Steps to reduce severe hypoglycemia risk for people with diabetes
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Hypoglycemia is common, easily missed and often underappreciated, and endocrinologists must adopt approaches to prevent and treat the condition in their patients with diabetes, according to a speaker.
Approximately 30% to 40% of people with type 1 diabetes have one to three episodes of severe hypoglycemia each year; rates of mild hypoglycemia are 50 times more common, Kathleen Dungan, MD, MPH, associate professor of medicine in the division of endocrinology, diabetes and metabolism at Ohio State University School of Medicine, said during a presentation at the American Association of Clinical Endocrinology annual meeting. In the U.S. alone, there are an estimated 97,000 emergency department visits for hypoglycemia annually, Dungan said.
“The No. 1 reason hypoglycemia is often missed is because we do not ask about it,” Dungan told Healio. “Hypoglycemia assessment should be part of every visit with people with diabetes who are at risk — people on insulin, sulfonylureas or medications known to cause significant hypoglycemia.”
Expert consensus generally slots hypoglycemia into three categories, Dungan said during her presentation. Level 1 is a blood glucose measurement of less than 70 mg/dL; level 2 is glucose less than 54 mg/dL, and level 3 is any severe event characterized by altered mental or physical status requiring assistance. Symptoms can range from sweating and warmth, tachycardia and palpitations, nausea and tingling, to mental dullness, confusion and visual disturbances. Symptoms can sometimes be subtle or, in cases of hypoglycemia unawareness, unknown to the patient, Dungan said.
“We rely a lot upon an HbA1c, so there is a tendency that, if the HbA1c is good, [the patient] must be fine,” Dungan said. “That is often far from the case. Patients may or may not be monitoring their glucose values. They may or may not have the full understanding of the ramifications of repeated hypoglycemia or even undetected hypoglycemia.
Managing lows
Clinicians should prepare patients to address hypoglycemia with proper education on recognizing the symptoms and triggers of a low event. Frequent blood glucose monitoring, wearing a medical identification card, practicing the “rule of 15” (consume 15 g of carbohydrate, wait 15 minutes to see if glucose increases, repeated if needed) and informing friends and family members are all important, Dungan said. Glucagon should be prescribed for all individuals at increased risk for level 2 or level 3 hypoglycemia so it is available if needed.
“There is also a whole cascade of options in terms of insulin therapy,” Dungan told Healio. “For example, we know the newer long-acting basal insulins, longer-acting insulin glargine U-300 carries less hypoglycemia risk than do insulin glargine (Lantus, Sanofi) or insulin detemir (Levemir, Novo Nordisk), which carry less hypoglycemia than NPH insulin. In patients with type 2 diabetes, insulin-sparing therapies will cause less hypoglycemia. Anytime you can minimize use of insulin or sulfonylurea, you can minimize hypoglycemia.”
Addressing hypoglycemia unawareness
Hypoglycemia unawareness is often induced by antecedent hypoglycemia; a clinical diagnosis is based on the patient’s subjective sense of a reduction in symptoms of hypoglycemia, Dungan said.
Often, it is not perceived as a problem until a serious event occurs.
“The first step is identifying it and describing to the patient why it is important,” Dungan said. “Sometimes patients have hypoglycemia unawareness because they had frequent hypoglycemic events. If you can make adjustments to therapy to eliminate those events, then it can return to normal.”
Impaired awareness is reversible with 2 to 3 weeks of hypoglycemia avoidance, she said. Education programs exist to help patients restore their “sense” of lows.
“Sometimes cognitive behavioral therapy is needed,” Dungan said. “A person may have beliefs that if they ever have a hyperglycemic event, that that is somehow worse than any hypoglycemia. We need to explore the rationale for that.”
Education and cognitive interventions plus continuous glucose monitoring is likely the ideal solution for any person with hypoglycemia unawareness, she said.
“Most patients with hypoglycemia unawareness on multiple injections of insulin a day probably need CGM as well,” Dungan said.
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Dungan K. The unrecognized crisis of severe hypoglycemia. Presented at: American Association of Clinical Endocrinology Annual Scientific and Clinical Conference; May 26-29, 2021 (virtual meeting).
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