 Hello everyone, this is Dr. Ahmet Ergin and today we are going to talk all about low blood sugars So let's summarize what we are going to talk about today So we will start with what number is a low blood sugar number That is a big point that everybody needs to know number two is how do you really feel when blood sugar is really low, right and Can you also have a low blood sugar if you are not adiabatic that is also a common question that I get and Harm, how harmful is it really? Like do you really get harmed if you have low blood sugars mild blood low blood sugars or moderate to severe low blood sugars? How harmful it is we will discuss about that and what happens if you have severe Hypoglycemia, how does it feel and how do you really treat that the next thing we're going to talk about is The what causes low blood sugar because it is something that everybody needs to know to be able to prevent the low blood sugar and of course, we're going to talk about how to reduce the risk and One of the things that commonly can lead to hypoglycemia or low blood sugar is exercise We will talk about how exercise can affect or cause low blood sugar And we will discuss some about the fear of low blood sugar because once you have a low blood sugar You may start being fearful of low blood sugar and it can make a big change in your diabetes management And of course, we will treat how to treat we will talk about how to treat low blood sugars effectively and quickly and We will talk about a symptomatic low blood sugars as well as sometimes people will have a low blood sugars And may not know it. We will also have a touch base on Sometimes blood sugar being normal, but feeling low as well So stay tuned and we will dive deep into it right now So if you're new to the channel, I will just describe what we do here I'm an under chronologist by trade and Davi. This is my passion What we do is we treat patients either in person in our Florida West Palm Beach office or Virtually across Florida and New York State as well. So we can do everything and actually better than in person visits through virtual care Including remotely monitoring your blood sugars and staying in touch with you all the time So we have a different way of practice and these videos are educational and of course if you need individualized care Definitely, we will be more than happy to help you if you live in Florida or New York State Let's move on the first topic. What number is really low? typically We consider low blood sugar less than 70 milligram per deciliter That's 3.9 nanomall. We have a lot of members from outside the United States. They're sometimes asking about the numbers that is not in That that that I would say in metric units So 3.9 will be the the low blood sugar for that and 70 milligram per deciliter But on the other hand less than 54 is Really what we are concerned about that's really clinically important to low blood sugar now Less than 70 is important. Yes, it is but it's really not a big deal If you are just having 65 or 70 occasionally If you're going below 54, you will really have Quite a bit of symptoms and it will not feel good at all and it can also cause Problems in the body as well. So that's why we consider less than 54 symptomatic and and not necessarily symptomatic But it's clinically important Just because you can actually have symptoms even if your blood sugar is at 100 if you are normally running at 300 And going down to 100 sometimes can cause symptoms as well So, how do you feel? Really when you have a low blood sugar, well, it doesn't feel good. That's for sure So what happens is basically your body will go into a panic reaction We divide the symptoms into neurologic or neurogenic or adrenergic or adrenal induced so basically your body pumps a lot of adrenaline as If you are about to die, so it causes a lot of heart racing Sweating Panic reaction excessive hunger Shaking in the hands as if you're losing blood same reaction if you were bleeding to death Is given by the body like feeling clammy hot heart racing All that stuff that happens with any panic reaction in the body So it doesn't feel good at all The neurological symptoms could be dizziness could be confusion. It could be irritability I'm being snappy So if your husband or wife tell you why you're having a you know problem with me, you can just say oh my blood sugar is low I'll go although you have to prove it sometimes because that doesn't always work that way But regardless definitely neurological symptoms can happen severe confusion can happen I have seen people like zoning out totally When they have low blood sugars, they may actually hear you sometimes and they may not even respond so if somebody is Not responding to you Don't think that they are in salt trying to insult you or offend you just check your blood sugar Especially if they have diabetic. Okay, that's not that's a better idea But those things can happen, especially if this if the low blood sugar gets deeper and deeper Their responsiveness will be lower and lower and if they're not responsive at all and if somebody has diabetes What do you do? You have to make sure that you find Glucogon and if it is a relative or a friend You should probably know whether they're keeping your glucagon typically forage But it's not a bad idea to be familiar But how to use glucagon as well if somebody's having severe low blood sugar which at that point They may not even be responsive at all to you. So don't try to show Honey and sugar into their mouth that may not be very helpful Although if there's nothing else you can do if there's no IV line or or a glucagon around Then yeah, you have to do something so putting a little bit of a honey in the side of the mouth Can still help but it may not be very helpful Especially if they have taken a heavy dose of insulin you have to better call 911 before losing too much time I would say call 911 try to look for a glucagon Put some honey at the same time Do your best, but these are the number of things that you should be considering when somebody is unresponsive with diabetes Now can you have low blood sugar if you do not have diabetes? Yes, you can we call that reactive hyperglycemia That typically happens a lot of 10 to 15 years mostly after gastric bypass surgery or in some insulin resistant patients or prediabetic patients or some people who are just just being Prone to it Especially after a high carbohydrate load so sometimes they may eat just cookies bread or pasta stuff like that that are high carb But not a lot of fat content in the food that can spike your blood sugar significantly And that causes the insulin discharge of course But then since some of these carbs are rapidly absorbed and disappears from the blood And insulin may still Stick around and that excessive insulin can drop them Below 70 so they may start with 80 blood sugar. They may go up to 190 Although they're not diabetic, but it can happen go to 190 We call people diabetic if they're spiking more than 200 after meals, right? so they may go to 180 190 after a big heavy carbohydrate load and then the next thing you know that their blood sugar is actually plummeting down to 60 a very fast and they will feel that and that's we call that the reactive hyperglycemia dietary adjustment is the key and sometimes we do Medication management as well, but the dietary adjustment generally fix that problem when it happens in non-diabetic patients We discussed about the severe hyperglycemia a little bit But what causes low blood sugar is is manufacturers So I think that is the most important thing that you have to be familiar with Because that is basically what most people do not understand and the patient education is a key So I'm going to talk to you about a few things that can cause low blood sugar You should understand the risk concept You are at risk if you have certain features for low blood sugars low blood sugar does not happen Just from a one single thing it happens from many factors generally coming together So if you have a long duration of diabetes, let's say at least 10 15 years or more Then you're actually losing glucagon producing cells. Glucagon is the main hormone that makes you Contra act the low blood sugars so insulin reduces your blood sugar and glucagon increases the blood sugar Initially glucagon is a nuisance because it tends to increase your blood sugar for diabetics but later on actually that hormone goes away and then you totally lose the Protection against low blood sugar so that is one of the problems having diabetes for a long time can increase your risk of low blood sugar Especially if there's other offending factors such as some medications which we will discuss such as sulfonylureas or insulins Can make you more prone to have hyperglycemia or low blood sugar? Very easily if you're older That is also a risk factor because as you get older your reflexes your response your panic reaction everything becomes more dull Things become slower your body does not respond as well So your blood sugar may be dropping quite a bit and you may not even realize that the other on the other hand in older people They tend to not metabolize the medications well So they may occasionally be Overmedicated or drug interactions can happen which can potentiate the effects of medications and again older individuals do not Metabolize the medications sometimes too well They tend to have more chronic kidney disease chronic liver disease, etc Their organs are not well functioning at their protective hormones like glucagon or their liver. They're not as good They're not as robust. So as if you're older and you're diabetic, you're again at high risk of low blood sugars now, of course sometimes low blood sugar happens when either the doctors or the patients are Extremely passionate about bringing their blood sugars to as low as possible Well, when you do that and when you try to use everything in the world to trying to reduce your blood sugars Sometimes you are really putting yourself at risk of dropping your blood sugar too low It's like if you are trying to if it takes two hours from go from a to b from cda to cdb And if you're trying to make this in one and a half hours trying to save another half an hour Yes, you can do it But then you may have an accident down the road, right? If you're going faster and without caution Same thing with diabetes if you're trying to use a lot of medications to try to bring the blood sugar down as much as possible Or you're reciting your diet too much But you're also taking medications to reduce the blood sugar Then you're really looking for trouble. That is another big factor that you have to balance out How much medication you are taking? What's your diet and so forth a lot of people go into a diet? You'll like for example, they hear about this keto diet They say oh, I'm gonna do this and then they don't think about their medications They're already on and a suddenly next thing they know is they bottom out because they're taking medications that can cause severe low blood sugars and That's why I always tell you guys always talk to your doctor Preferably a diabetes specialist or a neurochronologist so that you can actually modify your regimen if you are going into a diet Again, if you're on let's say a cell phone a urea such as Glypozide Glyboride glima paride, these are the cell phone ureas or megalithinize that are more shorter-acting agents such as Repa-Gyllainide or Nathe-Gyllainide some people know these as starlyx or prondin These are medications also although they are pills They still put you at significant risk of low blood sugars if you do not have a regular eating schedule So you have to be very careful about these drugs if you're on them You have to have a regular eating schedule same thing with insulins if you're taking insulin I'm not talking about the long-term insulin or a long-acting insulin But I'm talking about the short-acting insulins if you are taking short-acting insulins for meals You better eat that meal so if you're taking ten units of novel log or hemologue or a pedra And that ten units will do its job. It's gonna bring your blood sugar down. So if there's no blood sugar Coming or if there's no carbohydrates coming into the bloodstream from the food There will be no balancing. So we typically give short-acting insulins to balance the The sugar that's coming from the food, right? So but if you do not have that then you will definitely Go down on The blood sugar very rapidly. So you cannot just take a short-acting insulin and just forget about the forget about your lunch or dinner Which happens actually to people a lot, especially if you're at work, you know, things can happen very quickly If you had a previous low blood sugar You know, it's like having a criminal record if you had a criminal record They they expect you to potentially have another crime. So they watch you, right? So so if if you are if you had a low blood sugar, that's not a crime I'm just giving an example But if you have a if you have a low blood sugar that that means that there is something going on that put you at Hypoglycemia or low blood sugar to begin with So whatever it may be unless it is totally fixed You are at risk of having another low blood sugar. So that is something that you have to pay attention The fear of hypoglycemia kicks in low blood sugar fear of low blood sugar kicks in once once somebody have a Severe low blood sugar. It's not a good feeling at all That is that's that's a psychological thing that we have to address separately But again, we always pay attention if somebody had history of low blood sugar Again, the another big factor is exercise, right? So when you guys exercise your body starts utilizing the blood sugar like heavily So if your blood sugar is normal or mildly a little bit high before the exercise I always tell my patients eat some carbs now how much carbs that is generally one gram per kilogram per hour or like maybe you can say half half a gram per per pound per hour and depends on the intensity of exercise and you know occasionally though interestingly if you're doing a high intensity exercise that can Discharge a lot of adrenaline at the beginning and your blood sugar actually may go up during the exercise Which follows by a low blood sugars down the road in like let's say three five six hours later But if you do not want to actually drop your blood sugars during the exercise like in the middle of the exercise You may want to mix the high intensity and low intensity exercise So high intensity exercise will actually boost your blood sugars and low intensity or cardio We'll try to bring your blood sugars down So that that is a strategy, but the most important strategy is checking the blood sugars You can do a finger sticks if that's what you have you can do you can use your dexcom g6 or g7 is coming You can use freestyle librae or freestyle librae 2 is coming You know all those good advancements You can use if you have the means if your insurance covers it great tools to help you understand What's going on with your blood sugars why dexcom g6 is so good or g7 or freestyle librae 2? Because they actually tell you what is about to happen based on the current to drop in your blood sugars So if you are starting your exercise a hundred and fifty and your blood sugars are dropping at 60 milligram or 90 milligram per hour Or depending on the minutes, you know that the machine calculates and tells you it shows you for example two arrows down That means that you're going to drop severely so stop the exercise and eat something before you go down there So these are the important things that you have to be really really on top of if you are exercising, which is important I'm not saying don't exercise you have to exercise It's just that especially if you're on insulin and certain agents that can drop your blood sugars You may be at significant risk Now of course guys, you know, they're not every medication is high risk So you can be on ozampic ribalsis Ribalsis, Turulosidae, Bydrian, Genuvia, Jardians, Farsiga, Invokana, Methformin These agents are not high risk, Pyaglutazone, Octos, these medications are okay So they do not really cause it so but what ends up happening in my practice is if somebody is having low blood sugars I don't just turn a blind eye to it. So what I do is I say, okay Let's just try to manage this. If we can change our medications to something else that does not cause low blood sugar Let's do it We try to find ways to always always avoid low blood sugar Why first of all, it doesn't feel good second of all It causes people to eat more and more as every time they have a low blood sugar They kind of try to eat more and that causes significant problems weight gain and so forth rebound High blood sugars that those are the problems associated with low blood sugar So our goal in my practice is always always avoid prevent low blood sugar and find ways to do that That three changes education and medication management is the key when it comes to these points Now, of course, alcohol is another big factor. Just a glass of wine at night is not gonna really do too much But if you're going and partying and having three or four shots you are looking to Have low blood sugar next morning because you're actually shutting your liver off now liver is the biggest glycogen store Which is glycogen is the molecule. That's like a packed glucose together. So The biggest glucose depot is your liver And when you shut that off you are basically are totally helpless So if there is insulin in your system Even if there is glucagon that's trying to save you like an internal glucagon that's trying to save you Your body is still is going to be non responsive When you are under the effect of alcohol so Another point is the chronic kidney disease if you have underlying chronic kidney disease starting from stage 3 stage 4 stage 5 You are at very high risk of low blood sugar, especially you if you're using cell phone urea And insulin again if you're not using cell phone ureas or megaliton eyes or or insulins You're not necessarily at high risk. Just because you have chronic kidney disease like I hear a lot of patients on GLP1 agents such as ozampic trilocity sometimes trigenta and so forth DPP for inhibitors They really don't cause any problems just because the way they work is not necessarily through a kidneys then I'm metabolized by the kidneys and As a result you you're not looking for a problem So if somebody has a kidney failure, we choose the drugs accordingly. We do we you know, we look at things holistically That's part of being a doctor. So that's why my advice is Watch these videos and learn as much as you can about diabetes But let the doctors make a decision for you Do not stop and start medications Do not go on your own to do things to help your diabetes because more than likely you are going to end up having a problem associate with it now malnutrition and You know is a big factor some people just go in a this crash diets and that's just not going to help Sometimes when you're sick and you know, you just don't have any means of eating your appetite is down You have cancer God forbid, you know, these are the things that can definitely reduce your glycogen and glucose stores and It may definitely put you at risk of low blood sugars Now so we discuss about the risk factors about hot is, you know Why low blood sugars can happen what are the risk factors? But then you know, of course how to treat is the biggest thing, right? So it's actually how to treat is very easy. I call it 15 or 20 rule So basically what you do is you try to use a heart candy or glucose tablets, which are proven to be the best Some people use crackers. Some people use juice Regular coke whatever But you have to be very careful about how much you're ingesting because at the moment of stress or panic People tend to eat the whole kitchen. It's a don't do yet. So it's try to stick with your 15 to 20 rule. Basically you are eating You know say 15 20 grams of carbs, which is equal to for glucose tablets Which is equal to half a glass of juice equal to three to four crackers And then Basically, you're checking it again in 15 to 20 minutes So at that point if your blood sugar is above 70, that's great If you're going to have a meal go ahead and have your meal go ahead and take your medication You should be all right But still monitor your blood sugar maybe at least an hour after a meal If you're not going to have a meal at that point even if you're at the above 70 I would suggest checking it again at 15 20 minutes again to make sure that the staying up Or maybe having a more Snacks such as something that has protein and fat in it along with carbs So it can actually keep you until the next meal. That is also very important if you have had Esophonylurea agent such as glupazide liboride with disgust insulin etc. If there is the effect of insulin in your body That is another reason that you have to be really keeping an eye on it If your blood sugar is not going above 70 after eating 15 to 20 grams of these carbs Then you eat another 15 to 20 grams and again check it again in 15 to 20 So that is a cycle that goes on on and on So if you are if you're above 70 great monitor again great meal time You're good to go but still monitor at one hour If your blood sugar is not coming up keep eating at 15 20 grams And at some point, you know once you're above 70 You can have a small snack with protein and fat and you should be good to go one thing You should be paying attention also, which is a mistake a lot of people do Is relying on your continuous glucose monitoring system when you have a low blood sugar? That's not necessarily the time to rely on your dexcom g6 or g7 whatever it may be It's not the time to rely on your freestyle liberate So freestyle liberate Ordex com g6 Is not going to tell you that your blood sugar is up. Why? Because they are delayed They are telling you the blood sugar in your tissue level not necessarily in the blood level So the transition from blood to tissue and then the time the sensor detects the the sugar increase All those chemical reactions to happen and all that so in this time of rapid changes in the blood sugars You do not rely on your cgm or continuous glucose monitoring device You rely on your finger stick. Yes, they try to you know market you those things are no more finger sticks and so forth Yeah, yeah, that's typically most of the time is true But in the time of like severe situation like a severe low blood sugar You're you're trying to fix it your blood sugars are changing rapidly That's not a time to rely on your dexcom or freestyle liberate. That's that's a good clinical point I want you to remember rely on your finger stick up checks at those times Now when do we use the glucagon? That's another point that we need to discuss Glucagon is a time when you don't use it on yourself somebody else uses glucagon on you Glucagon is available in a traditional format where it comes in a potter And you have to mix it and then you have to get an intramuscular injection Nowadays, there are new formulations where it comes in a pre pre filled syringe So all you have to do just take the syringe on and just jab it into the muscle of that person who's not responsive And just let it run to the system Also, there is a nasal glucagon the the one that's called The the pre filled one. I believe it's called g-voke It's a good drug, but it's new drugs. So it may not be covered by your insurance But you can always have your physician try if they're willing to try Also, the other thing that that the nasal glucagon is called baksimi Also is available Again, you know insurance companies may not be that great, but your physician if they're astute and if they are On top of their game, they should know how to get you those medications Especially if you have commercial insurance, there are many ways of finding coupons, copay cards and and stuff like that. So For some people that may be an easier thing to do, especially As a family member, let's say your wife is Is diabetic and You're you're you're really fearful that she may have a severe low blood sugar But you're afraid of using A needle or a syringe that you have never used before Uh, if that's the case you may want to try to go for a nasal because all you have to do is just It's like a like a osman medication. Just do two puffs and and then you're good to go So what happens if your blood sugar is low, but you don't really feel it But that happens a lot in patients who have um blood sugar problems frequently So if they're having frequent of blood sugar low blood sugar, your body at some point just stops responding It's like this is too much. We are having low blood sugar every day. I'm done. I'm not gonna tell you that your blood sugar is low Uh, I'm just joking. That's not not the body talks to you. It's just this called in in medicine We call this down regulation when something happens repeatedly your body becomes risk responsive to it So so as a result, you know, this is a problem Why because you are not going to realize that you're really low until your blood sugar goes low So what's the treatment for that? We just tell the people just calm down I have a lot of patients who are so obsessed about their blood sugars They rather live in the 40 50 blood sugars than than a 180 blood sugar. I'm like, look, yes High blood sugar is harmful But low blood sugar is harmful too and actually it can cause you Cost your life. So let's say you're having a low Driving you have a you have a low blood sugar severe low blood sugar and then you pass out What's gonna happen? You're gonna kill somebody you may die yourself So don't put yourself at risk of low blood sugar. Do everything you can to avoid the low blood sugar. So But sometimes I just can't change people's minds, you know, they just they're just stuck in what they think they know And but you know, that's something that the treatment for that is basically relaxing The sugars so your body will realize the difference. Oh, yeah, now your blood sugar is coming high Now when I go low, I know I'm going low So the difference is what your body realizes So you have to give your body a break and let your blood sugars go up a little bit not like in 200s 300s But at least in the sometimes in in the high 100s Is going to allow your body to realize that you actually can have a low blood sugar when you're going down to 70 so Anyways, and there are some people who will actually have low low blood sugar symptoms without having low blood sugars Right, so we sometimes treat people and we have very effective medications and dietary modifications And we can bring people to blood sugar from 400 down to 100 within a week or two nowadays, right? And we do that a lot actually And some people love it. They are impressed. They love us But some people will say oh doc, you're killing me because like i'm shaking when I'm like down to 100 I'm shaking and they're right, you know, I'm not blaming them if that's the case. We just relax it We just say let's just come down. Let's just bring your blood sugars up a little bit to 150 180 whatever You're comfortable with and we take it easier on these patients to bring their blood sugars down Maybe in the in the in the next few months instead of just three weeks so I do not recommend treating blood sugars when they are down to just um, you know 100 and You know, that's not something to treat. It tends to go away. Your body gets adjusted to it And that is basically what it is and as long as you know what it is, you should be good to go Again guys, this is dr. Ahmed Ergin. I hope that Lecture was helpful to you. I think every diabetic should know about how to deal with hyperglycemia and low blood sugars What puts them at risk and if they are at high risk medications and they are having low blood sugar They have to discuss their doctor. Again, if you're in florida or new york, uh, we are definitely available Just call us Give us a thumbs up for this video And we are going to bring up more and more videos. Please support us subscribe share these videos So that everybody can benefit from it. So again, we'll see you in the next video. Have a wonderful day