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ADA, Endocrine Society release consensus statement on hypoglycemia, diabetes
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The American Diabetes Association and The Endocrine Society have collaborated to deliver a consensus statement on the effect of hypoglycemia in patients with diabetes, according to a report in the Journal of Clinical Endocrinology & Metabolism. Data from recent clinical trials and other studies were used to update their previous report published in 2005.
The workgroup consisted of five members of the ADA and five members of The Endocrine Society with expertise in different specialties of hypoglycemia. In an interview, Endocrine Today Editorial Board member and workgroup member Philip E. Cryer, MD, of the Washington University School of Medicine, said much of the current paper is unchanged since the 2005 report.
Philip E. Cryer
“The important thing is that one cannot really use an absolute number to define hypoglycemia because the thresholds for symptoms and/or other responses of hypoglycemia tend to shift. They shift to lower glucose levels in patients with recurrent hypoglycemia. It’s also true in patients with diabetes who have hypoglycemic episodes from their treatment and with people on insulin who have recurrent episodes of hypoglycemia,” Cryer said. “On the other hand, in patients with poorly controlled diabetes, the thresholds shift higher.”
According to the consensus statement, the workgroup reconfirmed the previous definitions of iatrogenic hypoglycemia in patients with diabetes as all episodes of an abnormally low plasma glucose concentration that expose the individual to potential harm.
Additionally, Cryer said he acknowledged the debated alert value of ≤70 mg/dL in the classification of hypoglycemia in diabetes. Again, this alert was addressed in the previous report.
“We think that’s a practical, pragmatic value that is based on elements in which we cited,” he said.
Four of the five classifications remain consistent with past recommendations, including: severe hypoglycemia, documented symptomatic hypoglycemia, asymptomatic hypoglycemia and probable symptomatic hypoglycemia. The fifth classification previously known as “relative hypoglycemia” is now known as “pseudo-hypoglycemia.” This was a reasonable change of language, Cryer said.
The workgroup also reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia and identified knowledge gaps that should be addressed by future research.
Currently, the group recognizes patient education, dietary intervention, exercise management, medication adjustment glucose monitoring and clinical surveillance as strategies known to prevent hypoglycemia.
However, they wrote that the current knowledge gaps in clinical understanding of hypoglycemia include surveillance methods, understanding which patients are at the greatest risk, new technologies and underlying mechanisms. The group suggests further focused research in these areas to better address the gaps in hypoglycemia and reduce the effect of iatrogenic hypoglycemia on patients with diabetes, they wrote. – by Samantha Costa
Disclosure: The workgroup meeting was supported by educational grants to the ADA from Lilly USA and Novo Nordisk and sponsorship to the ADA from Sanofi. Cryer reports recent consultancy for Novo Nordisk. All other researchers report no relevant financial disclosures.
Philip E. Cryer, MD, can be reached at Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8127, St. Louis, MO 63110; email: pcryer@wustl.edu.
Perspective
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Kenneth Cusi, MD, FACP, FACE
This consensus statement is important because it offers a true comprehensive view of hypoglycemia covering a number of important aspects from understanding the mechanism to the clinical implications. There are three key areas this statement addresses.
First, it increases the awareness of hypoglycemia as a primary problem with type 1 and type 2 diabetes. Second, they help the clinician understand that there are important subpopulations particularly vulnerable like the elderly, patients in the hospital, pregnancy, teenagers and children. Third, they offer practical guidelines in terms of management with a very useful step-by-step approach, a diagnostic algorithm and a check list, which is something that is useful for the clinician.
We’ve learned that hypoglycemia is not just a consequence of trying to intensify control. However, in noncompliant patients the risk is highest when we try to manage and optimize control. The clinician should be aware of patients that are not compliant and reconsider aggressive insulin management in those patients.
At least 10% to 20% of patient in the hospital develop hypoglycemia. There is no real systematic approach to it and perhaps this is another gap we have in our knowledge. We have an increasing elderly population also prone to hypoglycemia with decreased renal and liver function. They are taking multiple medications. Additionally, they don’t feel the symptoms of low blood sugar as other patients and when they become hypoglycemic the consequences can be much more devastating than younger people. They might fall; they may hurt themselves more or be more prone to potential cardiac arrhythmias.
There’s very little data on pregnancy and hypoglycemia. Women with type 1 diabetes are three to five times more prone to hypoglycemia. We need to learn more populations and perhaps apply these to glucose monitoring techniques. There’s also evidence that there might be long-term effects of hypoglycemia. One study suggested it could be associated with doubling risk for dementia. However, we need to do more work in this area.
The other thing that is important with these guidelines is they identify future areas of need. For example, we are not sure what the long term risks are and we don’t have good prospective studies to see which are the best ways to present hypoglycemia and this is a little bit of a paradox because we have better glucose monitoring than ever before.
Therefore, we need studies in which we test these new techniques and see what they can provide us in the long-term. The bottom-line is that we should encourage every physician to read this consensus statement because they put into a single body, a lot of information that is essential for the management of our patients.
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