Ask D"Mine: Chasing Zebras in Diabetes

http://type2diabetestreatment.net/diabetes-mellitus/ask-dmine-chasing-zebras-in-diabetes/

Got questions about life with diabetes? So do we! That"s why we offer our weekly diabetes advice column, Ask D"Mine, hosted by our snarky diabetes expert Wil Dubois, a veteran type 1 and diabetes author.

This week, Wil is taking on a query about what seems to be false blood sugar lows... or are they? Do fainting spells with diabetes always point to hypoglycemia?

Got your own questions? Email us at AskDMine@diabetesmine.com

Jess, type 1 from Utah, writes: I have an employee who has had type 1 for 10 years. In fact, we have both had type 1 for almost the same amount of time. So we definitely understand each other. She has had these fainting spells. In fact, she passed out on her first day of work. Rather eventful day. Anyway, when she gets faint, she turns ashen grey, gets super confused and uncoordinated and weak. I haven’t had her hit the ground again since the first day, but it’s been close, trying to get her to a chair fast enough.

We check her blood sugar every time this happens because your first assumption is a low. She usually has tested before it happens, we test during and then check again after. I really can’t find any consistent numbers that I can correlate and say Aha! That’s the cause. She has been anywhere from 105-400 when this happens. Now, everyone wants to point fingers at her control being less than perfect. She tests at least five times a day. She uses an insulin pump and she stays pretty on top of it. Her blood sugars do swing and she does her best to chase them. She’s a stressed-out student who is working her way through college.

So I ran across information that extended hyperglycemia can cause a type of neuropathy that affects the heart. But medical people usually say it’s probably not the "Zebra" (exotic diagnosis). She doesn’t seem to have any other complications up to this point. At least, none that have been recognized. But still, what do you think? Could it be the Zebra?

Wil@Ask D’Mine answers: For readers who’ve only seen zebras at the zoo, let me give you some background. In medical school, budding young docs are taught that if they’re walking in the woods in Vermont and hear hoof beats, it’s probably not a zebra. It’s a way of reminding them that while anything is possible, the most likely is, well, the most likely. So if their first thought is that their patient’s symptoms match pseudomyxoma peritonei, they should probably rethink their diagnosis, as pseudomyxoma peritonei is one of the rarest diseases in the world.

In general, I think that the Zebra lesson is a good one for doctors, especially new ones with more knowledge than experience. It helps avoid wasted time barking up empty trees. It’s probably even better advice for average citizens now that we all live in the Age of Google. For instance, if I noticed that my waistline was gradually expanding, I was having tummy aches, and my appetite was down, Uncle Google might lead me to believe I had pseudomyxoma peritonei, as those are some of its symptoms.

Of course they’re also the symptoms of eating bad corn dogs and two hundred thousand other things, including Zebraititus Hypochondriasis, all of which are more likely than pseudomyxoma peritonei.

OK, I made that last one up. There’s no such thing as Zebraititus.

So I can’t fault the docs for looking to low blood sugar as the cause of a young T1’s fainting spells. It’s the most likely cause. Still, the hoof beats in the Vermont forest could be a Zebra. Maybe a circus train derailed, freeing all the animals. Maybe misguided eco terrorists freed one from a zoo. After all, just because pseudomyxoma peritonei is one of the rarest diseases on the planet doesn’t mean people don’t get it. They do.

For years I had a zebra Xing sign above the door of my clinic office. It was a way of thumbing my nose at medical tradition and a reminder to keep an open mind at all times. I know that Zebras happen. I’ve seen it personally.

But even working under a zebra crossing sign, I’d still look to blood sugar as the key to your young employee’s woes. It sure seems to fit the bill, if not all the evidence. So the first thing I’d troubleshoot before I went zebra hunting is her meter. Is the meter working correctly? Is it giving us good, reliable data? There are a lot of crap meters out there and health insurance plans are forcing more and more PWDs into using these shady pieces of gear.

And it’s worth noting that many of the poorer meters give the least accurate info in the low blood sugar range.

So my first advice to you is to expand your struggling college student’s employee benefit plan to include one really good meter and 100 strips to go with it. Look at it as a potential investment in increased productivity. Let’s not rule out the most likely cause until we’re really sure it’s not the issue. Keep in mind that none of us have a universal lights-out point. Each and every hypo affects each and every one of us differently. Some of the contributing factors are the speed of the blood sugar drop, the amount of active insulin in the blood, the type, nature, volume, and timing of the most recent meal, and the baseline average blood sugar of the PWD. That list doesn’t even include stress, sleep hygiene, illness, and a million other factors. My point being, don’t assume someone has to be at 35 mg/dL to pass out.

But if the tree I’m barking up turns out empty, before I looked at heart neuropathy, I’d look to a different place in the bloodstream, and that’s volume and pressure. Why? Well if the hoof beats weren’t from a white-tailed deer (common in Vermont), the next most likely hoof beater in the Vermont woods is a moose.

Low blood pressure is a common trigger of syncope—a Zerbra-esque word for a temporary loss of consciousness. It happens when the blood pressure drops low enough that the brain doesn’t get quite enough oxygen. Why would that happen in a young, healthy-ish person?

I can think of two common causes. Is she on the “recommended” ACE inhibitor that all D-folk are supposed to take if they need it or not? It’s the standard of care: All of us sugar-impaired people take this med, as it can shield our kidneys from the ravages of elevated sugars. But they are blood-pressure lowering meds. If her dose is just a little too high, it might trigger syncope from time to time.

The other common cause of syncope, which can exist hand-in-hand with the ACE inhibitor, is dehydration. Does she drink lots of water? And, hey, coffee doesn’t count. Ingesting large amounts of caffeine can have a diuretic effect, mildly dehydrating the body and lowering the blood pressure. As a struggling, working college student, I imagine your girl might be a caffeine addict.

But if that’s not it either, well, what about your Zebra? The neuropathy of the heart? Could that be the cause? Yes, but… Well, I’ll get back to the “but” in a second. This type of neuropathy is called cardiac autonomic neuropathy. And you are correct that it can trigger fainting.

So why am I so quick to rule out something that seems to fit the bill?

Because I don’t think she’s had diabetes long enough to get this “side effect.” She’s only had diabetes 10 years and you told me that’s she’s “pretty on top of it.” Even in poorly controlled type 1 diabetes, ten years is the earliest you’d see any long-term complication pop up, and the autonomic neuropathies aren’t typically in that first wave.

It takes a lot of high glucose over a long time to create that kind of damage.

So to answer your question, just like a zebra could be in the Vermont woods, she could have this side effect earlier than most people get it.

But my money is on it being the deer. Or the moose.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn"t adhere to Healthline"s editorial guidelines. For more information about Healthline"s partnership with Diabetes Mine, please click here.

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