Treatment Strategies for Hypoglycemia and Hyperglycemia

Many patients with diabetes often do not completely grasp the consequences of hypoglycemia and hyperglycemia on vascular health, and health care providers should not assume that a patient has been well educated on the pathophysiology of diabetes.

Some fundamental points to review include the basic concept of carbohydrates, which convert to glucose in the digestive tract. Glucose then enters the blood, triggering the pancreas to release the hormone insulin into the bloodstream. Insulin then takes the glucose out of the blood and brings it to cells, which use the glucose for energy. When the pancreas does not produce sufficient insulin, an excess of glucose remains in the blood vessel, resulting in hyperglycemia, inducing vascular damage. In addition, white blood cells are damaged and lose their effectiveness in combating disease. With insulin resistance, there are fewer receptors on the cell to receive insulin and glucose; therefore, the cells do not receive glucose for energy.¹

Hypoglycemia

This occurs when the level of insulin in the blood is greater than glucose, lowering glucose to levels below 70 mg/dL (3.9 mmol/L). Some call this an “insulin reaction” because it often occurs when too much insulin is given to a patient. It may also occur with excessive physical activity without eating enough carbohydrates. Because sulfonylureas stimulate insulin release, reminding patients to eat regular meals may reduce hypoglycemic excursions. If someone consistently has high blood glucose levels greater than 200 mg/dL (11.1 mmol/L), hypoglycemic symptoms may be experienced when blood glucose lowers into a normal range (between 80 and 150 mg/dL; 4.4 and 8.3 mmol/L, respectively). A small (15 g) carbohydrate and protein snack will help abate these symptoms because it will increase the blood glucose slightly and the protein will maintain the blood glucose for a longer period of time. It is important to communicate the need to attain normal glucose levels at a slower progress to avoid these symptoms from occurring. The brain is at risk when glucose dips below 70 mg/dL (3.9 mmol/L).

Symptoms of hypoglycemia include:

• Shaking, sweating, or clammy skin
• Sudden nervousness, confusion, headache, or irritability
• Rapid heart rate
• Dizziness, weakness, or fatigue
• Hunger and nausea

Severe hypoglycemia is glucose less than 40 mg/dL (2.2 mmol/L), which can cause unconsciousness and death. A significant concern is hypoglycemia unawareness if a patient experiences frequent episodes of low blood sugar. Asking patients if they experience hypoglycemic events and symptoms is essential because if they do, they may need to reduce medications or further evaluate their medication routine. One possible cause of hypoglycemic events is inappropriate insulin dosing, such as more frequently than every 4 hours, which is referred to “insulin stacking.” This occurs when there is still active insulin working in the body at the time a patient checks blood glucose and doses with more insulin to lower the glucose level.

Treatment

Teaching a patient the “Rule of 15” is the appropriate management for hypoglycemia. If you suspect hypoglycemia, instruct the patient to check blood glucose. If the result is lower than 70 mg/dL (3.9 mmol/L), instruct the patient as follows:

1. Consume 15 g of fast-acting carbohydrates, such as 4 ounces of juice or regular soda (NOT diet), 1 tablespoon of jelly or sugar, or 3 glucose tablets. Although some consider a candy bar appropriate for treatment, the fat in the candy actually slows digestion of the glucose and delays recovery of blood glucose.
2. Check blood glucose 15 minutes later. If the result is higher than 70 mg/dL (3.9 mmol/L), instruct the patient to eat something with protein and carbohydrates to maintain their glucose level if the next planned meal is more than 1 hour away.
3. Consume an additional 15 g of carbohydrates if glucose remains less than 70 mg/dL. (3.9 mmol/L).²

Hyperglycemia

All forms of diabetes cause hyperglycemia if they are not properly treated. During an episode of hyperglycemia, the insides of blood vessels becomes irritated and damaged when glucose is elevated, similar to sandpaper or chards of glass rubbing an interior vessel wall. Most complications of diabetes arise when the smaller blood vessels of the body become even smaller from this damage. Frequent problems occur in the brain, eyes, heart, kidneys, and peripheral nerves, which have smaller vascularity and are affected first. Resulting stroke, blindness, myocardial infarction, renal disease, and peripheral neuropathy become chronic conditions to manage. Common symptoms include the following:

• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Random glucose greater than 200 mg/dL (11.1 mmol/L)
• Frequent infection
• Blurry vision

In the clinic, you may see a woman with frequent urinary tract infections, wounds that are not healing, or complaints of vision impairment. A random blood glucose test is recommended to determine whether hyperglycemia is present and whether a referral is necessary for further evaluation of this blood glucose elevation. Glucose and ketones are not normal findings in the urine and represent blood glucose elevation, which requires follow-up testing and management for possible diabetes.³

Treatment

More frequent blood glucose monitoring with accurate record keeping is important during any illness. The following sick day guidelines are important to review with patients:

• Monitor glucose every 4 hours.
• Take usual medications, especially long-acting insulin for an individual with type 1 diabetes. If the patient is unable to eat, contact their health care provider for medication adjustments.
• Stay hydrated. Drink at least 1 glass of water per hour.
• If the patient has type 1 diabetes, check urine ketones every 4 hours.
• Monitor for symptoms of ketoacidosis, such as fruity-smelling breath, nausea and vomiting, stomach cramps, and unconsciousness.

For the patient with hyperglycemia and diabetes, steroid treatment should be prescribed only when necessary and often with instructions to contact the endocrinologist or provider responsible for diabetes management. Steroids increase blood glucose, usually at higher levels in the evening and at an increased level over time. The patient should also be instructed to increase blood glucose monitoring while taking steroids and will often require higher doses of insulin for the duration of the steroid treatment. As the steroid dose tapers, the insulin dose may also gradually decrease.

Other medications that elevate blood glucose include beta-blockers, thiazide diuretics and statins in higher doses, and some antipsychotics, such as clozapine and olanzapine. Antiviral medications used for HIV and hepatitis C, such as protease inhibitors, also elevate blood glucose.⁴

Exercise and Glycemic Control

The American Diabetes Association recommends 150 minutes weekly of moderate physical activity. Providers should evaluate each patient’s exercise routine to allow education and encourage the patient to meet this activity goal. Explain that exercise uses excess glucose (often in stored fat) and will decrease the blood glucose level. Encourage your patients to begin exercising even just 10 minutes daily, if they aren’t already, and to work up to 30 minutes a day for 5 days.

Glycemic targets are individualized. Generally speaking, a glycated hemoglobin (A1C) lower than 7% (53 mmol/mol) will minimize the risk of vascular complications. A1C testing should be done at least twice annually if glucose is well controlled; if it is uncontrolled, however, testing should be done quarterly. Asking a patient what his or her most recent A1C result was will help their provider identify the level of control and what additional education may be required to maintain or achieve it. Discovering whether the patient actually knows this last result will illustrate the level of involvement in their diabetes management.

Conclusion

Glycemic excursions threaten vascular health. Hypoglycemia can increase the risk of dementia; confusion; vascular disease, such as a cerebral vascular accident and myocardial infarction; and death. For the patient with diabetes, heart disease is the number-one reason for death. Therefore, reinforce medication compliance and carbohydrate knowledge. Teach the Rule of 15.

When you encounter a patient with diabetes in the clinic, review their medications and diabetes knowledge, and remind the patient of sick day guidelines. It is important to help the patient understand the link between illness and glucose control. Do not assume the patient has been well educated. Understanding and reinforcing basic treatment guidelines can have a great impact in patients’ overall glycemic control and vascular health.

Nanette Coleman is a family nurse practitioner and certified diabetes educator who works as a coverage provider for Walgreens Healthcare Clinic in the St. Louis market. She is committed to providing easy-to-understand health education for her clients to improve overall self-care and health management.

References

1. What is insulin resistance? Joslin Diabetes Center website. joslin.org/info/what_is_insulin_resistance.html. Accessed August 25, 2016.
2. Hypoglycemia. American Diabetes Association website. diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html.
3. Inzucchi SE, Bergenstal RM, Buse JB, et al; American Diabetes Association (ADA); European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach.Diabetes Care.2012;35(6):1364-1369.
4. Tsai A. Medications that raise blood glucose.Diabetes Forecastwebsite. diabetesforecast.org/2015/nov-dec/medications-that-raise-blood.html. Published November 2015. Accessed August 25, 2016.