TREATING HYPOS

THE LATEST LOW-DOWN

Knowing how best to treat a hypo isn’t always easy – sometimes it feels hit and miss. However, New Zealand-based researchers have done groundbreaking work on hypo treatment methods.

For people living with type 1 diabetes, keeping blood sugar under tight control with insulin is all important. But this inevitably brings a risk of hypos – hypoglycaemia – when blood sugar drops too low.

Likewise, people living with type 2 diabetes may find themselves dealing with hypos if they’re on insulin therapy or sulphonylurea tablets.

When you go low, you need a hit of glucose fast, to bring your blood sugar into target range again. But it’s easy to undertreat the low, which can mean your body keeps desperately craving food. You cram in snacks, and, before you know it, you’ve eaten enough to send your blood sugar high again – a “rebound high”. You need more insulin to bring it down, but it’s even harder to know how much you need this time. Next thing, you’re on a blood-sugar roller coaster until you finally find the right balance.

For the past decade, a small team of New Zealand researchers have been investigating the optimum treatments for hypos. Diabetes Nurse Specialist Lindsay McTavish has spearheaded the research, working with endocrinologists Esko Wiltshire, Jeremy Krebs, and Brian Corley, and geriatrician Mark Weatherall. It’s research the whole diabetes community can benefit from.

WHICH HYPO TREATMENT WORKS BEST?

Ideally, a hypo treatment works as quickly as possible – not just so you can function normally again fast, but to calm your body’s food cravings and make sure you don’t end up consuming more sugar than you need and going high. What works best for that?

Lindsay McTavish realised that most hypo treatment guidelines were based on expert opinion rather than solid evidence.

In 2008, with Esko Wiltshire, Lindsay conducted a trial at a national diabetes youth camp. With the permission of children, parents, and camp leaders, they tested four commonly used treatments when children had hypos: glucose tablets, jellybeans, orange juice, and fruit Mentos.

In the end, 52 hypos were treated with glucose tablets, 45 with jellybeans, 44 with juice, and 48 with fruit Mentos. Blood glucose was measured at 0, 2, 5, 10, and 15 minutes.

The conclusion? Glucose tablets, juice and fruit Mentos all gave similar quick results. However, jellybeans produced a lower, slower response.

HOW MANY CARBS DO YOU NEED TO TREAT A HYPO?

Until recently, most guidelines around the world, including in New Zealand, recommended giving a standard amount of carbohydrate (usually 15g for adults and less for children) to treat a hypo. (Although sometimes weight-based protocols were used for children.)

Lindsay and his coresearchers had used a weightbased method in their study at the children’s camp – treating hypos in each participant with 0.3g carbohydrate per kg of body weight. This had been effective.

Lindsay suspected that weightbased hypo treatments could also be more effective for adults with type 1.

Lindsay McTavish, Diabetes Nurse Specialist

They recruited 34 adult participants with type 1 who had frequent hypos and tested three different protocols on them:

• Treating hypos with 0.2g glucose per kg body weight

• Treating hypos with 0.3g glucose per kg body weight

• Treating hypos with a standard 15g glucose. The glucose was in the form of Dextro glucose tablets.

The results showed that, for adults with type 1 diabetes, a weight-based hypo treatment of 0.3g of glucose per kg of bodyweight is superior to a standard 15g treatment and avoids rebound highs.

HYPO TREATMENTS FOR PUMP USERS

Lindsay and his co-researchers turned their attention to insulinpump users – adults and children – to see whether the benefits of the weight-based protocol would hold for them, too.

Sure enough, the weightbased treatment based on 0.3g of glucose per kg of bodyweight was more effective in resolving hypos than a standard treatment amount, and did not result in excessive rebound highs.

WHAT ABOUT TYPE 2?

In 2018, the researchers launched a study, funded by Diabetes NZ, to see whether weight-based protocols for treating lows were effective for adults with type 2 diabetes who use insulin.

The results were not so clear cut as those for type 1. However, using 0.3g of glucose per kg of body weight was effective, as was a standard dose of 30g of glucose.

KEY POINTS

• For children and adults with type 1, whether using pumps or not, a hypo treatment of 0.3g of glucose per kg of body weight is generally most effective, with the least risk of a rebound high.

• For children with type 1, glucose tablets, juice, and fruit Mentos are equally effective hypo treatments. Jellybeans are less effective.

• For adults with type 2, a hypo treatment of 0.3g of glucose per kg of body weight is effective, as is a fixed dose of 30g glucose.

• Glucose tablets and juice have the carbohydrate content in the nutritional information panel, allowing you to calculate the exact dose of carbohydrates. Fruit Mentos don’t have this information on the roll packets, but each regular sized Mentos lolly contains 2.8g carbohydrates.

• See the latest type 2 guidelines here: t2dm. nzssd.org.nz/Section97-Management-ofhypoglycaemia

REFERENCES

Effective treatment of hypoglycaemia in children with type 1 diabetes (2011). http://doi.org/10.1111/j.13995448.2010.00725.x

Weight-based hypoglycaemia treatment protocol for adults with Type 1 diabetes (2015). doi.org/10.1111/dme.12730

Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy (2018). https://doi.org/10.1111/dme.13576

Optimizing the management of hypoglycaemia in individuals with type 2 diabetes (2018). doi.org/10.1111/ dom.13231