(Reuters Health) - When people with diabetes experience a dangerous drop in blood sugar, glucose tablets might be a better option than a sugary food or drink, a study suggests.
 
People with diabetes can develop hypoglycemia, or low blood sugar, if they skip a meal, exercise harder than usual or take too much insulin or other diabetes medications.
Low blood sugar can cause fatigue, anxiety, rapid heartbeat, sweating, mental confusion or even coma or seizures if not treated quickly.
 
For a new study, researchers pooled data from four papers in the medical literature that compared the effect of dietary sugars and glucose tablets on relieving low blood sugar symptoms, including three randomized trials, which are generally the most reliable kind of medical study.
 
As reported in the Emergency Medicine Journal, the adults and children in the studies had type 1 or type 2 diabetes. All of them were awake throughout their episodes of low blood sugar.
 
Altogether, 515 low blood sugar episodes were treated with dietary sugar and 232 were treated with glucose tablets.
Across the four studies, different forms of dietary sugars were used, including Skittles candies, orange juice, Mentos candies, jelly beans, cornstarch, milk and glucose gels.
 
In general, the individual substances were about as effective as the glucose tablets for getting blood sugar levels to rise.
When results from all four studies were combined, neither dietary sugars nor glucose tablets reliably returned blood sugar levels to normal within 10 to 15 minutes, according to the research team.
 
"Regardless of the oral (method) used to treat hypoglycemia, time is required for absorption before the measured blood returns to the normal range and the patient’s symptoms improve," the authors wrote.
However, people who used glucose tablets seemed to feel better faster. Patients who used sugary foods were 11 percent less likely to feel relief from their symptoms within 15 minutes.
Glucose tablets are available in drugstores and online. Prices on Amazon.com range from about $5 for a pack of 10 tablets, to about $9 for a bottle of 50.
 
“Although the results lean toward glucose tablets, everybody reacts differently to low blood sugar,” said Susan Renda, a certified diabetes educator at Johns Hopkins Comprehensive Diabetes Center who was not involved with the study.
“We can’t say that this study controls for individual differences in low blood sugar, like measuring a patient’s glucose level or checking to see how they feel,” she told Reuters Health.
 
“We don’t want to discourage people from using dietary sugars,” said study co-author Dr. Jestin Carlson, an emergency physician at Saint Vincent Hospital in Erie, Pennsylvania.
 
“Glucose tablets seem to work better, but if you’re using dietary sugar, that’s OK too,” he told Reuters Health by phone.
What’s most important is to treat low blood sugar right away, according to Renda. She said, “Whether it’s Skittles or glucose tablets, people should carry something with them at all times for whenever they feel a drop in blood sugar.”
 
As of 2014, approximately 29 million Americans - about 9 percent of the U.S. population – had been diagnosed with diabetes, according to the Centers for Disease Control and Prevention.
 
SOURCE: bit.ly/2dELvhQ Emergency Medicine Journal, online September 19, 2016.
 
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ABSTRACT
Background While glucose tablets have been advocated for treating symptomatic hypoglycaemia in awake patients, dietary sugars may be more convenient. We performed a systematic review to compare the impact of these treatment options on the relief of symptomatic hypoglycaemia, time to resolution of symptoms, blood glucose levels, complications and hospital length of stay.
 
Method We searched PubMed, Embase and the Cochrane Library through 28 June 2016 and assessed the quality of evidence using the Grades of Recommendation, Assessment, Development and Evaluation approach. Reference lists from a subset of the resulting articles were mined for additional, potentially eligible papers. We calculated the risk ratio (RR) of each treatment option for the preselected outcomes of interest.
 
Results Of the 1774 identified papers, four studies met the inclusion criteria; three randomised controlled trials totalling 502 hypoglycaemic events treated with dietary sugars and 223 with glucose tablets and one observational study with 13 events treated with dietary sugars and 9 with glucose tablets. The dietary forms of sugar included sucrose, fructose, orange juice, jelly beans, Mentos, cornstarch hydrolysate, Skittles and milk. In the pooled analysis, patients treated with dietary sugars had a lower resolution of symptoms 15 min after treatment compared with glucose tablets (RR 0.89, 95% CI 0.83 to 0.95).
 
Conclusions When compared with dietary sugars, glucose tablets result in a higher rate of relief of symptomatic hypoglycaemia 15 min after ingestion and should be considered first, if available, when treating symptomatic hypoglycaemia in awake patients. 
 
DISCUSSION
Symptomatic hypoglycaemia in patients with diabetes occurs frequently and is often managed by the individual, family or friends.2 While several treatment options are available including multiple forms of dietary sugars, we found that glucose tablets result in the lowest risk of recurrent or persistent hypoglycaemia after administration in awake patients with symptomatic hypo- glycaemia. Despite the relatively frequency of hypoglycaemic episodes, there remains limited data examining the ideal form of oral sugar replacement. Although glucose tablets and dietary sugars may be viable treatment options, few studies have exam- ined the most appropriate dose of carbohydrates. While a 15 g tablet is commonly advocated, 20 g tablets or even a weight- based approach, such as 0.3 g/kg, may be more effective in treating hypoglycaemia.
 
Two of the studies included in this review reported response to hypoglycaemia treatment in very small subsets of 3–9 patients.10 13 This increases the risk of bias and reduces the power to find statistically significant results. Another factor reducing our ability to analyse results is the variability of the specific carbohydrate content of tested foods and beverages. Orange juice is often diluted with water, and milk can have varying fat content that changes its glycaemic index. We were unable to control the commercial products featured in this review and there may be other confectionary or food products that, if studied, performed equally as well.
 
There was significant clinical heterogeneity among the included studies limiting our ability to perform a meta-analysis. While we did pool the results of dietary sugars, these were the results from several different sugars (eg, fructose, sucrose, etc) and in different amounts (eg, orange juice with 15 g of carbohy- drates vs 40g). Specific dietary foods performed similar to
glucose tablets in many of the individual comparisons but when pooled, food sources underperformed in the treatment of hypo- glycaemia compared with glucose tablets.
 
There was heterogeneity with the types of sugars used in each study, and different populations were examined in various studies. Two of the three RCTs examined dietary sugars and glucose tablets in paediatric patients with diabetes.3 12 Identification of hypoglycaemia in paediatric patients can be challenging as young children may have difficulty recognising and communicating their symptoms.16 Also, symptomatic hypo- glycaemia may occur at varying levels in children, often below those resulting in symptoms in the adult population, highlight- ing the differences between managing hypoglycaemia in these two populations.16 This may limit the generalisability of paedi- atric findings to adults and vice versa.
As nearly 10% of the world’s population lives with diabetes, effectively treating symptomatic hypoglycaemia is important as many patients with diabetes experience these episodes regu- larly.1 2 5 Non-severe hypoglycaemic events occur frequently (between 0.4 and 1.7 times per week).2 While severe hypogly- caemic events are less frequent (roughly once annually), 49% of cases require additional medical care such as visiting an ED, highlighting the need for early recognition and treatment of symptomatic hypoglycaemia.2 The ED visits are more common with increasing age, with those aged 80 or older having nearly twice the risk of young adults.
 
The impact of hypoglycaemic events is also personal. Patients report feeling tired, fatigued, anxious, nervous and less alert even after being treated for symptomatic hypoglycaemia.2 These events can affect a patient’s ability to work as 18% of non- severe hypoglycaemic events lead to lost work time.2 Patients with non-severe hypoglycaemic events may be able to self- manage their condition. Patients with severe hypoglycaemic events may still be conscious but require assistance from a third party. Both patients and those assisting patients with symptom- atic hypoglycaemia may be unsure of the exact carbohydrate content of the dietary food they are using to treat a hypogly- caemic event.
 
They may elect to use standard 15–20 g glucose tablets, when available, although dietary sugars can still be used if glucose tablets are not available.
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