People assume that only type 1 diabetics get severe low blood sugar reactions because they’re dependent on insulin. Insulin can cause severe hypoglycemia, but you don’t have to be on insulin to experience a life-threatening episode of low blood sugar.

The rates of low blood sugars in type 1 diabetics are higher, but it may be more dangerous in type 2s because they’re often older and sicker. Many type 2s are overweight or obese or have heart disease or metabolic syndrome, i.e., high blood pressure and high cholesterol, on top of diabetes. On the other hand, type 1 diabetics are often young and healthy in every other way except for their inability to produce insulin.

The Two Types of Hypoglycemia

To understand the dangers of hypoglycemia, you need to understand that there are two types. One is the mild type, where you just feel extra hungry. This can happen even with pre-diabetes, if you drink something very sweet. It means your body is making too much insulin in response to the sugar flooding your system, which will make your blood sugar fall. This type of hypoglycemia doesn’t hurt you—it just feels uncomfortable. If you tend to get episodes of hypoglycemia caused by eating sweets, you can treat it by avoiding foods with a high sugar content, unless you eat them with other foods that contain protein and/or fat. A mixed diet with a balanced amount of protein, fat, and sugar keeps blood sugar stable over time.

Type 2 diabetics who are on sulfonylureas—medications that stimulate the pancreas to produce more insulin—can suffer from low blood sugar attacks that are as severe as those caused by injected insulin. These medications, including Amaryl, glyburide, glipizide, Prandin, and Starlix, all stimulate the body to make extra insulin. When there’s too much insulin in the body, blood sugar can fall dangerously low, even low enough to kill you, although this isn’t common. Kidneys can fail because they don’t metabolize the drugs and the patient stops eating. California endocrinologist Dr. Anne Peters reports, “I had a patient with low blood sugar that we couldn’t get above 50 because the sulfonylurea drugs were already in her body and weren’t being excreted.” Of course, type 2s on insulin—about one-third of all type 2 diabetics—are also subject to low blood sugar.  

Fortunately, the most popular drugs for type 2 diabetes, such as metformin, and the class of diabetes drugs called gliptins, like Januvia, may cause annoying but not dangerous low blood sugar reactions.

It’s very important for type 2 diabetics to differentiate among the different diabetes drugs, because once you have low blood sugar that causes you to pass out, your risk of dying in the next few years doubles. That statistic bears repeating. Once you have a low blood sugar reaction that sends you into unconsciousness, you are twice as likely to die in the future, usually of heart disease. The medical community isn’t sure exactly why—a severe low blood sugar reaction may damage the nervous system—all they do know is that once you have such an episode you have to be extra careful for the rest of your life. You must avoid these severe reactions at all costs. 

The most important factor in avoiding low blood sugars is to check your blood sugar levels regularly. If you’re on insulin, you should check four times a day. If not, work with your doctor, dietician, or healthcare team to adjust your medicine. You need less insulin if you’re exercising, more if you’re not. No one should make these adjustments on their own without their healthcare team to help them.

“If your blood sugar is below 80 frequently, tell your doctor to adjust your insulin,” Dr. Peters suggests. “Never skip meals; you have to be regimented to maintain a balance. Do not go on a diet without telling your doctor, dietician, or healthcare team.” Important measures:

  • Know the warning signs of low blood sugar: feeling weak, shaky, sweaty, hungry.
  • Don’t make assumptions; always test your sugar to see if it’s low.
  •  Always carry glucose tablets. It takes three to four tablets to get 15 grams of carbs, which is what you need.
  • Drink half a glass of juice or a glass of milk or soda if you’re feeling symptoms. Or, start with simple sugar and eat a small meal.
  • Do not go out without something to treat a low.
  • If you take insulin at night, leave the glucose tablets on your night table. You’ll know you’re having a low if you have nightmares and wake up sweaty or your bedmate notices kicking or moaning. The treatment has to be there at arm’s reach.
  • Don’t get complacent. People get in trouble because one day they don’t pay attention to their blood sugar and go out and work hard in the garden and they go dangerously low.
  • Have a strategy for everything. Life is all about preparation. You have to be organized.