Ask D’Mine: High and Tired, Who’s at Risk of a Coma?

Got queries about life with diabetes? Keep sending ‘em our way. You’ll get all the info you need — and more! — at our weekly diabetes advice column, Ask D’Mine, hosted by veteran type 1, diabetes author and community educator Wil Dubois.

Not much is off-limits here, as you’ll see today (except of course specific medical instructions for your own care; that’s what doctors are for)

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

Cheryl from Texas, type 2, writes: My blood sugar has always been high. I can’t remember an A1C under 7.5. But I just saw a new doctor last week and my sugars have actually been in the normal range lately. The thing is, I’ve been extremely tired and have a total lack of energy. I also feel dehydrated. Is this normal for having normal blood sugars?

Wil@Ask D’Mine answers: No. No, it’s not. Freaky. You finally get your sugars down and now you’ve got all the symptoms of high blood sugar. That’s really weird.

Oh, but by the way, congratulations on your fabulous new diabetes control!

OK. So tired. And thirsty. (Puts on thinking cap.) One thing that sometimes happens to people who run really high for a long time is that once they get “normal,” they feel low. It’s called relative hypoglycemia. It’s sort of a reverse acclimation. If you’re high for a long time, “normal” feels low to your body. Your body has to get used to the new normal. This generally happens with rapid therapy changes though, like starting insulin, when blood sugar can be normalized very quickly. But super tired and super dehydrated aren’t really your typical signs of lows anyway, so relative hypoglycemia is probably off the table.

(Adjusts thinking cap.)

So maybe we need to think about all the other things that come with diabetes that have nothing whatsoever to do with blood sugar. After all, there’s more to diabetes than blood sugar!

If you wake up tired you might have sleep apnea, as the majority of T2s do. It causes skipped breaths at night, and that causes sleep disturbances. Even though you thought you slept through the night, you never get into the kind of deep sleep you need to really get rested. Getting tested for sleep apnea is a bit annoying, but it’s something to talk to your doc about.

If you start out OK, energy-wise, then run out of steam quickly during the day, you might want to look toward your thyroid. Ask your doc about a TSH test. Oh, while you are at it, you might be anemic, too, so while you’re getting a blood draw anyway…

This handy chart lists around 50 more possible causes of fatigue including pregnancy (better blood sugars = improved fertility!), medication side effects, various heart stuff common to T2s, and even some super-scary stuff like cancer.

I think you can see where I’m going here. But just in case you can’t, let me spell it out: I rather doubt your new fatigue and new thirst has anything to do with your new blood sugar. But your symptoms are caused by something, and your doc is going to need to figure out what that something is. Oh, and one last thought, the two symptoms might not be related to each other at all. Just because they started together doesn’t mean they are caused by the same thing. You might be fatigued from one thing and thirsty from another.

Now, for those of you who like to analyze symptoms, there’s a really cool symptom finder here, but be warned, searching symptoms online is the leading cause of ANXIETY.

Edward from New York, type 2, writes: Can type 2s go into a coma if their blood sugar gets too high?

Wil@Ask D’Mine answers: You betcha. In fact, type 2s can go into two different types of comas. First, although not terribly common, you T2s can go into the same diabetic ketoacidosis (DKA) coma that we T1s can. Here’s how DKA works: If there’s no insulin around to help the cells in your body eat sugar, the body goes to plan B: burning fat. Now on the surface, that sounds like great idea. Who wouldn’t want less fat? Burning fat should be a good thing, right?

Well… maybe not.

Because where there’s fire, there’s also smoke. And in this case, the smoke is a trio of acids called ketone bodies. And it so happens that if you get too many of these critters in your blood stream they can actually change the pH of your blood, and that results in all kinds of bad things including coma and even death.

But T2s always have some insulin, right? Wrong. If you’ve had T2 forever and ever, your pancreas is pooped. Your insulin resistance can plum wear it out. Long-term T2s can have insulin levels of pretty much zero. They might as well just join our T1 club at that point. But freakier, and more common, is a temporary state called glucose toxicity.

So now I gotta talk about the prairie dogs.

You all know what prairie dogs are, right? I think they’re related to rats and moles, actually, but they’re much cuter and have a better name (perception is everything: if they were called prairie rats, no one would be busy saving them from housing developments). Oh, and they have the endearing behavior of sitting up on their hind legs on top of their mounds à la lemurs.

Now, when eagles fly over prairie dog villages, the prairie dogs dive for cover down their holes to avoid becoming lunch to a predator on the wing. Smart varmints. So I want you to picture the beta cells in your pancreas (the ones that make insulin) as being prairie dogs and your high blood sugar as the eagle.

Got it?

Right. When the blood sugar gets high enough, the beta cells dive for cover. They temporarily shut down. If the beta cells are hiding underground in their holes, they aren’t making insulin and POOF! Instant temporary type 1 diabetes. Well, OK, you aren’t really type 1 ’cause you don’t have an autoimmune disease, but you’re in the same physiological state for all practical purposes. No insulin means you can go DKA. Well, not can go DKA, probably will go DKA. In point of fact, if you, as an adult with no previous history of diabetes arrive at an ER in DKA it can be really difficult sorting out if you’re a LADA T1, or glucose toxic T2. Either way, you’ll get put on insulin to save your furry hide.

In the long run, of course, a glucose toxic T2 recovers. The prairie dogs come back out of their holes once the blood sugar comes back down, and in many cases the person will do just fine on oral meds.

So that’s the first kind of coma. The second is unique to you T2s and is called a Hyperosmolar Hyperglycemic State (HHS). Luckily, it’s quite rare as it carries a 20% mortality rate (DKA runs around 2% for comparison). It’s sometimes called a “nonketotic coma” as it is caused by a fluid imbalance associated with very high blood sugars in the absence of ketones. Ya can’t be DKA without the “K.”

HHS is pretty complicated. I loved one definition that called it a “metabolic derangement.” I personally think of it as a forest fire of high blood sugar (north of 600 mg/dL) and dehydration that feed off each other. And I’m not talking about garden-variety, hey-I-need-a-drink-of-water dehydration. I’m talking dehydration on the cellular level. As it progresses, sodium and potassium levels get out of whack too. Basically, it’s a physiological train wreck in slow motion, snow balling out of control on many levels simultaneously.

HHS is most common in the elderly T2, and often is triggered by an illness that reduces fluids (like being too sick to your stomach to drink or throwing up a lot from the flu).

On the bright side, the prevalence is only one case per 1,000 person years. So it’s not too likely to happen to you. On the dark side (other than the high death rate) the prevalence is expected to spike over the next few years as T2 is becoming much more common.

Bottom line: done poorly, diabetes Type 1 or Type 2, is dangerous businesses—and no one has an exclusive on coma risk. Sorry to say.

Disclaimer: 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.

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