When it comes to treating diabetes, you are the most important person involved.

Learning that you have type 2 diabetes can be traumatic. That’s understandable. Diabetes is a lifelong disease that demands daily attention. Monitoring. Metering. Medications.

If not properly managed, diabetes can have debilitating and irreversible consequences.

With proper care, most people with diabetes can achieve and maintain blood glucose levels as close to normal as safely possible. But people with the disease need to be wary of the severe problems that can occur on both ends of the spectrum. Hypoglycemia, or too-low blood sugar, is a side effect of some glucose-lowering medications. In rare situations, blood sugar can also escalate to a dangerously high level, causing problems such as ketoacidosis and hyperosmolar coma.

Hypoglycemia

Hypoglycemia is a potential problem for anyone who takes insulin or several other glucose-lowering medications, including sulfonylureas or glinides, either alone or in combination with other antidiabetic drugs. Hypoglycemia is far less common among people with type 2 diabetes than among those with type 1, but it can be serious when it occurs.

Blood sugar may become abnormally low in people who take too high of a dose of medication in the setting of exercise, too little food or carbohydrates, a missed or delayed meal, or a combination of these factors. As you pursue near normal blood sugar control more aggressively, your risk for hypoglycemia increases.


It’s important that people with diabetes, and those who live and work with them, learn to recognize and understand hypoglycemia so it can be prevented and treated before it becomes a life-threatening crisis.

Spotting the signs of hypoglycemia

Many experts associate hypoglycemic reactions with blood sugar levels below 60 mg/dL, but it’s difficult to pinpoint the level at which hypoglycemia symptoms will affect an individual because each person responds differently. For instance, your blood sugar might fall below 40 mg/dL without causing any symptoms, while someone else might feel symptoms coming on when his or her blood glucose falls below 70 mg/dL.

Over time, the symptoms may become subtler. You may or may not experience
1. Palpitations
2. Sweating
3. Anxiety
4. Fuzzy thinking
5. Hypoglycemia unawareness, in which a person experiences no warning symptoms even when their blood sugar levels are very low.

Low blood sugar usually sets off alarms in many organ systems.
The brain, which relies on glucose to function, is especially sensitive to sugar deprivation.

The first signs of hypoglycemia resemble those of an anxiety attack because a decline in blood sugar stimulates the autonomic nervous system.



Epinephrine (also known as adrenaline) is secreted, causing
1. Sweating,
2. Nervousness
3. Trembling
4. Palpitations
5. A fast heart rate
6. Lightheadedness and often
7. Hunger.
The release of epinephrine is a corrective response to hypoglycemia not only because it signals you to eat, but also because it prompts your liver to make more sugar.

If hypoglycemia is not treated rapidly, it may get worse and affect brain function, leading to
1. Blurred vision
2. Slurred speech
3.

Confusion
4. Other behavior that resembles drunkenness, such as belligerence or silliness.

A further drop in blood sugar levels or failure to treat the condition promptly may result in
1. Loss of consciousness 
2. Seizures and even
3. Death.

An episode of hypoglycemia while driving can cause a serious car accident, especially if you postpone treating yourself, thinking you can make it to your destination.
Don’t risk it: stop and get something sweet right away if you don’t have anything handy in your car.

Not everyone experiences all these symptoms, and it can be hard to tell the difference between hypoglycemia and anxiety over a problem at work or an argument with your spouse.

In addition, beta blockers (used to treat high blood pressure and heart disease) can mask the early symptoms and result in more severe hypoglycemia. That’s why doctors often look for alternatives to beta blockers in people with diabetes.

Alcohol can also mask the symptoms of hypoglycemia, which is one reason it must be used cautiously.

If hypoglycemia occurs during sleep, the only clues may be damp pajamas (from sweating), vivid nightmares, or a nagging headache on awakening. It’s important to be attuned to these early signs and to know what blood sugar levels set off hypoglycemia.

Preventing hypoglycemia is preferable to treating it. If you’re taking insulin, you may experience hypoglycemia at some time, most likely because of a change in eating patterns, such as missing a meal.

But if you engage in binge drinking of alcohol, have irregular eating patterns, or have liver or kidney disease, you are at particular risk.

Treating low blood sugar

While it’s a good idea to test your blood glucose level if you suspect you’re having a hypoglycemic reaction, often there just isn’t time. Once you start to feel strange, don’t put off treatment. Follow the 15/15 rule, as explained by the U.S. National Library of Medicine:

Eat 15 grams of carbohydrate and wait 15 minutes. The following foods will provide about 15 grams of carbohydrate:

A. 3 glucose tablets
B.

Half cup (4 ounces) of fruit juice or regular soda
C. A glass of milk
D. 6 or 7 hard candies
E. 2 tablespoons of raisins
F. 1 tablespoon of sugar

After the carbohydrate is eaten, wait about 15 minutes for the sugar to get into your blood. If you do not feel better within 15 minutes, more carbohydrate can be consumed. Your blood sugar should be checked to make sure it has come within a safe range.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) — in which blood sugar levels soar very high — is far more common among people with type 1 diabetes than those with type 2. It develops when insulin falls to a critically low level, often when you miss insulin injections or use too little insulin during a period of illness or unusual stress. Illness and stress increase your vulnerability because the hormones released in these situations oppose the action of insulin. Unless insulin doses are maintained or increased, insulin insufficiency develops.

When your insulin levels are very low, cells can’t absorb glucose from the bloodstream to make energy. Instead, they begin to break down stored fat.

A natural byproduct of this fat breakdown are acids called ketones. When they reach high levels, the body can’t metabolize them fast enough. As a result, the ketones accumulate in your bloodstream, making your blood acidic. At the same time, your kidneys excrete large amounts of glucose-rich urine, causing dehydration.

Symptoms of DKA include
A. Increased thirst
B. Frequent urination
C. Rapid breathing
D. Nausea, vomiting
E. Fatigue
F. Abdominal pain
G. “fruity” breath.

As the condition progresses, blood pressure falls because of dehydration.



Confusion and even coma can develop if blood sugar levels become extremely high.
Because the warning signs often develop over several days, regular blood glucose tests can alert you when levels are becoming high enough to increase the risk for DKA.

You can also detect the development of DKA by monitoring ketones in your urine. This test is easily performed at home using a urine dipstick for ketones.

Urine ketones should be checked whenever your blood sugar levels become unusually high or when you’ve developed a new illness, especially one with gastrointestinal symptoms such as abdominal pain, nausea, or vomiting.

Call your doctor immediately if your urine test shows more than a moderate level of ketones (30 to 40 mg/dL).

Treatment of Diabetic Ketoacidosis involves
A. Insulin,
B. Fluids, and electrolytes (minerals such as sodium, potassium, and chloride) given through a vein.

Untreated, DKA can be fatal.

Hyperosmolar coma

In rare cases, blood glucose levels may rise to extremely high levels (over 800 mg/dL), leading to severe dehydration and confusion or coma.

This most commonly occurs in elderly people when blood sugar increases because of an impaired ability to recognize thirst, illness, or stress.

If the person affected can’t respond by drinking more liquids — either because he or she doesn’t feel thirsty (not uncommon in the elderly) or because neurological damage (for example, after a stroke) makes drinking fluids difficult — blood sugar levels can skyrocket.

As the problem worsens,
1.

Confusion
2. Sleepiness and
3. Seizures follow dehydration
Resulting in a condition called hyperosmolar coma.

This rare condition, which occurs most often in elderly people with type 2 diabetes, can be fatal and requires hospitalization, often in an intensive care unit.

Again, careful glucose monitoring and strict adherence to your treatment program can help you prevent hyperosmolar coma..

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