Uncontrolled diabetes may lead to three main types of medical
• Low blood sugar, also called called hypoglycemia or low blood
• Abnormal increase of acids in the blood, a condition called diabetic
• Very high blood sugar, referred to as hyperosmolar hyperglycemic
All the above conditions are called acute complications of diabetes because
they are usually transitory and are corrected by timely treatment. However,
delay in treatment of these medical emergencies can be disastrous, which in
extreme cases can lead to death.
LOWBLOOD SUGAR (HYPOGLYCEMIA). Sugar provides energy to all the
cells and muscles in your body. If your blood sugar falls too low, your body
cannot function properly. The level of blood sugar at which hypoglycemia
develops varies among individuals. Many laboratories rank blood sugar
level below 60 mg/dL as hypoglycemia or low blood sugar. But a person
whose blood sugar usually remains high may experience symptoms of low
blood sugar even at higher levels. In contrast, people who keep their blood
sugar low through tight control, may not feel the symptoms of low blood
sugar until sugar in their blood drops down as low as 30 mg/dL. In rare
cases, some people with diabetes who have developed low blood sugar
unawareness, a condition resulting from damage caused to their nervous
system by diabetes, may even fail to recognize the symptoms of low blood
sugar. This is a dangerous situation, which if not properly handled, may
CAUSES OF LOW BLOOD SUGAR. In diabetes, your blood sugar may
become low for any one or a combination of the following factors:
• Injecting an excess dose of insulin or taking large doses of diabetes
pills such as sulfonylureas, which stimulate secretion of insulin
from the pancreas. With excess insulin, the cells in the body pull in
too much sugar from the blood, leading to low blood sugar.
• Taking long-actinginsulin that peaks its action during the middle of
• Delaying or missing a meal or eating too little food to match the
amount of injected insulin.
• Unexpected or unusual exercise. Enhanced insulin action resulting
from unusual and vigorous exercise may contribute to low blood
sugar. Also, exercise helps rapid absorption of insulin in the body.
Thus, exercising after injecting insulin will accelerate the absorption
of insulin that may cause severe drop in blood sugar.
• Alcohol consumption. Under normal conditions when sugar in the
blood begins to fall, sugar produced by the liver prevents it from
falling too low. But when you drink alcohol, your liver’s function
Symptoms of Low Blood Sugar
The symptoms include:
- Nervousness – Hunger
- Trembling – Headache
- Fatigue – Nausea
- Anxiety – Slurred speech
- Irritability – Blurred vision
- Sweating – High pulse rate
- Dizziness – Sudden rise from sleep
- Light-headedness – Drowsiness
- Mental confusion – Unconsciousness
of releasing sugar in the blood will be depressed. In such a situation,
the liver may not be able to offset the fall in blood sugar.
• Delayed digestion. Nerve damage in the stomach, a complication of
diabetes, causes delayed emptying of food from the stomach into
the intestines (gastroparesis). As a result, food takes time to be
absorbed as sugar in the blood. But the injected insulin, peaking its
action earlier than food absorption will cause low blood sugar.
• Menstruation. Women with diabetes who use insulin may experience
low blood sugar during their menstruation cycle. This may
be due to changes in the hormonal activity during menstruation.
Self-Treatment of Low Blood Sugar
When you experience any of the symptoms of low blood sugar,
you should immediately eat some food or drink a beverage, containing
10 to 15 grams of carbohydrate, for example:
• 10 to 15 grams of oral glucose or 2 to 3 glucose tablets.
Glucose works fastest; 10 grams of glucose will raise
your blood sugar by about 40 mg/dL in about 30 minutes.
• 1 tablespoon (3 teaspoons) of honey or sugar dissolved in
• 1/2 cup of orange or apple juice.
• 1 cup of regular or skimmed milk.
• 1/2 cup (4 oz) of regular soda drink.
• 3 Graham crackers.
After 15 to 20 minutes of the above treatment, recheck your blood
sugar. If blood sugar is still low (less than 60 mg/dL) or symptoms
still persist, take an additional 15 grams of carbohydrate that
should solve the problem. Recheck in 60 minutes; if blood sugar
is still low, seek medical help.
Injecting Glucagon. When your blood sugar falls too low, you may
become unconscious and unable to self-treat low blood sugar. Oral feeding
should be avoided under this situation or the food will get stuck in your
lungs and cause pneumonia. In such a condition, you should immediately
receive a shot of glucagon. Glucagon, as noted in Chapter 1, is a hormone
produced by alpha cells of the pancreas, which stimulates the release of
stored sugar or glycogen from the liver and raises blood sugar.
Glucagon as an injectable drug is chemically identical to human glucagon
and is a safe drug. Glucagon is available by prescription in pharmacies in
the United States. A glucagon injection comprises 1 milligram (1 unit) of
glucagon powder and 1cc of water-like solution for dilution.
To inject glucagon is easy. It is injected anywhere under the skin; the
result is fast; the patient regains consciousness within 5 to 10 minutes after
Preventing Low Blood Sugar
The best way to prevent low blood sugar is to manage those controllable
factors that contribute to its fall. To prevent low blood sugar:
• Take your diabetes medication at the proper time and in right doses.
• Take your meals at regular times every day.
• If you are prone to low blood sugar after exercise, take a sugarcontaining
snack such as sweet crackers or orange juice before you
• Recognize the symptoms of low blood sugar and treat falling blood
sugar before it falls too low.
• Keep glucose (such as glucose gel or glucose tablets) handy for use
in an emergency situation to treat low blood sugar.
the injection is given. Someone at home or work should know how to inject
you with glucagon, because when your blood sugar is running too low you
will not be able to self-inject. As a side effect, glucagon injection may cause
nausea and vomiting. If low blood sugar does not improve even by injecting
glucagon, somebody should rush you to a hospital where intravenous
glucose (dextrose) may be administered.
DIABETIC KETOACIDOSIS. DKA or diabetic ketoacidosis is a serious
medical condition in which blood sugar becomes very high (400 to 1,000
mg/dL), the body starts burning its own fat, poisonous substances called
ketones are produced in the body, and acids in the blood become very high.
How does this happen?
Insulin, as noted before, helps sugar move from the blood to enter into
muscles and cells in your body where it is needed for energy. When,
however, the body does not produce enough insulin or the insulin it
produces is ineffective, sugar remains trapped in the blood and is not delivered
to the cells of your body. As a result, the cells do not get energy and
begin to starve. In such a situation, the body looks for an alternate source of
energy that it finds in its stored fat reserves. The body burns this fat to get
energy and, in this process, poisonous substances called ketones are
produced that accumulate in the blood. Too many ketones cause an
abnormal increase of blood acids.
The kidneys try to get rid of excess ketones through increased urination.
Excretion of large amounts of urine, called diuresis, causes severe loss of
water, sodium, potassium, and other nutrients. Loss of these nutrients may
disturb heart rhythm and impair functions of other organs. Loss of fluids
caused by excessive urination in DKA is harmful in other ways also. First,
the body becomes short of water and cannot excrete more urine to eliminate
sugar and ketones that may still be present in excess in the blood. Second,
due to the loss of fluids, sugar and ketones in the blood become highly
concentrated. Both these conditions tend to prolong ketoacidosis.
DKAis different from a condition called ketonuria, which occurs when
you do not eat food for 12 to 18 hours, and your body tries to derive energy
from its own fat reserves. In this process, fat reserves in the body tend to
break, producing ketones (acids) that are excreted in the urine in small
amounts. This is a normal phenomenon and is sharply different from DKA.
TYPES OF DKA. DKA can be mild, moderate, or severe. Its severity is
determined by the relative increase of sugar in the blood, ketones in the
urine, and the degree of acidity in body fluids. Usually, you are not confused
in mild DKA, confused/drowsy in moderate DKA, and unconscious or in a
coma in severe DKA. A severe condition of DKA with extreme blood
acidity can even lead to death.
CAUSES OF DKA. The main cause of DKA, as noted before, is an insulin
disorder in which insulin is either lacking in the body, or it is unable to work
properly, or both. As a result, blood sugar is not controlled and it rises too
high. Any or a combination of the following factors can cause a lack of
insulin or blunt insulin action in your body, contributing to DKA:
• Taking insulin injections of a lower dose than required.
• Skipping your insulin injection.
• Using expired and bad insulin.
• Avoiding insulin injections although injecting insulin may be
essential for controlling blood sugar.
• Insulin requirement may increase during illness such as the flu or
other infections, but a sufficient quantity of insulin is not injected.
Symptoms of DKA
- High blood sugar – Nausea and vomiting
(400 to 1,000 mg/dL) – Abdominal pain
- Excessive urination – Drowsiness
- Ketones in the urine – Fever
- Deep rapid breathing – Severe weakness
- Dehydration – Flushed face
- Excessive thirst – Cloudy thinking
- Excessive hunger – Fruity smell in breath
- Dry mouth – Loss of consciousness
• Certain factors tend to diminish insulin action in the body, resulting
in raised blood sugar levels. These factors include stress, shock,
excessive consumption of alcohol, certain drugs such as water pills
(thiazides), nasal decongestants (terbutaline), and cortisonecontaining
medications, including medicated skin creams and
• Raised blood levels of certain hormones such as glucagon, cortisol,
and growth hormones.
You can prevent DKA by taking these precautions:
• Do not allow your blood sugar to exceed 250 mg/dL.
• If you normally do not take insulin to treat diabetes, take it to regulate
uncontrolled blood sugar levels. Take rapid-acting insulin (see
chapter 14) to bring down high blood sugar.
• Do not miss your insulin dose.
• You may need to increase your insulin dose when you are stressed.
• Follow the sick-day rules:
– Test your blood sugar frequently.
– Take your insulin dose even when you are not eating or
you are vomiting when ill.
– If your blood sugar remains high, take an additional dose
of insulin immediately.
– Drink plenty of fluids, at least 1/2 to 1 cup every hour to
avoid water deficiency in the body.
– Use a dipstick such as ketostix to check the urine for
ketones; if ketones remain high, notify your doctor.
– Call your doctor if your blood sugar remains above 250
mg/dL and the urine has ketones.
– If your blood sugar remains above 300 mg/dL on 2 to 3
tests, call the doctor even if the urine is free from ketones.
Generally, an untreated infection is the immediate cause of very high
blood sugar levels, leading to DKA.
WHO GETS DKA. Although DKA can occur both in people with type 1 and
type 2 diabetes, it typically occurs in people with type 1 whose bodies do
not produce insulin (absolute deficiency of insulin). DKA can develop very
quickly when these people are stressed out or ill due to a cold, the flu, or
some other infection. People with type 2 diabetes may develop DKA when
they are under stress or have some severe infection.
TREATMENT OF DKA. Being an emergency condition, DKA needs to be
treated in a hospital or under the care of a professional with regular monitoring.
Treatment of DKA in a hospital may include:
Insulin Treatment. To lower high blood sugar in DKA and reduce the
resulting raised levels of ketones in the blood, administration of insulin is
essential. Insulin treatment of DKA in an adult person may start with intravenously
injecting a dose of regular insulin such as 0.15 unit per kilogram
of body weight. (When insulin is injected intravenously, that is, in a
vein, it begins to work quickly. Normally, insulin is injected in the skin.)
After this dose, a smaller dose of regular insulin such as 0.1 unit per
kilogram of body weight, per hour, may be continuously infused until
blood sugar is brought down to less than 200 mg/dL.
Fluid Replacement. To replace fluid loss caused by frequent urination and
vomiting in DKA, you should drink plenty of water. Adiet beverage, herbal
tea, or some other drink preferably with an artificial sweetener may also be
used. If drinking by mouth is not possible due to frequent vomiting, saline
water solution may be slowly injected intravenously. Low blood pressure
caused by dehydration improves with fluid replacement. Care is taken in
fluid replacement because excessive administration of fluids can lead to
brain swelling, causing dysfunction in the brain.
Potassium Replacement. Continuous administration of insulin and infusion
of fluids to treat water loss in DKA may dilute potassium in the blood and
drop its level. Potassium deficiency may produce irregularities in the
rhythm of heartbeats (arrhythmia) and cause breathing problems. To
resolve its deficiency, potassium is infused intravenously.
Administration of Antibiotics. If infection is present, it is treated by
Regular Monitoring. When you are treated for DKA in the hospital, your
condition is frequently monitored to assess that your blood sugar has been
controlled, urine has become ketone-free, fluid loss has been treated, and
electrolytes, including potassium and chloride in the blood, have normalized.
Usually, emergency treatment of DKA takes less than 12 hours in
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS). The condition in
which blood sugar rises greater than 900 mg/dL, making the blood too
sticky, is called hyperosmolar hyperglycemic state or HHS for short. HHS
can happen in both type 1 and type 2 diabetes, but it typically occurs in
people with type 2 diabetes who do not take insulin to control their blood
sugar. Excess sugar in the blood, as noted before, causes frequent urination,
Symptoms of HHS
HHS shares some of the common symptoms of DKA: excessive thirst,
frequent urination, fluid loss, acute weakness, drowsiness, and mental
confusion. But HHS has certain symptoms that distinguish it from
DKA. In HHS:
• Blood sugar may exceed 1,000 mg/dL.
• Because the body does not burn fat in HHS, ketones are not
produced and the blood has no increased acidity.
• The urine is almost ketone-free.
• Blood pressure is generally very low.
• Risk for seizures and stroke increases.
• Loss of consciousness is much more common.
leading to severe loss of fluids in the body. Loss of fluids makes the blood
thicker and more concentrated. Too much thickness of the blood in HHS
poses a high risk for blood clotting, a condition that may lead to a stroke or
Because HHS typically occurs in people with type 2 diabetes in whom
the pancreas is still making some insulin, their bodies do not break down
their fatty cells for energy. As a result, unlike the condition in DKA, there is
no excessive increase of blood acids in HHS. However, HHS is more
dangerous than DKA: the mortality rate in HHS is about 15 percent
compared to less than 5 percent in DKA.
CAUSES OF HHS. Any of the factors below may contribute to HHS:
• Persistently high blood sugar due to poor control of diabetes.
• An untreated infection, as in DKA, is usually the immediate cause
of raised blood sugar levels in HHS.
• High concentration of sugar in the blood. As people with diabetes
grow older, their kidneys become weak and do not excrete excess
sugar from the body as they should. As a result, sugar tends to
concentrate in the blood. (At a young age when your blood sugar
rises to about 180 mg/dL, your kidneys excrete excess sugar
through the urine. As the kidneys become weak with age, they are
not able to excrete excess sugar properly.)
• Stress. It decreases the action of insulin, raising blood sugar levels.
• Blood pressure-lowering drugs of the diuretic class. These drugs
increase the amount of urine (see chapter 19). Excessive urine
shrinks the volume of water in the body, leading to concentration
of blood sugar.
• Drinking too little water. Restricted intake of water decreases
dissolved sugar in the blood and increases its concentration.
• Raised hormones. As in DKA, raised blood levels of certain hormones
such as glucagon and cortisol may raise your blood sugar.
TREATMENT OF HHS. Treatment of high blood sugar in HHS is almost the
same as in DKA (noted before). In HHS, ketones are found in a small
amount and, therefore, their treatment is not a problem. The main problem
in HHS is the presence of very high levels of sugar in the blood. To bring
down high blood sugar levels in HHS, insulin is administered in a dose that
may be about 50 percent of the dose used in treatment of DKA. (This is
because HHS typically occurs in people with type 2 diabetes, who are
more sensitive to insulin than people with type 1 diabetes getting DKA).
HHS is a medical emergency to be handled in a hospital.
PREVENTING HHS. The measures for preventing HHS are almost the same
as that for preventing DKA.
The medical emergencies of low blood sugar, very high blood sugar,
and an abnormal increase of acids in the blood are preventable crises. Keep
your blood sugar under control and avoid the causes that lead to these
events. When, however, these emergencies do occur, they can be successfully
resolved by taking timely action as outlined in this chapter.