How to fix hypoglycemia unawareness

I went through a period recently with a lot of hypos. My basal insulin dose needed adjusting, so many of the hypos were prolonged and happened during the night. The need for insulin doses fluctuates, so what works one day might not work the next. It’s a topic that needs constant revisiting. The result of so many hypos was that I lost my hypoglycemia awareness and wouldn’t notice that my blood sugar was low until I went below 3 mmol/l (54 mg/dl).

There are a few dangers to this. First off, if your blood sugar goes too low you pass out, and if there’s no one around to inject you with glucagon there’s a chance you might not wake up again. There’s also something called dead-in-bed syndrome, where diabetics die in their sleep, most likely from hypoglycemia that triggers disturbances in the heart rhythm. I didn’t use to worry about this as I would always wake up, but as I now sleep peacefully through my hypos and only notice when I test in the morning, it’s become a real concern.

While we know that diabetic complications occur from high blood sugar, we know little about what persistent hypoglycemia does. My guess is that it’s not good for you to spend extended periods low as the blood sugar in non-diabetics probably stays around 5 mmol/l (90 mg/dl) for a reason. A cell starved of glucose can’t perform its basic functions, so it could lead to errors in DNA replication, and who knows where that might land you. A minimum of hyper- and hypoglycemia is ideal but not always easy to achieve when injecting insulin.

So, how do you regain hypoglycemia awareness? The reason you no longer notice low blood sugar is because the body adapts to it. The adrenaline that’s secreted as a warning – the body’s fight-or-flight response – doesn’t work anymore. That’s why you no longer sweat and get a racing heart when the blood sugar runs low. In other words, you need a reset. The way to do this is to avoid hypoglycemia for an extended period by setting a higher target range.

I used to strive for 4.5 – 8 mmol/l (81 – 144 mg/dl), which is a very tight range. To regain hypo awareness, I’ve increased it to 6 – 10 mmol/l (108 – 180 mg/dl). That means intentionally underdosing insulin for meals to avoid potential lows. It also means taking a glucose tablet when my blood sugar is at a perfect 5 mmol/l (90 mg/dl) to nudge it up to 6 mmol/l (108 mg/dl). Both these things are difficult to do for an obsessive-compulsive diabetic like me, but I’d rather see my HbA1c go a bit high than pass out at work or leave my partner alone in the world to care for our deranged cats.

It’s been a couple of weeks and so far, I haven’t had many hypos. Yesterday I felt a bit dizzy and sweaty after dinner, and when I tested I was at 3.4 mmol/l, so it might be that my hypo awareness is coming back. I’m keeping my target range high for another couple of weeks to see how it goes. I’ll update this post when the experiment to fix hypoglycemia unawareness is complete. Hopefully, I won’t go blind or lose my feet before then.