Clinical Focus Continuing education and moving points in medicine

Continuing Education Module 21: disease and alcohol

Clair Naughton outlines the issues of alcohol use in those with diabetes and discusses the potential risks of hypoglycaemia and how to avoid them

Enjoying a drink is part of Irish culture, birthdays, weddings, body weight and family history of diabetes was not examined.3 funerals or celebrating the start of the weekend. Irish people find Regular drinking increases the risk of acute and chronic pan- many good reasons to enjoy a drink. So, is drinking alcohol off creatitis. 70% of cases of chronic pancreatitis are due to long term limits for people with diabetes? The happy answer to that ques- heavy drinking. 50% of people who have chronic pancreatitis go tion is no. The majority of people with diabetes can continue to on to develop diabetes.4 enjoy drinking alcohol, but they do need to be aware of the effect Role of the in maintaining blood concentration that alcohol may have on their blood glucose levels in order that In order to understand the potential risks associated with they can drink safely. drinking alcohol with diabetes, it is important to have some Diabetes mellitus insight into how the body maintains normal blood glucose levels Diabetes mellitus is characterised by chronically raised blood and the vital role that the liver plays in this. glucose levels caused by an absolute or relative lack of the hor- In the fasting state the body has two major mechanisms for mone . In insulin is not being produced by maintaining blood glucose levels. The first is the breakdown of the pancreas, it is caused by an auto-immune destruction of the glycogen (glycogenolysis) and the second is the production of insulin producing beta-cells in the pancreas. It usually presents in glucose or . Glycogen is stored in the tissues childhood or early adulthood and it is treated with diet, exercise particularly the liver. It serves as the first line of defence against and insulin injections. hypoglycaemia as it is broken down into glucose and is secreted In type 2 diabetes there is insufficient insulin or ‘resistance’ to by the liver into the blood to maintain normal blood glucose the action of insulin. Family history of diabetes, being overweight levels. Glycogen stores may be depleted in someone with type and having a sedentary lifestyle are major risk factors for the 1 diabetes particularly if they have repeated episodes of hypo- development of this type of diabetes.1 glycaemia. Gluconeogenesis also occurs primarily in the liver Diabetes and alcohol: How much is too much and it involves the formation of glucose from non-carbohydrate The recommended alcohol intake for people with diabetes is sources. the same as for the general population. As 90-95% of alcohol is metabolised in the liver it shuts down • Men: No more than 17 standard drinks per week the process of gluconeogenesis and thus the bodies second line • Women: No more than 11 standard drinks per week of defence against hypoglycaemia. Therefore, alcohol tends to • Do not consume more than five standard drinks in one sitting. increase the risk of hypoglycaemia by impairing hepatic glucose • Allow at least two alcohol free days a week release.5 • One standard drink = Hypoglycaemia > Half a pint of larger In patients with diabetes treated with insulin, alcohol has > Standard pub measure of a spirit been implicated in up to one-fifth of hospital attendances with > Small glass of wine (125mls).2 hypoglycaemia.6 Consistently drinking alcohol to excess has been linked with Hypoglycaemia can have serious even life-threatening conse- high blood pressure and obesity which are risk factors for type quences. The brain can only utilise glucose as an energy source 2 diabetes. unlike other tissues that can switch from oxidation of glucose to There is some evidence to suggest that a moderate alcohol non-glucose fuels. Therefore the brain is dependent on a con- intake may have a protective effect against the development tinuous supply of glucose from the circulation to maintain its of type 2 diabetes. Some studies show a U-shaped relationship and function. If the continuous supply of glucose is between alcohol intake and the risk of diabetes demonstrat- interrupted for even a few minutes it can lead to central nervous ing a higher risk of developing diabetes with both low and high system dysfunction.1 For this reason the body employs multiple intakes of alcohol and a lower risk with a moderate intake of alco- mechanisms to prevent hypoglycaemia. The first response to hol. These protective effects require further evaluation however hypoglycaemia is the release of counter-regulatory and the evidence is not strong enough to advocate that teeto- and secondly the body generates a specific set of symptoms. tallers take up drinking alcohol. Also the interaction between These symptoms consist of autonomic symptoms (, alcohol intake and other risk factors for type 2 diabetes such as palpitations, hunger, sweating, and tremor) and neuro- This healthcare professional education is sponsored by Lundbeck Ireland Ltd. Lundbeck Ireland Ltd has had no editorial oversight of the final content Clinical Focus

Table 1: Tips for patients with diabetes to reduce risk of alcohol • Never drink on an empty stomach: Food can affect the rate of alcohol absorption. Starchy carbohydrate should be taken before alcohol. Initially the carbohydrate in the alcohol will cause the blood glucose to rise, but very soon the alcohol will lower the blood glucose level (by impairing hepatic glucose release). Therefore it is necessary to eat more carbohydrate when consuming alcohol rather than less to prevent hypoglycaemia • Always eat carbohydrate before going to bed: As the liver breaks down alcohol it will impair the hepatic glucose release. Due to the effects of alcohol the person may not wake up in response to the symptoms of hypoglycaemia. This is dangerous, particularly if they are sleeping alone. It is essential that the blood glucose is checked and starchy carbohydrate is taken before bed to ensure the blood glucose is maintained overnight • More frequent blood glucose checks: Patients should be advised to monitor their blood glucose levels more frequently when socialising to monitor the effect of the alcohol. Always check blood glucose level before going to sleep. Physical activity such as dancing will also increase the risk of hypoglycaemia on a night out • Carry identification: Patients should be advised to carry ID saying they have diabetes and tell the people they are socialising with that they have diabetes • Carry carbohydrate: Patients should be advised to carry carbohydrate so they have a convenient source of sugar if needed • Avoid binge drinking: It is not appropriate for anyone to binge drink. Any more than five standard drinks on one night is considered binge drinking • Discuss with diabetes team: Some patients may require an insulin adjustment or an increase in their carbohydrate intake the day after drinking alcohol as the increased risk of hypoglycaemia can continue the next day. Patients should monitor the effect alcohol has on their blood glucose level and discuss it with their diabetes team so that they learn to drink alcohol safely glycopenic symptoms (, tingling, blurred vision, difficulty • Alcohol can increase the risk of nocturnal hypoglycaemia or concentrating and faintness). Counter-regulatory hormones hypoglycaemia the following day by impairing hepatic glucose are released at a plasma glucose threshold of 3.5mmol/l, symp- release.4 toms of hypoglycaemia occur at a plasma glucose threshold of Other factors influencing hypoglycaemia include the person’s 3.0mmols/l and cognitive function deteriorates when plasma glu- glycaemic control at the time, recent exercise, insulin absorption, cose falls below 2.7mmols/l.7 alcohol in relation to food intake and the duration of diabetes. Who is at risk of hypoglycaemia Glucagon hypokit, which is used to treat severe hypoglycaemia, Not everyone with diabetes is at risk of hypoglycaemia. Hypo- only works when the liver has glycogen stores. It will therefore glycaemia is a common side-effect of all and certain not work to treat hypoglycaemia caused by drinking too much drugs used in the treatment of type 2 diabetes called sulphonylu- alcohol. It is essential that people with diabetes are aware of the reas which stimulate insulin secretion. Drugs in the sulphonylurea risks of hypoglycaemia following alcohol consumption to ensure category include Diamicron and Amaryl. Hypoglycaemia caused they maintain their margin of safety. If patients are aware of the by sulphonylureas can be prolonged and severe. The hypoglycae- periods where they are most likely to be at risk of hypoglycaemia, mia effect of insulin and sulphonylureas can be exacerbated by it will enable them to be proactive by adjusting their carbohy- the simultaneous ingestion of alcohol.1 drate intake or insulin dose accordingly. Patients on insulin therapy and sulphonylureas should be edu- Conclusion cated by their health care professional about the potential side Alcohol is part of everyday life for many people. Used sensibly effects of hypoglycaemia, including causes, treatment and avoid- it can be enjoyable. It is essential however for patients with diabe- ance. They should also be advised to carry carbohydrate with tes who are at risk of hypoglycaemia – that is those being treated them, ie. glucose sweets if they need to treat a hypoglycaemia with insulin or those on sulphonylureas – know of the potential episode when they are away from home. risks of hypoglycaemia and how to avoid them in order so that Alcohol and the risk of hypoglycaemia they can enjoy alcohol safely and maintain their margin of safety. Alcohol may be associated with hypoglycaemia in a variety of Clair Naughton is a regional development officer in the North West region with ways: Diabetes Ireland • Alcohol consumption can cause cognitive impairment affecting References a persons ability to detect the warning symptoms of hypogly- 1. Williams G, Pickup J. Handbook of Diabetes third Edition UK Blackwell Publishing Ltd 2004 caemia. If they are under the influence of alcohol they may not 2. HSE Dublin. Health A-Z Alcohol. HSE website 2013. Available from http://www.hse.ie/go/ take corrective action to prevent the plasma glucose falling alcohol/ 3. Alromaihi D, Zielke J, Bhan A. Challenges of Type 2 Diabetes in patients with alcohol further such as taking carbohydrate therefore will not prevent dependence. Clinical Diabetes (2012) Vol 30 No 3 neuroglycopenia 4. www.drinkaware.co.uk 5. Emanuele N, Swade T, Emanuele MA. Consequences of alcohol use in Diabetics. Alcohol • Alcohol has been shown to blunt the bodies hormonal coun- Health and research world (1998) Vol 22 No 3 ter-regulatory response to hypoglycaemia 6. Ricardson T, Thomas P, Weiss M, Kerr D. Day after the night before. Influence of evening • Third parties may mistake the symptoms of hypoglycaemia for alcohol on risk of hypoglycaemia in patients with Type 1 Diabetes. Diabetes Care (2005) Vol 28 No 7 Pg 1801-1802 symptoms of intoxication, which may have potential health or 7. Bolli GB. Mechanism, treatment and prevention of hypoglycaemia unawareness in Type even legal consequences for the individual 1 Diabetes International Diabetes Monitor 1998 Vol 10(1)

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