Definition of hypoglycemia:
When blood glucose level is lower than 70 mg/dl, this phenomenon is called hypoglycemia. Hypoglycemia is one of the diabetes mellitus acute complications and should be managed immediately.

Causes of hypoglycemia:
  1. Excess of insulin or oral hypoglycemia agent.
  2. Unbalanced diet.
  3. Delayed eating after taking medication.
  4. Drinking alcohol over an empty stomach.
  5. Excess exercise.
  6. People with liver or kidney dysfunction.

Symptoms of hypoglycemia:
  1. Autonomic symptoms: hungry, trembling, cold sweating, and palpitations. 
  2. Neuroglycopenic symptoms: slurred speech, inability to concentrate, blurred vision, drowsiness, conscious change, weird behavior, cramps, and unconsciousness.
  3. Non-specific symptoms: dizziness, headache, nausea, and numb lips.
  4. Unawareness hypoglycemia: patients diagnosed as diabetes mellitus for a long time, the elderly, or patients who have severe hypoglycemia in recent days. These patients may have neuroglycopenic symptoms without autonomic symptoms.
 
Treatment of hypoglycemia:
  1. While suspecting hypoglycemia, blood sugar level should be monitored immediately (if blood glucose monitor machine is not available at the moment, and patient’s consciousness is clear, it is recommended that intake food immediately.) and ingest 15-20 grams of sugary food such as juice around 120 -180cc, a tablespoon of honey or 3 to 4 cubes of sugar are all recommended. After 15 minutes, the blood glucose level should be rechecked again. If hypoglycemia persists, please repeat recommended management. If symptoms sustain, please go to hospital and seek for medical attention immediately.
  2. When condition improves, the patient still needs to eat one serving of carbohydrate food, such as one slice of thin toast or three slices of crackers in order to preserve energy, keep blood glucose level steady,and prevent hypoglycemia recurrent. 
  3. If hypoglycemia occurs while patients taking oral hypoglycemic agents, Acarbose (Glucobay®), patients should take monosaccharides, such milk or glucose tablets, should be intake, instead of cube sugar or candy.
  4. Avoid saccharin and aspartame while hypoglycemia occurs because saccharin and aspartame are not effective in elevating blood sugar. Avoid high-fat foods, such as chocolate and ice cream, because fat will delay the absorption of sugar.
  5. When hypoglycemia occurs before meal, the patient should eat food first, then take hypoglycemic drugs according to amount of food and blood sugar level. Especially for patients with type 1 diabetes, the insulin injections should not be discontinued without doctor’s advice.
  6. When patients unconscious, they should be taken to the hospital immediately. Family members should proceed with the following steps: 
    1. Do not inject insulin.
    2. Family should help patient’s head turned to one side in order to keep the airway open, do not forcibly fed. Give the patient sugar cream, syrup or honey 1-1.5 tablespoon applying directly into the oral mucosa with plastic dropper and massage till it absored. The patient should be taken to hospital immediately.
    3. If glucagon is available at home, family members could assist to inject glucagon (adult dose: 1 mg intramuscular injection; children dose: 0.5 mg intramuscular injection).
    4. When patient’s conscious recovered, family should provide food, with carbohydrate to keep blood glucose level steady.

Caution in daily life:
  1. Learn how to recognize hypoglycemia symptoms and follow doctors’ guidance.
  2. Friends and relatives should also know the symptoms of hypoglycemia and what to do in an emergent situation. 
  3. Self-monitoring blood glucose level regularly, maintain exercise habit and keep balanced diet
  4. Do not take oral hypoglycemic agents after delay intake time, sleep or or insulin injection, and avoid exercise during fasting period.
  5. Before exercise, individual should intake food; in case of strenuous exercise, one serving of food should be taken every 30 minutes.
  6. Glucagon should be kept in the freezer and stored under 25℃.
  7. When going out, it is suggested to carry sugar tablets, and bring the diabetes mellitus identification card at all time. 
  8. If blood glucose level is less than 120 mg/dl before going to sleep, snacks should be eaten, such as three piece of biscuits and a cup of milk. 
  9. Knowing the reasons of hypoglycemia is important to prevent further hypoglycemia occurrence.
  10. When having diarrhea or poor appetite, it is recommended that the patient drinks sports drinks, milk, and monitoring blood glucose level closely. In addition, inform doctor for diabetes mellitus history when seek medical attention.
  11. Avoid drinking alcohol over an empty stomach.
 
References
  1. American Diabetes Association (2019). Standards of medical care in diabetes-2019 abridged for primary care providers. Clinical Diabetes,37(1), 11-34. doi: 10.2337/cd18-0105
  2. Ortiz, M. R. (2017). Hypoglycemia in diabetes. The Nursing Clinics of North America, 52(4), 565-574. doi: 10.1016/j.cnur.2017.07.006
  3. Taiwanese Association of Diabetes Educators (2017). 2017 Diabetes education core textbook. Taipei: Taiwanese Association of Diabetes Educators.
  4. The Diabetes Association of the Republic of China (2018). Clinical practice guidelines for diabetes care 2018. Taipei: The Diabetes Association of the Republic of China.
  5. Yun, J. S., & Ko, S. H. (2016). Risk factors and adverse outcomes of severe hypoglycemia in type 2 diabetes mellitus. Diabetes & Metabolism Journal, 40(6), 423-432. doi:10.4093/dmj.2016.40.6.423
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