ASK THE DOCTOR

by Wesley W. Wilson, MD

NOTE: If you have any questions for "Ask the Doctor," please send them to the VOICE editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.

Wesley Wilson, MD is an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school.

Q: My husband sometimes has sudden and severe "lows," and I've had to call 911 several times. The doctors suggest we keep Glucagon on hand. What is Glucagon, and how does it help?

A: Glucagon is a hormone, naturally produced by the Alpha cells of the pancreas, and also available (by prescription) in "kit" form, for emergency use to correct hypoglycemia. If a person is experiencing a "low," an injection of Glucagon quickly raises blood sugar by causing release of glucose stored in the liver. The Glucagon kit contains powder, diluent solution, and a syringe. The diluent is added to the powder, which dissolves immediately, and the resulting solution is injected just like a shot of insulin. Blood sugar should rise rapidly, with changes evident in about 15 minutes. Although an individual undergoing a severe "low" cannot self-administer Glucagon, anyone who is at risk of hypoglycemia, and who can depend on another person for help, should have a Glucagon kit--and the "rescuer" should be trained in its use.

Glucagon is only one of the measures available to counter the risk of hypoglycemia. The first thing a person can do is test more frequently, especially if anything occurs that might increase the risk of hypoglycemia. Even a modest increase in exercise or physical activity, a lighter-than-usual meal, or a history of repeated "lows" at a given time of day, can increase the risk of hypoglycemia. Caution and early detection can prevent most severe lows.

Since the Diabetes Control and Complications Trial (DCCT) was published in 1993, there has been much emphasis on "tight control" of blood sugars, keeping the numbers as close to non-diabetic "normal" as possible, to reduce risks of complications. Although tight control brings an approximately 60% reduction in risk of eye, kidney, and nerve complications, it increases the risk of serious hypoglycemic episodes.

Although many people can detect, from how they feel, whether or not their sugars are below normal, that is not always a reliable test. Insulin-using diabetics can sometimes lose this ability, particularly if they have experienced repeated "lows." They are then said to have "hypoglycemia unawareness." This complicates blood glucose management, as the "safety margin" is gone, and now the first sign of a low may be confusion or (in children espcially) seziure. Is your husband always aware of his blood sugars, or is he sometimes surprised to find them down around 50 to 60mg/dL with no symptoms?

The measures needed to reduce the risk of hypoglycemia are the same ones used for careful management of diabetes. All persons with diabetes should watch diet and "do carb counting." They should have a daily regular program of exercise. They need to check blood sugars often. If there is any hint of something wrong, check the sugar. Early detection means prompt action can be taken. In extreme circumstances, that action might be a Glucagon injection.