Hypoglycemia + Heart = Things You Need To Know ASAP

 

Does this illustration scare you?

It should.

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I first encountered this slide during an academic lecture given by Dr. Mikhail Kosiborod, MD when I attended the International Hospital Diabetes Meeting in May. He was sharing data about cardiovascular events and outcomes. (If you’re not an academic, the smart people begin to sound like Charlie Brown’s teachers after a while.) But when this illustration came onto the screen, I frantically scribbled the study’s authors down.

This slide was the first time I saw so plainly what was happening to me when I had a moderate hypoglycemic episode. (Dr. Kosiborod said that a “moderate” hypo was 57 mg/dl or less.) Not just the “I feel like I’m dizzy and not all here and let’s concentrate on something insignificant and is it hot in here?” reaction. This was what was going on inside without me feeling most of it. 

Complications are not always from high blood glucose levels

We all know the long-term implications of high blood sugars. It’s that same old “-Opathy” chant that everyone sings loudly: “Retinopathy-neuropathy-nephropathy” with the back-up singers humming: “Don’t forget about stroke and amputation and arteriosclerosis and…big finish, everyone! Gum disease!”

But with lows, it’s a quick ditty: “Unconciousness, seizure, death.” It’s not a chart-topper, but it can be #1 with a bullet if you’re hypoglycemic. When I had those times of “Whoa…let’s stand in the kitchen and daze off into space,” it didn’t feel like I was doing any damage to my body. Sure, I felt like my head had been run over by Gravedigger and I was treading in molasses for several hours after some lows, but I recovered. Or so I thought. Now?

I am setting myself up for long-term complications with repeated moderate low blood sugars. So are you. 

Here’s what happens (you can follow along with the slide, but I’ll break it down in terms we all understand):

Inflammation

Every moderate hypoglycemic reaction sends out wonderful proteins to increase inflammation in our body. (I’ll cut to the chase. We don’t want that.) They are:

Vascular endothelial growth factor (VEGF ), is a signal protein that helps to promote the growth of new blood vessels. We need VEGF as we grow in a womb (to create the blood vessels), after exercise or injury, and VEGF can help create new blood vessels when there is an obstruction. But, much like really good food, it’s only good in moderation. Too much of it (“overexpression”) can contribute to asthma, retinal problems, and  cancers.  The levels go up when we have a moderate hypoglycemic episode.

C-reactive protein (CRP) is a protein released in response to inflammation. Some of our organs, like colons, show a greater risk of cancer when they’re chronically inflamed. This lovely protein also raises our risk for heart disease, high blood pressure, and coronary artery disease.

Interleukin 6 (IL-6) is an interleukin (No, I’m not a medical professional or a biology whiz, so I had to look it up. Fancy word for protein) that does double duty: it promotes inflammation and can help with healing in certain situations. In this case, when we have a low, it’s under the inflammation category. And it gets busy.

“IL-6 stimulates the inflammatory and auto-immune processes in many diseases such as diabetes,[22]atherosclerosis,[23]depression,[24]Alzheimer’s Disease,[25]systemic lupus erythematosus,[26]multiple myeloma,[27]prostate cancer,[28]Behçet’s disease,[29] and rheumatoid arthritis.[30]” – Wikipedia

Endothelial Dysfunction

Vasoconstriction, the narrowing of blood vessels, is not something you want unless you need to stop a massive bleed. But, when you don’t need to stop a hemorrhage, it’s not often something super to have going on. Vasoconstriction raises blood pressure (which is why vasoconstrictor medications are given to people with low blood pressure) and can cause erectile dysfunction. You know what else causes vasoconstriction? Caffeine. Sigh.

Time for a breather. Here’s a picture of a bunny, because this stuff is pretty heavy. Warning, after the bunny, there are no more cute things. 

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Abnormal Blood Coagulation

If it’s a medical term and it starts with “abnormal”: uh-oh.

Factor VII is another protein in our body that helps the clotting process. Too little Factor VII = hemophilia. Too much Factor VII = clotting when there shouldn’t be. Moderate hypoglycemic episodes increase this protein in the body.

Neutrophils are white blood cells. When inflammation starts, neutrophils head towards the area of inflammation. Because our body is doing the inflammation dance when we’re having a moderate low, neutrophils show up for the party, too.

Platelet Activation – platelets help to staunch bleeding by clumping and clogging a blood vessel. Great for stopping bleeding, of course, but lousy when the result is thrombosis. We increase platelet activation when we’re low.

Sympathoadrenal Response

We release adrenaline, epinephrine and norepinephrine as our blood sugar sinks into the basement. It’s that “fight or flight” feeling; that “out-of-control and my heart is racing” feeling. It’s our body’s adrenal response to get us to do something.

When we have multiple hypos, we can developed a suppressed sympathoadrenal response – and that’s hypoglycemic unawareness. Clinicians talk about raising a target blood glucose level because a person with diabetes has hypo unawareness to retrain the body to have that adrenal response again.

But your nervous system also factors into play here. Your autonomic nervous system. Your heart is part of this system. A moderate hypo causes your heart to beat faster (“Thud-thud-thud”) and can cause long-term issues with the timing of your heart (arrhythmia). We’re making our hearts work harder.

It’s Not Over When You Think It’s Over

Your blood glucose level comes up and the hypo is over. But what happened to your body is not over. Not by a longshot. This is what I learned at the symposia at ADA’s 75th Scientific Sessions on Hypoglycemia.

And it’s this:

Vascular issues can last up to two days and blood coagulation issues for up to a week. 
Every moderate hypoglycemic episode builds up inflammation and coagulation responses in my body. One sucky hypo a week was not uncommon for me, even with a Dexcom.

What Am I Doing Now?

I’m doing everything to prevent a moderate or severe low blood sugar. The research I did shows me that I can change the way I react to my lows and help prevent these “issues” from happening.

My CGM is constantly on my body and I’ve set it to alarm at 80mg/dl so that I’m still in my right mind to look at it and take action if I need to do so. Has this helped?

Yes. 

Instead of alarming at 70, when I often tell myself that I’m invincible and that my blood sugar will go back up on its own (I’ve said this to myself a lot…Yes, I know. False.), I’m catching that low. It also has prevented the response of eating everything in the kitchen because I’m in “fight or flight” (or “stuff your face or pass out”) mode. My stress level is lower and I feel more in control.

And that is what this post is about… giving you the info and giving you the opportunity to help yourself, because while you can’t control having diabetes, you can control how you manage it. And hypos are not so innocent.

 

Glucagon

glucagon-extinguisherThe red box.

I’ve shown it to coworkers. To family. To friends. I open the box up, show them the contents, and go through a complicated pantomime of what they would need to do. (Marcel Marceau is rolling in his grave. Silently, of course.) I had one staff meeting where my team played Rock Paper Scissors for who would use the red box. Make no mistake – it was the loser who got to administer it on me.

The red box is my glucagon kit and in all my years of T1, it has been used twice on me, and I was awake each time (although it was close). If you are having a severe hypoglycemic episode and can’t ingest glucose (because you’re unconscious or throwing up or can’t get another gram of glucose into you by mouth), it’s what’s going to help you.

It’s an insurance policy. The kits do expire and they’re aren’t cheap, even with a prescription, but it’s worth having – if you have someone with you who knows what the hell to do with it. It’s not a “take it and jab it into her butt and there you go” sort of deal. While you are incapacitated (and let’s be honest… if your blood sugar is 25, you’re not exactly spouting off the Declaration Proclamation verbatim, although you may think you are), the individual you trusted to use this kit must follow a set of directions that involves a few steps. It’s not like someone is going to rifle through your things and say…

“Hey, look! A glucagon emergency kit! Let me sit down and read the directions and get comfortable with this concept and figure out what to do…wow, there are a lot of steps… before I plunge a needle into your…”

If they don’t know what it is, what it’s for, what they need to do, it’s going to sit there.

So, here’s my challenge for you today.

If you have a glucagon kit, talk about it with the people who you love and hang out with you. If you have someone you work with that you trust, talk with him/her. I know that some people don’t want to disclose diabetes at work, but the last thing you want is to pass out and not have anyone understand why.)

  1. Show them where it resides (in your backpack, in the refrigerator, in your bedside drawer).
  2. Explain what it will do for you and what it won’t do.
  3. Tell them that you will do everything to avoid ever having to use this, but if it does need to be used, that you trust them to do whatever it takes to keep you alive – and it will keep you alive.
  4. Pull out the kit, go over the instructions, and answer any questions that they might have about it.
  5. Thank them. This is so important. Thank them for caring enough to help you if you can’t help yourself. It’s just as scary for them as it is for you when you are crazy low and/or unconscious.

 

I have an Eli Lilly Glucagon Emergency Kit for Low Blood Sugar. And you know what Eli Lilly did?

They made an app for the iPad and iPhone, giving you easy visuals to share and show – and prepare in case something does happen.

This is the website where you can get more info and click to download the app. I put it on my iPhone and it’s very easy to use:

www.lillyglucagon.com

app-screenshots

Until there are easier ways to administer glucagon (and there will be, because I believe that what is currently in clinical trials will become FDA approved – administered nasally versus intramuscular injection? Oh, yes.), it’s important that we give ourselves and those who are around us the tools and resources to help. (That nasal glucagon link? They are still recruiting, so you can help us all out if you are near a trial center.)

Now, what if you don’t have a glucagon kit?

Get one. Ask your doctor for a prescription and get one from your pharmacy. (Note: check the expiration date on the kit while you are standing at the pharmacy window. Do not accept a kit that has less than a year left to use it. Unlike some other supplies, this one will become less potent after the expiration date and because it’s expensive, don’t waste your money on a kit with just a few months left.)

As I said before, they are expensive and it’s one of the few things about my diabetes management in which I want to let expire.

Why do I tell you this?

I had a severe hypo a few weeks ago. Severe enough that I needed John to help me, because I could not longer use my legs to get more glucose. I was scared.

And after the disastrous event, both of us admitted that the red box was about a minute away from being used. If I hadn’t forced (and kept down) another juice box, it would have been a reality. I am thankful that I took the time to show John how it should be used and trust his judgement. I want everyone to be thankful. And everyone to have a red box – and never use it.