Health Administrator Vol: XXII Number 1& 2 - 2009 : 56-58 Pg.

12 - DIABETES, ALCOHOL, AND HYPOGLYCAEMIA

Alexandra Ward and David Kerr, Diabetes and Endocrine Centre, Royal Bournemouth
Hospital, Bournemouth BH7 7DW
Diabetic patients present a mirror image of the behavioural pattern of chronic alcoholics who
are non-compliant with medication, whose dietary habits are haphazard and whose self-care
is at best spotty. .....The two conditions together are not compatible with long survival

Books and pamphlets containing information
about the risks of alcohol and diabetes often contain
conflicting advice. They vary in their information
about the limits for daily consumption (ranging from
"moderate amounts" to "ask the dietician") and
some fail to mention the risks of hypoglycaemia
associated with alcohol. A small number of patients
with long-standing diabetes still slavishly adhere to
a policy of total abstinence based on the "education"
they received many years ago. In this article we
seek to address various aspects of the interplay
between diabetes and alcohol.
Alcohol, diabetes and glucose levels
Prolonged heavy drinking is an established
risk factor for pancreatitis, which may lead to the
development of secondary diabetes. In addition,
sustained alcohol use is associated with
hypertriglyceridaemia, another factor implicated in
pancreatic inflammation. However, for more
modest drinkers, the evidence is conflicting with
some studies showing that alcohol protects against
diabetes whilst others suggest that alcohol may be
an independent risk factor, at least in men.
Abnormalities in glucose tolerance among heavy
alcohol users usually resolve with abstention.
For patients with established diabetes, the
consequences of alcohol use on peripheral blood
glucose levels are variable and dependent upon a
number of factors. Problems with hyper and
hypoglycaemia are both possible and are
influenced by both the amount and frequency of
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alcohol use as well as the prevailing hormonal
mileu. Alcohol effects glucose production by the
liver by directly inhibiting hepatic gluconeogenesis.
This can be balanced by reduced peripheral
glucose uptake into muscle (i.e. insulin resistance)
and therefore the overall effect on blood glucose
levels may be neutral. To complicate matters
further, alcohol has been shown, under laboratory
conditions, to both enhance and impair insulin
secretion and action!
The current consensus is that alcohol use
within advised limits has no significant influence
on long term glycaemic control. However, as it is
well known that diabetes, per se, carries a 2-3 fold
increased risk of premature death from
cardiovascular disease, the putative benefits of
alcohol in this area should not be ignored.
Alcohol and Oral hypoglycaemic agents
Alcohol can alter the metabolism of certain
glucose lowering drugs (e.g. tolbutamide) and
chlorpropamide can cause a Disulfiram-like
reaction if used in combination with alcohol. There
is also a risk of lactic acidosis with the biguanide
metformin and this drug is contra-indicated inr
patients with established liver disease or on-going
alcohol misuse.
Alcohol and hypoglycaemia
In clinical practice, the major concern is the
risk of hypoglycaemia with alcohol. Alcohol may!
be associated with low blood glucose levels in aj
number of ways:
• Alcohol-induced fasting hypoglycaemia
• Potentiation of drug-induced hypoglycaemia
• Reactive hypoglycaemia in susceptible
individuals.
After a prolonged fast, (6-36 hours), liver
glycogen stores become depleted and an individual
may become at risk from hypoglycaemia as a result
of direct inhibition of hepatic gluconeogenesis by
alcohol. Fortunately such a scenario is rare. More
commonly alcohol has the ability to potentiate the
effect of glucose lowering drugs such as insulin or
sulphonylureas.
The brain is absolutely dependent upon a
continuous supply of glucose from the peripheral
circulation for normal function. Thus, as peripheral
blood glucose levels begin to fall below normal, a
complex and hierarchical system has evolved to
protect glucose supply to neurones (Figure 1).
Below 4.0 mmol/l, there is release of counter-
regulatory (anti-insulin) hormones particularly
glucagon, adrenaline, noradrenaline, cortisol and
growth hormone. Between 3.5 and 3.0 mmol/l,
patients develop characteristic warning symptoms
(sweating, shaking and palpitations) as a
consequence of activation of the autonomic
nervous system. The perception of these
symptoms which alert an individual to take
appropriate action i.e. eat something. Unfortunately
if blood glucose levels continue to fall, intellectual
(cognitive) function deteriorates. At 2.5 mmol/l,
blood flow to the brain increases in an attempt to
enhance substrate delivery.
Figure 1 Physiological responses of falling
blood qlucose
Alcohol can interfere with each of these
physiological processes by directly inhibiting
release of counter-regulatory hormones, enhancing
cognitive impairment and possibly reducing brain
blood flow. In practical terms, patients are at risk
from hypoglycaemia when they lose warning
symptoms. Alcohol will exacerbate this due to:
• A failure to develop the warning symptoms
due to attenuation of the autonomic response
• A failure to recognize the presence of the
warning symptoms
• A failure to take appropriate action despite the
recognition of the warning symptoms
Intoxication may also lead to errors in insulin
dosage although this is very uncommon. It is
important to remember that some of the
manifestations of acute hypoglycaemia can be
mistaken for alcohol intoxication (slurred speech,
irrational behaviour, aggression and
unconsciousness) with disastrous consequences
for patients.
Reactive Hypoglycaemia
In non-diabetics reactive hypoglycaemia
occurs when blood glucose levels fall into the
hypoglycaemic range 2-3 hours after eating a high
carbohydrate meal, probably due to an exaggerated
post-prandial insulin response. Patients with
reactive hypoglycaemia can experience a variety
of symptoms, particularly anxiety, tremor and light-
headedness and feel that they have to continually
eat to prevent attacks. Alcohol can both cause this
condition when taken with a carbohydrate-
containing mixer (eg. gin and tonic) and aggravate
the problem in established sufferers.
Alcohol and diabetic complications
In men consuming at least three alcoholic
beverages per day the prevalence of neuropathy is
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increased, regardless of the duration of diabetes Practical advice would be:
and these patients tend to be more symptomatic.
• Modest alcohol intake (2-3 units per day) is
Thus alcohol intake should be assessed in a patient
safe and may afford cardiovascular
presenting with early neuropathy and appropriate
protection
advice may limit the progression. Likewise,
impotence coexists in both diabetes and • Alcohol should always be taken with food
alcoholism, but the presence of both conditions
Alcohol reduces warning symptoms of
accelerates the problem. Other studies have
hypoglycaemia so monitor more frequently
suggested that progression of diabetic retinopathy
may be hastened by heavy alcohol use. Alcohol • Never drink alcohol before driving
intake needs to be addressed in those patients
• Always carry identification in case of
trying to lose weight-between 40-50% of patients
emergency
presenting with new-onset of type-2 diabetes are
clinically obese (body mass index > 30 kg/m2). A Suggested reading
similar proportion of diabetic patients have a raised
1. Kerr D, Drugs and Alcohol. In
blood pressure (>140/80 mmHg) and the
Hypoglycaemia and Diabetes. Eds BM Frier
consequences of alcohol use need to be
and M Fisher. Hodder and Stoughton 1993,
considered.
328-336
Conclusions and recommendations
2. Kolvisto et al, Alcohol with a meal has no
Patients with diabetes are potentially beset adverse effects on post-prandial glucose
by a host of restrictions to 'normal' life as compared homeostasis in diabetes mellitus. Diabetes
with their peers. Alcohol use is part of our culture Care 1993 16 1612-14
and thus health professionals should strive to
3. Flanagan D et al, Gin and tonic and reactive
provide standard advice to facilitate safe drinking,
hypoglycaemia: What is important - the gin,
within recommended limits, for these patients.
the tonic, or both? Journal of Cinical
Endocrinology and Metabolism 1998 83 796-
800.

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