Irreversible Hypoglycemia: A Complication of Alcohol and Insulin JAMA

This novel mechanism may in part underlie the well known hypoglycemic properties of alcohol in diabetic patients or in alcoholics with hepatic failure. When someone consumes alcohol, the liver may then neglect blood sugar level maintenance in favor of breaking down alcohol. A 50-year-old man, known to be an early, mid, and late stages of alcoholism alcoholic, presented after being found unresponsive at home in bed. He had been drinking the night before, but his family members could not arouse him in the morning. Further history elucidated that he had had a cough for 1 month and 2 days of epigastric pain without vomiting, hematochezia, or diarrhea.

The exception is sweet dessert wines, which pack 14 grams of carb in a tiny three-and-a-half-ounce glass. Alcohol consumption can lead to less predictable blood sugar levels, which can be a problem for people with type 2 diabetes. The liver plays a crucial role in both detoxifying the blood of alcohol and maintaining blood sugar levels. However, it struggles to perform both processes simultaneously and prioritizes alcohol metabolism over blood sugar maintenance, which can lead to hypoglycemia. Severe hypoglycemia occurs when someone has very low blood glucose levels.

Your “drinking with diabetes” checklist

In the absence of insulin, the triglycerides are broken down into free fatty acids, which are secreted into the bloodstream and delivered to the liver. The liver normally re-incorporates free fatty acids into triglycerides, which are then packaged and secreted as part of a group of particles called very low-density lipoproteins . In patients with ketoacidosis, however, the liver metabolizes the incoming free fatty acids in an additional, unusual way. Under the influence of excess glucagon, some of the free fatty acids are converted to ketone bodies and secreted into the blood, causing severe health consequences. Type 2 diabetes, which in most cases develops in people over age 40, has a somewhat different pathophysiology than type 1.

Third, alcohol may enhance the increase in triglyceride levels in the blood that usually occurs after a meal. A daily cocktail or two may improve blood sugar management and insulin sensitivity. If you have one or more drinks a day, you may find that your A1C is lower than during times you weren’t drinking. But if you don’t drink regularly, this doesn’t mean you should start. After all, other aspects of moderate drinkers’ lives may be behind the link. The patient received 15 ml of D50, improved immediately to a normal mental status, and had normal neurologic examination results.

• Five insulin-dependent diabetics were hospitalized with severe hypoglycemia after an alcohol debauch.
• When an individual does not eat overnight and between meals, the liver turns stored glycogen into glucose and releases it into the bloodstream.
• In the fasting state, as a first line of defense against hypoglycemia, glycogen is broken down into its constituent glucose molecules, which are secreted by the liver into the blood to maintain normal or near-normal blood sugar levels.
• At each visit, we collected blood before loading, and 15, 30, 60, 120 and 180 min after loading, to measure plasma glucose, IRI, triglyceride and ethanol concentrations.
• Lange et al. reported a similar pattern, but their study was less detailed in its control of diet, exercise, and insulin injections.

This requires a specific NAD +/NADH ratio for the reductive synthesis of glucose . Plasma glucose and insulin concentrations did not change during the OATT, and hypoglycemia was not identified . There were no differences in plasma glucose or ethanol fluctuations between the sexes, participants with differing alcohol‐metabolism genotypes, or participants with differing alcohol consumption habits. On the day of admission to the hospital and on the following day, the fasting blood sugar levels of the drinking type 2 diabetics were significantly higher than those of the nondrinking type 2 diabetics.

How to Adjust your Basal Rate While Drinking

Three subjects received wine on their first visit, and three subjects were given water. The wine contained 70 g ethanol and 2–3 g carbohydrate per 750-ml bottle. A volume was measured to provide 0.75 g ethanol per kg body wt (equivalent to 6.6 units [19.9 fluid ounces] for a 70-kg subject). Vomiting for any reason leads to dehydration which can lead to DKA. Whether you have type 1 or type 2 diabetes, it’s important to count your carbs and monitor your blood sugar while drinking.

On later days, no significant differences in fasting blood sugar levels existed between the two groups of diabetics. The pancreas, which is located behind the stomach, serves two functions. The first function, which involves most of the pancreatic cells, is the production of digestive enzymes. Those enzymes are secreted directly into the gut to ensure effective food digestion. Two of the hormones (i.e., insulin and glucagon) are potent regulators of blood sugar levels.

Tests of significance were applied both to values at given time points and integrated (area under the curve ) responses as indicated. Blood glucose values after treatment of hypoglycemia were not included in the calculation of mean values at subsequent time points or used in significance testing. Statistics were obtained using Microsoft Excel data analysis software package (version 7.0; Microsoft, Redmond, WA). Diabetes management is about how lifestyle, daily routine and technology can affect blood glucose le… Thus, alcohol metabolism significantly decreases the hepatic NAD +/NADH ratio . The acetate produced from breakdown of ethanol leaves the liver for its metabolism in extra hepatic tissues such as skeletal muscle.

Hypoglycemia and Alcohol: How Alcohol Is Connected to Low Blood Sugar

This situation can be amplified if the drinker vomits repeatedly. Vomiting can lead to dehydration and a reduced blood volume, which, in turn, increases the levels of certain stress hormones in the blood called catecholamines. Catecholamines further decrease insulin production and increase glucagon production. Accordingly, physicians alcohol consumption and blood pressure who treat diabetics known to consume large amounts of alcohol must be aware of the risk of alcoholic ketoacidosis in those patients. The ketogenic diet, which has become an increasingly popular diet, severely restricts carbohydrate intake to shunt metabolism towards fatty acid oxidation and production of ketones as a fuel source.

In some cases, women with diabetes may have no more than one alcoholic beverage a day. Statistics show that a startling 95 percent of alcoholics and almost 90 percent of those with alcohol use disorder are hypoglycemic. Understanding alcohol-induced hypoglycemia is the first step in overcoming both conditions. Table S1 | Changes in the measured values during the 20‐g alcohol tolerance test. Neuropathy, in addition tips for reducing alcohol consumption to other factors (e.g., vascular disease in the penis or altered hormone levels), also may contribute to impotence, which is a common and troublesome complication in diabetic men. The nerves that control erection are part of the autonomic nervous system, which controls numerous vital processes that occur without conscious efforts (e.g., breathing and the contractions of the gut necessary for proper digestion).

The Risks

However, substantial information on the association of alcohol and cardiovascular disease exists from population studies that included an unknown percentage of diabetics. Those findings suggest that alcohol consumption, particularly moderate consumption, may have a protective effect against cardiovascular disease. Abnormalities in the levels and metabolism of lipids are extremely common in people with either type 1 or type 2 diabetes and may contribute to those patients’ risk of developing cardiovascular disease .

Gin H, Morlat P, Ragnaud JM, Aubertin J. Short-term effect of red wine on insulin requirement and glucose tolerance in diabetic patients. Your liver is releasing this stored glucose every day and night to give your brain and body the fuel it needs to function. The same stored glucose contributes to high blood sugars levels during the “dawn phenomenon” in the morning, too. And it’s part of why we need background / basal insulin throughout the day. The connection between hypoglycemia and alcohol lies in how alcohol affects the liver.

Characteristics of the participants

When an individual does not eat overnight and between meals, the liver turns stored glycogen into glucose and releases it into the bloodstream. One might use the information in this report to counsel patients on the ketogenic diet to avoid alcohol intake, as it might precipitate hypoglycemia. We present a case of a woman who developed starvation ketosis with hypoglycemia while on a ketogenic diet after the consumption of alcohol. We discuss the adverse effects of the ketogenic diet including hypoglycemia and risks of starvation ketosis. Blood glucose, alcohol, insulin, cortisol, growth hormone, and glucagon levels were measured. If you’re having frequent trouble managing your blood sugar levels, you should consider if it’s safe for you to drink alcohol.

This potentially beneficial effect was observed in both men and women, regardless of age. The alcohol amounts administered in those studies were usually between 0.5 g/kg and 1 g/kg, leading to blood alcohol levels between approximately 0.03 and 0.1 percent2 . These data have confirmed the very early increase in plasma glucose after glucose and alcohol consumption, which is followed by an increase in insulin secretion. In the previous two studies carried out with white participants without diabetes, the plasma glucose concentrations were slightly higher15 or lower3 at the 15‐ or 30‐min time points. Plasma insulin concentrations were also higher 15 or 30 min3, 15 after loading with glucose and ethanol than after glucose alone. The authors speculated that the mechanism for the increase in insulin secretion might have been an ethanol‐induced increase in glucose absorption from the gut15 or an increase in gastrointestinal secretagogue secretion3.

In rare cases, however, the condition also may affect people with type 2 diabetes. In a milder form, ketoacidosis may even occur in people who are fasting. In those people, insulin levels are diminished, because the fasting has considerably lowered their blood sugar levels, thereby depriving the pancreas of its stimulus to produce and secrete insulin. Glycogen is a large molecule that consists of numerous glucose molecules and serves as a storage form of glucose in the tissues, particularly the liver.

Hypoglycemia and Alcoholism

IRI, immunoreactive insulin; NA, data not available; OGATT, combined 75‐g glucose and 20‐g alcohol tolerance test; OGTT, 75‐g oral glucose tolerance test; TG, triglyceride. At each visit, we collected blood before loading, and 15, 30, 60, 120 and 180 min after loading, to measure plasma glucose, IRI, triglyceride and ethanol concentrations. We measured IRI using an E‐test Tosoh II kit , and whole blood ethanol concentration was measured by gas chromatography at the Specimen Research Laboratory . Despite the potential health perks of drinking alcohol, there are some cautions as well. When drinking alcohol is combined with the medications most often used to treat diabetes—particularly insulin and sulfonylureas, low blood sugar can result. While a glass of wine with dinner probably isn’t a big deal, a mojito on an empty stomach at happy hour is.

A 32-year-old man was found confused and moaning in bed by family at 5 a.m., and brought in by family at 9 a.m. Family members stated he had eaten lunch and dinner with them the previous day, then went out drinking alcohol with friends and came home at 3 a.m. Past medical and surgical histories were unremarkable, and he takes no medications and has no allergies. I wish I’d had someone to sit me down on the sidewalk, slap me and remind me sternly about the rules of drinking alcohol with type 1 diabetes, which, for the record, are these. When you’re drinking alcohol with diabetes, you’re at risk of an alcohol-induced hypo.

These glucose and insulin responses were different from those in the present study. There was an initial ethanol‐induced glucose disappearance in healthy participants, but not in participants who were obese or had diabetes, in one previous study15. This suggests that the response to ethanol consumption might differ, depending on the individual’s insulin secretory ability or degree of insulin resistance, as well as between white and Asian individuals.

Alcohol MetabolismAlcohol i.e., ethanol is metabolized in the liver by alcohol dehyrogenase to acetaldehyde, it reduces nicotinamide adenine dinucleotide (NAD+) to NADH facilitated by cytochrome P450 E1. Understand, however, that the body can only withstand so much disruption. Hypoglycemia is just one of the common health problems connected to alcohol dependency, as the body’s systems struggle to keep up with the intake of substances. Your system cannot function properly under the influence of substances.

Both hormones are produced in areas of the pancreas called the Islets of Langerhans, which, quite literally, are “islands” of hormone-producing cells in a “sea” of digestive enzyme-producing cells. Among other cell types, the Islets of Langerhans include an inner core of insulin-producing beta cells surrounded by a layer of glucagon-producing alpha cells. This is because their body already has difficulties balancing blood sugar levels, which increases the likelihood of experiencing hypoglycemia. If an individual with diabetes is hypoglycemic and their blood sugar levels do not improve after eating carbohydrates, they should seek medical attention. A doctor may need to administer treatment with glucagon to restore their usual blood sugar levels. Avogaro A, Duner E, Marescotti C, Ferrara D, Del Prato S, Nosadin R, Tiengo A. Metabolic effects of moderate alcohol intake with meals in insulin-dependent diabetics controlled by artificial endocrine pancreas and in normal subjects.

Because insulin is a key metabolic hormone, insulin deficiency leads to major impairment of the body’s regulation of carbohydrate, lipid, and protein metabolism. Cardiovascular disease continues to be one of the leading causes of death among all Americans and is the leading cause of death in people with type 2 diabetes . The relationship of alcohol consumption to cardiovascular disease in diabetic people has not been well evaluated.

The patient reported that she had been drinking large quantities of alcohol, but she had eaten all her meals yesterday. She continued to be alert and oriented, and was discharged the next day. Examination revealed a well-nourished, hemodynamically stable (temperature 37°C, pulse 113, blood pressure 152/98, oxygen saturation 95% room air), non-toxic, unresponsive female. She withdrew all extremities to painful stimuli, and had no clonus and no meningismus. She had no signs of traumatic injuries; her pupils were reactive, and her cardiopulmonary and gastrointestinal examinations were normal. The blood glucose concentration, as determined by fingerstick, was 32 mg/dl.

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