Wil Dubois

Need help navigating life with diabetes? Then Ask D’Mine! That would be our weekly Question & Answer column hosted by veteran type 1, former community educator and diabetes author Wil Dubois.

This week, Wil's talking alcohol -- a somewhat taboo topic in the diabetes healthcare world. Which is a shame. Read all about it here.  

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Brad, type 1 from Nevada, writes: I’ve been reading in the #DOC some talk about how glucagon may not work if you’ve been drinking alcohol? I am currently in college and tend to enjoy these times out with friends, but haven’t had any serious lows or anything needing glucagon so far. I have never been told that by my doctor or educator, and I wonder why that is? Could you share more on that? 

[email protected] D’Mine answers: What a perfect question for St. Patty’s day, historically a big drinking day for the college crowd… well, for lots of crowds, actually… but thank you!

Anyway, the answer is, yes. Social media has it right! Glucagon and booze are as bad a mix as texting and driving, lions and hyenas, or brussels sprouts and chocolate sauce. Simply put, glucagon won’t work when it’s drunk. 

... which is ironic as you are much, much more likely to need the damn stuff when you are drinking, because—even though we don’t want to admit it—we type 1s can’t handle alcohol as well as sugar-normals.

So much for a just universe.

To understand why both of these are the case, and they are related, we need to first understand how the body’s sugar supply and regulation systems work in the absence of alcohol. Every living cell in your body, from a cardiac muscle cell to a cell in your little toenail, “eats” a sugar called glucose to get the energy it needs to live and do its assigned task. Simply put, glucose is the fuel that our bodies run on. That glucose comes from three sources: digested carbohydrates, glycogen stored in the liver, or from “sugar” manufactured by the liver.

When you eat, a large portion of the carbs in the meal go straight into the blood stream, but because we can’t eat all the time (although some of us might enjoy that) another portion of the glucose is stored in the liver for later use—the glycogen. This is why the liver is sometimes called a “battery,” as it stores spare energy. But that’s short-changing the liver, as it’s more of generator than a simple battery. Here’s why: In addition to storing extra sugar, the liver also stores other components of the food from the meal, largely lactate, glycerol, and amino acids. If the “battery” runs low, the liver can actually manufacture glucose with those components thanks to the magic of gluconeogenesis.

Pretty frickin’ cool.

It works pretty much like this: In the two- or three-hour window following a meal, the body is “run” on the sugar of the meal. Outside that window, it’s run first on the stored sugar, and later, if needed, on sugar made by the liver.

Hormones control which sugar source is used, and when. For sugar regulation, the two primary hormones are our friends insulin and glucagon. Glucagon, a native hormone in the pancreas, is a trigger hormone that instructs the liver to either release stores of glycogen or to begin the process of gluconeogenesis.

Which is where glucagon emergency kits come in. They hold an injectable form of glucagon, intended for emergency use only, to help reverse really bad lows that result in the PWD being lights-out and unable to consume carbs to treat the low. The kit provides a manual boost of glucagon, which in turn signals the liver to dump its supply of glycogen and to start turning the stored lactate, glycerol, and amino acids into even more sugar, which is why the emergency injection can take a while—up to 30 minutes—to bring someone back around. Manufacturing sugar takes a little time.

Phew. So much for the basics. I need a drink, and so, too, do you probably by now. But as you’ll soon see, maybe we shouldn’t.

Alcohol is actually quite toxic -- for anyone, not just us. The body freaks out when alcohol is ingested and the top priority of the body is to break it down into less toxic substances. Who gets the job? The liver. And the problem for us is that it’s such a high priority that the liver drops all its other jobs just to work on it.

How long does it take? Well, it depends on how much you drink. More alcohol = more time. Each drink takes the liver up to 1.5 hours to process, but apparently the drinks stand in line one at a time. Two drinks = 3 hours. Three drinks = 4.5 hours. Four drinks = almost seven hours. Remember that during this time, the liver is off the job when it comes to supplying sugar for the body to run on, greatly increasing the risk of hypoglycemia for type 1s. More on that in a sec.

So one drink is no issue at all. At least not with a meal, as the body is running on the “meal sugar” for that first few hours (let me go get my drink, I’ll be right back), and the liver will be back on the job by the time the sugar in the blood from the meal is used up. But when it comes to more drinks, the math gets riskier, as you can see. At two drinks, it’s sorta 50/50, but at three drinks the liver is still off the job waaaaaay into the zone where it should be providing sugar for the body to run on.

So you come up sugar-short.

Worse, actually, because as a type 1 diabetic you take insulin, and some of the fast-acting stuff may still be in your body, and your basal will be for sure. So you are sugar-short and taking a blood sugar-lowering medication!

Can you say hypo-gly-cem-ia?

So the alcohol has opened a huge hypo window, and when it comes to binge drinking, the hypo window can actually be 36 hours out! And these aren’t normal lows. In “normal” lows, we’re simply dealing with too much insulin. Now we’re talking about SUPER-lows, with too much insulin and no help from the liver. These are, no kidding, potentially killer lows.

It’s this mix of no carbs coming in, the liver being off the job, and the presence of glucose-lower meds (either insulin or, in type 2s, pills) that set PWDS up for serious lows, which can hit hours downsteam of the drinks themselves—possibly when you are sleeping it off—that makes heavy drinking so dangerous for PWDs.

Now, I’ve said that the liver can’t multi-task. Or you’ll commonly read that it “forgets” to release sugar in the presence of alcohol, or that alcohol “blocks” the liver, or that can only do one thing at a time, or whatever. But what’s really going on metabolically? Why is the liver is unable to multi-task drinking and sugar delivery/manufacture?

Well, that’s some deep science. Here’s the deal: Alcohol triggers oxidation of acetaldehyde in the liver and increases the nicotinamide adenine dinucleotide-hydrogen (NADH)-to-nicotinamide adenine dinucleotide (NAD) ratio. In the words of one scientist, “Alcohol intake leads to significant impairment of glucose metabolism.” Or, in plain English: Booze messes with the hormone signals the liver normally receives that tell it what to do.

And which hormone would that be? Glucagon. 

So that’s why a glucagon emergency kit won’t work when you are drunk and low. It was glucagon that was supposed to keep you from getting low in the first place, but thanks to booze’s effect on the NADH-to-NAD ratio, its signals got scrambled. Adding more glucagon is like calling a wrong phone number again and again and again. You’ll still get the increasingly pissed off little old lady in Hackensack, not the person you were trying to call.

As to why no doc or educator has ever warned you, I suspect it’s a severe form of the same misguided logic that you shouldn’t discuss birth control with teens—because it will turn them into raging sex fiends, right? So they think talking alcohol with patients migth actually encourage drinking (sigh). Given your college age, and recent exit from teenagism, I’d bet your educators simply avoided the whole subject of alcohol, and with it the subject of the ineffectiveness of glucagon along with it, which is crazy. Shame on them.

Thank goodness for the #DOC that you learned of this valuable fact that was neglected by your care team, and thanks for reaching out to me for more details.

 

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.
Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.