LS tells you that they frequently attend company mixers where they feel compelled to have at “least a few drinks”, to fit in and network. The tricky part of this scenario is that LS lives with type 1 diabetes. Since they don’t have a working pancreas, their circulating levels of insulin and glucagon are often mismatched to their body’s needs.

When discussing the situation, LS says they feel confident they can handle alcohol and prevent lows since they have lived with type 1 diabetes for over ten years. LS shares, “I feel comfortable recognizing when both arrows are pointing down and I am heading for a glucose crash”.

As educators, we are committed to taking person-centered approach while encouraging safe practices.

In regards to LS, we realize alcohol’s impact on the thought process and blood glucose levels. We know that alcohol can affect critical thinking and possibly impair recognition of an impending hypoglycemic event. Inebriation also has many symptoms in common with hypoglycemia. Plus, alcohol consumption slows glycogen breakdown in the liver, which increases the risk of hypoglycemia. Lastly, based on a study published in Endocrinology Advisor, higher levels of alcohol in the blood can delay and blunt the effectiveness of glucagon rescue medications.

In the worst-case scenario, if LS experiences severe low blood sugar and passes out, alcohol ingestion can blunt the effectiveness of the glucagon rescue medications.

Alcohol and Glucagon Pathophysiology Review

The body considers alcohol a toxin and as soon as it reaches the bloodstream, the liver prioritizes metabolizing the alcohol and breaking it down. During this clean-up process, the liver is distracted from responding to endogenous glucagon, the hormone that signals the liver to break down glycogen for energy and liberate glucose into the bloodstream. This clean-up can last for up to 8 hours, making delayed hypoglycemia a real possibility.

When a person with type 1 diabetes drink alcohol, they at increased risk of hypoglycemia because the liver isn’t breaking down stored glycogen to increase blood glucose levels.

Let’s get back to LS. What if LS is drinking gin and diet tonics and only munching on low-carb vegetables and cheeses during the mixer? LS is not ingesting many carbohydrates, so glycogen stores may be low and the liver is busy cleaning up the alcohol and blood sugars start dropping. By the 4th drink, LS isn’t thinking very clearly, says they “feel funny” and passes out.

A colleague of LS carries a glucagon emergency kit and provides LS with a dose and calls 911. After 15 minutes, LS still hasn’t regained consciousness, so a second dose is administered. The paramedics arrive and check the glucose, it is 53.

Simply put, glucagon rescue medications may not work if the person drinks too much alcohol.

After reviewing the package inserts of all available US manufactured Glucagon Rescue Meds, there are no warnings for alcohol intake decreasing the effectiveness of glucagon rescue meds. So, I dug a little deeper and found a decent study on the topic which describes the impact of alcohol ingestion on glucose-regulating hormones.

I also found a very helpful monograph published by Lilly Baqsimi in Canada. Baqsimi is a powdered glucagon rescue medication that is delivered nasally. The Baqsimi monograph clearly states several warnings, “Alcohol can suppress hepatic gluconeogenesis and chronic alcoholism can deplete liver glycogen stores. Therefore BAQSIMI may be less effective in presence of acute or chronic alcohol ingestion. Alcohol-induced hypoglycemia is associated with a failure of blood glucose levels to rise normally after glucagon administration. BAQSIMI may not work if the person drinks too much alcohol.“.

Keeping it Real and Safe

In conclusion, having a conversation with people with type 1 about the suppressive nature of alcohol on glycogen release for many hours after consuming alcohol is very important. Another important teaching point is that glucagon rescue meds may not be as effective and timely in raising glucose to safe levels.

As a general rule of thumb, encouraging people with type 1 to eat 15gms of carbs with each drink and have a glass of water in between, may help make sure they have enough circulating carbs and slow the pace of alcohol consumption to help the liver with processing. They may also consider decreasing their insulin dose in association with alcohol intake to prevent this serious side effect.

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