Can alcohol intoxication cause hypoglycemia?

Can Alcohol Intoxication Cause Hypoglycemia?

Yes, alcohol intoxication can cause hypoglycemia, particularly in individuals who are fasting, malnourished, or have diabetes, though the risk in otherwise healthy, well-fed individuals is relatively low.

Mechanism of Alcohol-Induced Hypoglycemia

Alcohol causes hypoglycemia primarily by inhibiting hepatic gluconeogenesis, the liver's ability to produce new glucose 1. This mechanism is particularly dangerous because:

• Glucagon administration will not reverse alcohol-induced hypoglycemia, since the problem is impaired glucose production rather than excessive insulin 1
• Alcohol also decreases growth hormone secretion, which normally helps maintain blood glucose levels 2
• Cognitive impairment from hypoglycemia can be mistaken for simple intoxication, delaying recognition and treatment 3

Risk Varies by Population and Context

In People with Diabetes

The risk is substantially elevated, especially for those on insulin or insulin secretagogues 3, 1:

• Moderate alcohol consumption enhances the glucose-lowering action of insulin and oral medications 1
• Evening alcohol consumption increases risk of nocturnal and fasting hypoglycemia the following morning 1, 4
• In one controlled study of type 1 diabetics, moderate wine consumption (0.75 g/kg) in the evening led to hypoglycemia requiring treatment in 5 of 6 subjects the next morning, with blood glucose nadirs of 1.9-2.9 mmol/L 4
• Alcohol blunts awareness of hypoglycemia, increasing risk of severe episodes 1

In Non-Diabetic Individuals

The incidence is low in well-fed, non-diabetic individuals 5, 6, 7:

• In a study of 378 intoxicated non-diabetic patients, only 4% had hypoglycemia (glucose <67 mg/dL) and only 1% had profound hypoglycemia (glucose <50 mg/dL) 6
• This rate was not statistically different from non-intoxicated controls 6
• Another study found hypoglycemia in only 0.9% of ethanol-positive patients, with severe hypoglycemia in just 0.2% 7
• Moderate alcohol consumption by healthy, fed subjects does not typically cause acute hypoglycemia 5

High-Risk Scenarios

Hypoglycemia risk is markedly increased in 5, 7:

• Fasted individuals consuming alcohol
• Chronic alcohol-dependent individuals
• Malnourished patients
• Repeat visitors with multiple episodes of intoxication (2.0% hypoglycemia rate vs 0.2% in single-visit patients) 7

Clinical Recommendations

For Patients with Diabetes

Alcohol should always be consumed with food to minimize hypoglycemia risk 3, 1:

• Limit intake to ≤1 drink/day for women and ≤2 drinks/day for men (one drink = 12 oz beer, 5 oz wine, or 1.5 oz distilled spirits, each containing ~15 g alcohol) 3, 1
• Increase frequency of blood glucose monitoring for several hours after alcohol consumption and the following morning 3
• Do not omit food when consuming alcohol; alcoholic beverages should be an addition to the regular meal plan 3
• Be aware that delayed hypoglycemia can occur 10-12 hours after evening consumption 4

Absolute Contraindications to Alcohol

Advise complete abstention for 3, 1:

• History of alcohol abuse or dependence
• Pregnancy
• Liver disease
• Pancreatitis
• Advanced neuropathy
• Severe hypertriglyceridemia

Important Clinical Pitfalls

• Do not rely on ethanol level to predict hypoglycemia risk—there is no linear correlation between blood alcohol concentration and glucose levels 7
• Hypoglycemia symptoms can be mistaken for intoxication alone, leading to delayed recognition 3
• Routine glucose screening is not necessary for all intoxicated patients in the emergency setting, but should be performed selectively based on clinical presentation, fasting status, nutritional state, and diabetes history 7
• The anion gap may be elevated in hypoglycemic intoxicated patients, which can serve as a clue 6