Hypo signals and glycogen when following a ketogenic diet

I'd be extremely worried about not waking up during a nighttime hypo @Rianne

I don't know enough about the chemical processes your body may be going through but just a suggestion - why not try a continuous glucose monitor such as the libre to get a picture of what your levels are when you are asleep?

Rianne said:

And, if glycogen in the liver gets depleted, is a glucagon injection useless in case of an extreme hypo?

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I'm probably in nutritional ketosis most of the time and I've had several Glucagon injections for severe hypos while low carbing. Low carbing or ketosis doesn't stop your liver storing glucose, whatever carbs you take in and whatever protein is converted into glucose through gluconogenesis will get stored in the liver, keeping the liver stocked up with glucose is top priority for your body. That is why you are more vulnerable to a hypo after you've already had a hypo, because your body is prioritising restocking any liver stores that were used up in treating the previous hypo.

However, being in ketosis does mean that keeping the liver stores filled with glucose is a more complex process for your body, it's not very efficient to expect your liver store to get filled up via gluconogenesis only. So if you have had a hypo, or if you've been working out in a way that would have used up liver stores, do replace that glucose in the most efficient way possible - ie by actually eating some carbs.

For me, glucagon injections have been followed up with IV dextrose on a couple of occasions. So that's the alternative treatment to glucagon.

There's nothing about ketosis that would stop blood sugar dropping to dangerously low levels - you are still taking insulin, it's the insulin that causes blood sugar to drop. There's nothing chemical about ketosis that stops blood sugar dropping. The chemical things that stop blood sugar dropping is: 1) adrenaline - this is the stress response when your body sense low blood sugar adrenaline is released and causes hypo symptoms, like high heart rate, adrenaline is counter regulatory to insulin and will increase your insulin resistance when it's in your system; and 2) your own alpha cells releasing endogenous glucagon - as well as the naff beta cells in your pancreas there are also alpha cells in your pancreas and the alpha cells respond to low blood sugar by releasing the hormone glucagon to tell your liver to release some glucose stores and bump you back up. The alpha cells are also triggered by the adrenaline response to a low blood sugar, so if your hypo symptoms are changing on keto, suggesting less of an adrenaline/stress response, that might slow down your alpha cell response.

The way to encourage more of an adrenaline/stress response to a hypo is to tell your body that low blood sugar is not normal, to avoid dropping under 4 and to run a bit higher for a while. You want to teach your body that low blood sugar is something really unusual and something that it should panic about with a nice definitive release on adrenaline - causing hypo symptoms that actually wake you up.

My insulin needs dramatically decreased with keto.
My lantus went from 5 units to one or two and my humalog went from 5-8 to 1/2-1.
It CAN take the body a littl while tonadjust and not over or under compensate.

I would error on the side of caution and adjust your insulin doses if you're comfortable with that.