Minimizing Hypoglycemia in Diabetes

Abstract

Hypoglycemia caused by treatment with a sulfonylurea, a glinide, or insulin coupled with compromised defenses against the resulting falling plasma glucose concentrations is a problem for many people with diabetes. It is often recurrent, causes significant morbidity and occasional mortality, limits maintenance of euglycemia, and impairs physiological and behavioral defenses against subsequent hypoglycemia. Minimizing hypoglycemia includes acknowledging the problem; considering each risk factor; and applying the principles of intensive glycemic therapy, including drug selection and selective application of diabetes treatment technologies. For diabetes health-care providers treating most people with diabetes who are at risk for or are suffering from iatrogenic hypoglycemia, these principles include selecting appropriate individualized glycemic goals and providing structured patient education to reduce the incidence of hypoglycemia. This is typically combined with short-term scrupulous avoidance of hypoglycemia, which often will reverse impaired awareness of hypoglycemia. Clearly, the risk of hypoglycemia is modifiable.Hypoglycemia is the major limiting factor in the glycemic management of diabetes with a sulfonylurea, a glinide, or insulin (1,2). It is often recurrent, causes significant morbidity in most people with type 1 diabetes and in many with advanced type 2 diabetes (i.e., those with absolute endogenous insulin deficiency), and is sometimes fatal. Hypoglycemia limits maintenance of euglycemia over a lifetime of diabetes and, thus, generally prevents full realization of the benefits of glycemic control. It impairs defenses against subsequent falling plasma glucose concentrations and can cause impaired awareness of hypoglycemia, therefore resulting in a vicious cycle of recurrent hypoglycemia.The problem of hypoglycemia in diabetes has been recently reviewed in detail (1,2). The intent of this article is not to reiterate that information but, rather, to summarize the relevant background and then focus on pragmatic approaches to minimizing hypoglycemia. Efforts to minimize hypoglycemia include acknowledging the problem, considering each risk factor, and applying the relevant principles of intensive glycemic therapy (3-6). The principles of intensive glycemic therapy include avoiding sulfonylureas and glinides; using more physiological insulin regimens, such as insulin analogs, when insulin is indicated; ensuring users are confident in their self-management; considering insulin treatment technologies such as continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and CSII with CGM (ideally with suspension of insulin infusion when glucose levels fall to a selected low value) for selected patients; and closed-loop insulin or insulin and glucagon replacement or pancreas or pancreatic islet transplantation for the few patients in whom hypoglycemia persists. However, for the majority of people with diabetes who are at risk for or are suffering from iatrogenic hypoglycemia, the principle...

Cognitive deficits associated with impaired awareness of hypoglycaemia in type 1 diabetes

“…This is consistent with the dynamic nature of the IAH syndrome: awareness status may fluctuate and may even be restored by avoidance of hypoglycaemia [41]. When excluding the five participants whose hypoglycaemia awareness status had changed, group differences became more evident, thus demonstrating that persistent IAH status was most negatively associated with cognitive deficiency.…”

Risk factors for hypoglycaemia in in-patients with diabetes treated with continuous insulin intravenous infusion

“…Similar conclusions can be found in recently published papers and recommendations describing the pathophysiology, prevention and management of hypoglycaemia [18,[22][23][24][25][26][27]. Clinical practice also indicates that patients who have had type 1 diabetes for more than 10 years are at the highest risk for hypoglycaemia.…”

Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006–2013

“…Clinicians and patients can now choose from 12 different classes of glucose-lowering medications to manage hyperglycemia. Unlike insulin or sulfonylurea drugs, most of the newer agents have not been implicated as a cause of hypoglycemia, which can be a serious complication of glucose-lowering therapy, particularly in the elderly (3). However, utilization of these newer agents has significantly contributed to increasing costs of diabetes management (4,5).…”