unawareness, temporarily raise glycemic targets for several weeks to help restore awareness 1

4. Exercise Considerations

• Always carry carbohydrates during physical activity
• For exercise within 1-2 hours of mealtime insulin, consider reducing the insulin dose 1
• Monitor glucose before, during (for prolonged activity), and after exercise
• Consume additional carbohydrates based on pre-exercise glucose levels and exercise intensity

5. Emergency Preparedness

• Ensure glucagon is prescribed and available for all individuals at risk of severe hypoglycemia 1
• Educate family members, roommates, or caregivers on glucagon administration
• Prefer intranasal or ready-to-inject glucagon preparations for ease of use 1

Special Considerations

• If hypoglycemia unawareness develops, implement a 2-3 week period of scrupulous hypoglycemia avoidance 3
• For protein-rich meals, be aware that protein can increase insulin response without raising glucose, so avoid high-protein foods when treating hypoglycemia 1
• For those using α-glucosidase inhibitors, use pure glucose (not complex carbohydrates) to treat hypoglycemia, as these medications prevent digestion of polysaccharides 1

By implementing these strategies systematically and consistently reviewing their effectiveness, most individuals can significantly reduce the frequency and severity of hypoglycemic episodes while maintaining good overall glycemic control.