How to Handle Nighttime Lows with Type 2 Diabetes

Nighttime lows—aka nocturnal hypoglycemia—can be scary and dangerous. Especially if your doctor has never talked to you about them before.

If you live with type 2 diabetes (T2D) and are on insulin or other blood-sugar-lowering medication, it’s important to learn how to prevent and treat nighttime lows. Being aware can help you recognize the signs of low blood sugar, be prepared with the right treatments—such as glucose tablets for standard lows and emergency glucagon for severe lows—and lead to more productive conversations with your doctor.

Why do nighttime lows happen in people with T2D?

Constance Brown-Riggs, MSEd, RDN, CDCES, CDN, author of “Living Well with Diabetes 14 Day Devotional: A Faith-based Approach to Living with Diabetes,” is familiar with this topic through her practice. 

Constance explains that nighttime lows can happen in people with T2D for a variety of reasons:

• If you’re exercising late at night
• If you’re skipping meals
• If you’re taking too much insulin
• If you’re drinking alcohol without eating

“You can have an effect from the physical activity that lasts for hours,” Constance says. “So, certainly, if you’re exercising at night, you are at risk for hypoglycemia. If you skip your evening meal, that’s also a risk factor.”

Constance says people with T2D may forget to check their blood sugar levels before bed, which increases their risk of nocturnal hypoglycemia.

“If you’re eating your evening meal, taking pre-meal insulin and check your blood glucose before going to bed, it may be in your ideal range,” she says. “But what can happen is sometimes people forget that insulin is still working in the system and you may be subject to nocturnal hypoglycemia as a result of that.”

Nighttime lows and the hidden dangers of drinking

Alcohol is another common cause of nighttime lows.

“If you’re drinking, particularly in the evening, make sure that you’re eating something as well,” Constance says. “Also be sure you’re careful to monitor your blood glucose after you’ve been drinking because just like you can have that low as a result of physical activity, you can also have a low as a result of alcohol.”

This happens because the liver, which typically helps to detox alcohol from the system, also kicks in.

“It will kick in to release extra glucose in the system,” Constance explains. “But, if the liver is busy because its priority is to detox the alcohol from the system, it’s not going to be able to do two things at once. As a result, you end up with nocturnal hypoglycemia.”

Constance helps clients with these types of challenges all the time.

“A client I had would have nocturnal hypoglycemia during the week,” she explains. “She never had it on the weekend, and I thought that was so strange.”

After stepping into investigation mode, Constance discovered that her client was drinking during the week but not on the weekend because she was taking care of her grandchildren. That’s why she only had nocturnal hypoglycemia during the week, not on the weekend.

Why are nighttime lows potentially more dangerous than daytime lows?

Nighttime lows are potentially more dangerous than daytime lows because you are not alert. They can catch you off guard in your sleep. You may not wake up to them until they’re dangerously low. Sadly, some people do not wake up to them at all.

“Unfortunately, for many people, they don’t wake up when they’re having an episode of hypoglycemia,” Constance says. “One of the reasons is that the counterregulatory hormones are somewhat suppressed in your sleep, so you don’t feel the symptoms. You don’t feel shaky and nervous—you’re asleep.”

If you don’t wake up to your lows, you may fall unconscious or even start having seizures.

“Even during the day, hypoglycemia, if it’s severe, is dangerous,” Constance says. “But the fact is, there’s more of a risk overnight.”

Constance explains that if you take insulin or a secretagogue like Prandin (repaglinide) or Starlix (nateglinide), it stimulates the pancreas to release insulin. This means you’re adding more insulin to your system, increasing your risk of nighttime lows.

Any blood-sugar-lowering medication increases your risk.

“If you’re on more than one medication to manage your diabetes—more than one hypoglycemic medication—that too can be a risk factor,” she says. “It’s not so much your type 2 diabetes diagnosis that puts you at risk—it’s more the treatment.”

How to prepare for nighttime lows with type 2 diabetes

When Constance works with people with T2D who are struggling with nighttime lows, she starts by asking one simple question: “Do you understand hypoglycemia?”

If they are unsure, she explains. Then, she asks them: “Do you know the symptoms of low blood sugar?”

All too often, people with T2D aren’t educated on hypoglycemia and its warning signs when diagnosed. Asking later can feel shameful or embarrassing—Constance provides a safe space to educate and ask questions.

“Of course, we have charts, and we have all kinds of literature that talks about the typical symptoms of hypoglycemia, but not everyone has those typical symptoms,” Constance explains. “Symptoms are very individual.”

Constance worked with a client who saw blinking lights when they were low, for example. 

“She could almost anticipate how low she was based on how fast the lights were blinking,” Constance says.

General diabetes education is a key component to managing nighttime lows. Constance bases her conversations with clients on where they’re at in their diabetes journeys, what medications they’re taking and whether they’re at risk. 

“Ideally, by the time they come to see me, their doctor should have had that conversation with them when they prescribed the medication,” Constance says.

But that’s not always the case.

“Nine out of 10 times, unfortunately, they come in and haven’t had that conversation with their physician,” she shares.

Tracking nighttime lows with type 2 diabetes

Sometimes, Constance advises her clients to set alarms in the middle of the night to determine whether they’ve had a low blood sugar episode.

“Oftentimes, they’ll wake up clammy, sweaty and drenched,” she says. “They may wake up very irritable, or their partner may tell them, ‘You were thrashing all over the place last night.’ They may also be having nightmares. All of those are symptoms of nocturnal hypoglycemia.”

Constance says it’s not just important for someone with T2D to be educated about nighttime lows and the warning signs, but for their partners, friends, roommates or whoever else lives with them to be educated too.

“If you don’t tell them, they might just think you’re having a nightmare,” she says. “They need to be educated, not just on the symptoms, but on how to treat with glucagon.”

What is an emergency glucagon?

Glucagon is a hormone the human body produces to prevent low blood sugar—but in people with diabetes, sometimes this natural production isn’t enough during severe hypoglycemia. 

Emergency glucagon is a medication used when a person with diabetes is experiencing severe hypoglycemia (low blood sugar) and cannot eat sugar .” 

Once injected, it raises blood sugar by signaling the muscles and liver (where glucose is stored in your body). The effect of glucagon is the opposite of insulin’s, raising blood sugar rather than lowering it. 

It comes in several forms, including nasal spray, auto-injectors, prefilled syringes and a powder that must be mixed with a liquid before injection.

For people with T2D, Constance recommends BAQSIMI nasal spray. This is an emergency glucagon that’s administered through your nose.

Constance says nasal glucagon is much more approachable for loved ones than traditional injection-based glucagon options. Ultimately, it’s up to the person with T2D to choose their preferred emergency glucagon option. Talking with your doctor can help you decide which option is the best fit for your management style.

How to avoid overtreating your lows with food

Another component of proactively managing low blood sugar is avoiding overtreating your lows with food.

“I understand it’s miserable when you’re low, and your instinct tells you to take that container of orange juice and guzzle the whole thing down,” Constance says. “But you’re going to go from one extreme to the other and your blood glucose is going to go sky-high.”

Constance advises following the rule of 15:

• Take 15g of fast-acting carbohydrates like glucose tablets. 
• After consuming 15g of carbs, wait 15 minutes and then check your blood sugar.
• If your blood sugar levels are still not above 70 mg/dL/3.9mmol/L, then treat again.
• Repeat the cycle until your blood sugar levels have settled.
• If food-based treatments are not working, emergency glucagon may need to be used and emergency services should be called to ensure your safety.

After your blood sugar levels have settled, if you’d like to have your meal, Constance says it’s okay. If it’s not close to mealtime for you, Constance still advises people with T2D to have a snack after going low.

“Half a peanut butter sandwich, for example, is a good choice to have before your regular mealtime,” Constance says. “Something with protein, as well as a carbohydrate.”

In an hour or two, Constance recommends checking your blood sugar again. 

“Make sure your blood glucose remains within range,” she says. 

Why shouldn’t severe lows be treated with candy or juice?

“Make sure they know not to give you anything by mouth if you’re unconscious because you can aspirate—in other words, choke on that,” Constance shares. “I had a friend who had that experience, and both she and her husband happened to have diabetes. She panicked when he had a severe hypoglycemia episode. She put jelly in his mouth, and he aspirated. You don’t want to make matters worse if they’re unconscious. He’s okay, but it’s a reminder of why you treat with glucagon.”

Emergency glucagon should be used to raise blood sugar quickly when you’re not awake or alert enough to administer it yourself or use food-based low blood sugar treatments. That’s why it’s so important to train and educate your family, friends, colleagues or anyone who’s around you often on how to use it, just in case.

How to overcome nighttime low fears: the answer isn’t running high

While sharing information and awareness is meant to be empowering, it still comes with its own set of fears.

“It’s understandable,” Constance says. “If they’re running high all the time, much higher than they should be, we have a conversation about the steps to prevent nocturnal hypoglycemia. If they’re able to avail themselves of a continuous glucose monitor (CGM), it can give them more confidence by helping them see exactly what’s going on and can alert them if they’re going low.”

The American Diabetes Association’s (ADA) Standards of Care emphasize the use of CGMs for people with T2D. The ADA recommends that anyone on blood-sugar-lowering medication should wear one. Now, people with T2D have more over-the-counter (OTC) options when insurance won’t cover it, such as Dexcom Stelo or Abbott Lingo or Rio.

“We try to build confidence over time,” Constance says. “So the patient will understand if they eat a certain number of carbohydrates and take a certain amount of insulin to go with it, they’ll be fine.”

Continuous glucose monitors provide people with T2D with a clear picture of their blood sugar levels and how their diabetes management behaviors, patterns and style impact them. They can see their data in real time throughout the day, whereas a blood glucose monitor (BGM) is helpful but limited in this regard.

Advice for people with T2D who are new to nighttime lows

Everyone with T2D learns about different things at different points in their diabetes journey—that’s okay. If nocturnal hypoglycemia is new to you, start a conversation with your doctor based on your treatment plan. That’s what Constance suggests.

Here are some phrases she recommends using to self-advocate:

• If you take insulin: “I’m on insulin. I understand if I’m on insulin, I’m at risk for hypoglycemia.”
• “Should I have a glucagon prescription?”
• “What should I do as a result of being at risk for hypoglycemia, especially nocturnal hypoglycemia?”
• “What should I look for in terms of hypoglycemia?”
• “What glucose range should I be in?”

Using any of these questions should open the floor for an honest conversation with your doctor. Your doctor should be able to take any of these questions and run with them, providing you with clarity, peace of mind and clear action steps to get ahead of nighttime lows—helping you feel more at ease about your T2D management.

“It’s your care it’s your body,” Constance says. “You’re the one living with diabetes. You should be able to have all the tools that you need to manage your diabetes successfully.”

If you’re newly diagnosed with T2D or supporting someone who is, it’s okay to feel overwhelmed. Check out our Beginner’s Guide to Thriving With Diabetes for tips and resources to make it more manageable.