This article is more than 5 years old. Information may no longer be current.
A taste of dysglycemia
A patient with type 1 diabetes asks about a wine tasting.
Click Here to Manage Email Alerts
A 41-year-old woman with long-standing type 1 diabetes came to see me for a follow-up visit. Complications included diabetic nephropathy with proteinuria, and peripheral diabetic neuropathy. She had reasonably good hypoglycemic awareness and good glycemic control: fasting blood glucose levels were 80 mg/dL to 120 mg/dL, and levels during the daytime were in the middle to high 100s.
The patient strictly adhered to her medication regimen: glargine (Lantus, Sanofi Aventis) 6 U in the morning, 8 U at night and glulisine (Apidra, Sanofi Aventis), 5 U to 7 U per meal.
Other medical history consisted of hypertension, hyperlipidemia, depression/anxiety and finger fracture. Drug sensitivities included trimethoprim-sulfamethoxazole and erythromycin, which caused diarrhea, as well as ezetimibe-simvastatin (Vytorin, Merck/Schering-Plough), which had caused elevated transaminase levels.
 Ronald Tamler |
Medications included lisinopril, carvedilol, duloxetine (Cymbalta, Eli Lilly), pramlintide (Symlin, Amylin) 12 U with meals, losartan (Cozaar, Merck), and rosuvastatin (Crestor, AstraZeneca).
The patient did not smoke and stated she was consuming three alcoholic drinks per week. Physical exam was unremarkable: the patient was a petite white woman, 5 ft, 114 lbs, BMI 22, blood pressure 120 mm Hg/80 mm Hg and heart rate 82 bpm. Her HbA1c was 6.8% and her creatinine levels were stable at 1.5 mg/dL (calculated glomerular filtration rate 40). Otherwise, lipids and chemistry were normal or at goal.
The patient asked me about an upcoming occasion that she needed to attend for her job as a wine journalist: She was about to go to a four-day wine tasting event and was wondering how to maintain her blood glucose levels in the normal range.
What is the best advice for this patient?
- The patient is at risk for hyperglycemia: increase glargine and glulisine by 20%.
- The patient is at risk for hyperglycemia: have her take pramlintide with every glass of wine.
- The patient will not be affected because she will spit out the wine at the tasting event. Continue the same regimen.
- The patient will not be affected because although wine contains alcohol (which can reduce blood sugar), it also contains carbohydrates (which can raise it).
- The patient is at risk for hypoglycemia: She needs to monitor her blood glucose levels particularly frequently during the event and the following day. Decrease her glargine by 20%, hold the pramlintide and give 20% less glulisine when she has a full meal.
CASE DISCUSSION
A patient’s response to alcoholic beverages can be quite unique, and most patients know how they react to different forms of alcohol. Beer contains plenty of carbohydrates and will usually induce rapid hyperglycemia. On the other hand, beverages with higher alcohol content can cause severe hypoglycemia, which can sometimes be delayed by many hours and may be worsened by impaired hypoglycemia awareness.
Although most wine is spat out during tasting events (C), the amount actually consumed is sufficiently large to cause blood glucose irregularities. One cannot assume, however, that the carbohydrates in a glass of wine will perfectly balance out the alcohol effect (D). Hyperglycemia is less likely with wine consumption than hypoglycemia — answers A and B are, therefore, wrong. The blood sugar drop with pramlintide can be particularly precipitous if the patient’s hypoglycemia awareness is impaired after consuming alcohol.
The correct answer is E: The patient is at risk for protracted hypoglycemia at this event and must monitor her blood glucose levels carefully. She did reduce her insulin doses. Nonetheless, she measured her blood sugar levels as many as eight times per day and noticed that she was having hypoglycemia with levels down to the 50s without symptoms.
She was able to prevent worse hypoglycemia by eating bread several times per day and did not take any glulisine or pramlintide throughout the event.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, N.Y.