New report addresses hypoglycemia and its impact on patients with diabetes

A consensus report on hypoglycemia and diabetes from the American Diabetes Association (ADA) and the Endocrine Society defines iatrogenic hypoglycemia as any episode of an abnormally low plasma glucose concentration that exposes the patient to potential harm. The workgroup also recommends individualization of glycemic targets based on several factors. It emphasizes that patients with type 2 diabetes might be particularly vulnerable to adverse events associated with hypoglycemia, including an increased risk of subsequent mortality and cardiovascular mortality.

The workgroup copublished its guidance in the May issues of Diabetes Care¹ and the Journal of Endocrinology and Metabolism²(bothonline April 15).

Glycemic thresholds for symptoms of hypoglycemia can shift; as such, a single threshold value for plasma glucose that defines hypoglycemia cannot be assigned, according to the workgroup. “Nonetheless, an alert value can be defined that draws the attention of both patients and caregivers to the potential harm associated with hypoglycemia,” it wrote. Patients taking a sulfonylurea, glinide, or insulin are at risk for hypoglycemia, and these patients should be alerted to risk when plasma glucose falls to ≤70 mg/dL.

The workgroup classified hypoglycemia as follows:

• Severe hypoglycemia:An event requiring assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions.
• Documented symptomatic hypoglycemia:An event during which typical hypoglycemia symptoms are accompanied by measured plasma glucose ≤70 mg/dL.
• Asymptomatic hypoglycemia:An event not accompanied by typical hypoglycemia symptoms but with measured plasma glucose ≤70 mg/dL.
• Probable symptomatic hypoglycemia:An event during which typical hypoglycemia symptoms are not accompanied by plasma glucose determination but that was likely caused by plasma glucose ≤70 mg/dL.
• Pseudo-hypoglycemia:An event during which a person with diabetes reports any typical hypoglycemia symptom with measured plasma glucose >70 mg/dL but approaching that threshold.

Glycemic targets should be individualized based on age, life expectancy, comorbidities, preferences, and an assessment of how hypoglycemia might affect the patient’s life. In individuals with type 2 diabetes, the risk of hypoglycemia is related to types of medications used. A hemoglobin A₁c <7.0% may be appropriate for many patients with recent-onset type 2 diabetes, but less aggressive goals may be considered as the disease progresses, or with known cardiovascular disease, extensive comorbidities, or a limited life expectancy.

Strategies to prevent hypoglycemia include patient education, dietary intervention, exercise management, medication adjustment, and glucose monitoring.

Risk factors and remediation should be discussed with patients receiving insulin or sulfonylurea/glinides. Patients and caregivers should be educated to recognize and treat hypoglycemic episodes and should understand the pharmacokinetics of medications they are taking.

Patients on long-acting insulin secretagogues and fixed insulin regimens should be instructed to follow a predictable meal plan. Those on flexible insulin regimens should couple insulin injections with meals. Patients on any hypoglycemia-inducing medication should be advised to carry carbohydrates at all times.

Patients on insulin, sulfonylureas, or glinides should be instructed to check blood glucose when hypoglycemia symptoms are present to confirm the need for carbohydrates, and should report this information to their healthcare provider for medication adjustment.

The treatment regimen should be adjusted to avoid frequent hypoglycemia/hypoglycemia unawareness. The drug class that poses the greatest risk of hypoglycemia is the sulfonylureas; consider substituting another class of agents for patients who have troublesome hypoglycemia, the report writers recommend. Patients on insulin or insulin secretagogues should have their hypoglycemia risk assessed at all visits.

The report notes that older adults with diabetes are particularly vulnerable to hypoglycemia; it is the most frequent metabolic complication among elderly persons in the United States. Predictors of hypoglycemia include advanced aged, recent hospitalization, and polypharmacy. Minimizing the risk of hypoglycemia in the elderly includes:

• Careful education about hypoglycemia symptoms and treatment.
• Assessing the elderly for functional status to apply individualized glycemic targets.
• Avoiding the use of short-acting insulin sliding scales.
• Replacing glyburide with short-acting insulin secretagogues or medications that do not precipitate hypoglycemia.

The workgroup devised a checklist for providers to ensure that hypoglycemia has been addressed adequately during a patient visit. It also developed a patient questionnaire that can be completed in the waiting room to help clinicians learn how often the patient is experiencing hypoglycemia and how well patients recognize symptoms of low blood glucose.

Reference

1. Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and The Endocrine Society. Diabetes Care. 2013;36:1384-1395.
2. Seaquist ER, Anderson J, Childs B, et al. Consensus statement: hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and The Endocrine Society. J Endocrinol Metab. 2013;98:1845-1859.