New Guidelines Stress Hypoglycemia Affects All Diabetics

Fran Lowry

April 23, 2013

A workgroup of the American Diabetes Association (ADA) and the Endocrine Society has developed new guidelines to make clinicians more aware of the dangers of hypoglycemia and help them protect their patients with diabetes from episodes of low blood glucose.

The guidelines are published online April 15 in Diabetes Care.

"The most important take-home from the guidelines is that clinicians need to recognize that hypoglycemia is a real problem for their patients and that it is associated with bad outcomes," Elizabeth R. Seaquist, MD, from the University of Minnesota, Minneapolis, who led the workgroup, told Medscape Medical News.

The workgroup defined hypoglycemia as a blood glucose reading of less than 70 mg/dL. An episode of severe hypoglycemia was one that required intervention by paramedics or a visit to an emergency room.

We all recognize that hypoglycemia happens more often in patients with type 1, but it clearly happens in patients with type 2. Dr. Elizabeth R. Seaquist

Clinicians tend not to realize that hypoglycemia is a risk for patients with type 2 diabetes, who make up the vast majority of diabetes patients in the United States, Dr. Seaquist said. "Generally, the type 1 patients have an endocrinologist involved in their care, at least at some level, but it is the generalist who takes care of type 2 patients for the most part. We all recognize that hypoglycemia happens more often in patients with type 1, but it clearly happens in patients with type 2," she noted.

Workgroup Examines ACCORD, ADVANCE and VADT

Dr. Elizabeth R. Seaquist

Dr. Seaquist, who is a member of both the American Diabetes Association and the Endocrine Society, invited 5 members of each of the 2 organizations who had expertise in different aspects of hypoglycemia to participate in the workgroup. It considered the mounting evidence that patients with type 2 diabetes can be particularly vulnerable to adverse events associated with hypoglycemia.

Over the past decade 3 large trials examining the effects of glucose lowering on cardiovascular events — Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE), and the Veterans Affairs Diabetes Trial (VADT) — found that an episode of severe hypoglycemia was associated with an increased risk for subsequent mortality.

"There are certainly acute risks with hypoglycemia. People feel shaky and sweaty, they can get confused, which can be inconvenient, but more important, it can make them unable to do whatever task they are doing at the moment, like driving. When people lose consciousness they are clearly at risk for injury from accidents, and that is a real concern with hypoglycemia," Dr. Seaquist explained.

People also die from hypoglycemia, although the exact numbers for this are hard to pinpoint.

"It is difficult to come up with exact numbers, because it is difficult to decide if someone dies in hypoglycemia or not if we don't do an autopsy. In older patients with type 2 diabetes who have other health problems, we know that an episode of severe hypoglycemia increases their risk for mortality in subsequent months, but we don't know the reason this is so," she said.

Balancing good glycemic control against hypoglycemia risk is something that has to be assessed for each patient. Dr. Elizabeth R. Seaquist

The risk for hypoglycemia is also different for different patients, and this makes good diabetes management challenging.

"Our report illustrates how difficult diabetes management can be. Clinicians need to make certain they do everything they can to develop a treatment regimen that will lead to a level of glycemic control that will minimize complications while guarding against the risk of hypoglycemia. Balancing good glycemic control against hypoglycemia risk is something that has to be assessed for each patient," she stressed.

For example, an elderly patient with a limited life expectancy may not need such tight glycemic control, whereas a younger patient who can expect to live for decades will benefit from optimal glycemic control.

"We know that having a [hemoglobin] A1c of less than 7 minimizes the risk for eye and kidney problems, but if someone is elderly and not going to live for 20 years, we may not need to bring the blood sugar down to that level, because they won't be around to enjoy the benefits of tight glycemic control and that might even put them at greater risk for hypoglycemia," she remarked.

Tools Developed to Help Doctors Manage Diabetes Patients

The workgroup came up with 2 tools that will be helpful for clinicians managing those with diabetes. One is a questionnaire they can give out in the waiting room to help them understand whether their patient is having hypoglycemic episodes.

The Hypoglycemia Patient Questionnaire asks people how well they can recognize symptoms of low blood glucose, how many times in a typical week their blood glucose goes below 70 mg/dL, how many times they have had a severe episode of hypoglycemia that required someone's help, whether they check their blood glucose before driving, and whether a spouse, relative, or other person close to them knows how to administer glucagon.

The other tool is a checklist for clinicians to use during office visits to help them make sure they have thought about all the things related to hypoglycemia.

The Hypoglycemia Provider Checklist asks clinicians if they have reviewed the Hypoglycemia Patient Questionnaire, asked the patient about circumstances surrounding severe or moderate hypoglycemia, discussed strategies to avoid hypoglycemic episodes, made appropriate medication changes, prescribed glucagon, and recommended carrying a snack or glucose tablets or other source of 15 g of carbohydrate in case of hypoglycemia episodes.

"People with diabetes need to have their glucose meter with them so they can check their blood sugar if they feel unusual or think they might be having hypoglycemia, and we also recommend they carry carbohydrate with them. Clinicians should remind their patients to have these items with them," Dr. Seaquist concluded.

The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly and Novo Nordisk and support to the American Diabetes Association by Sanofi. The sponsors had no input into the development of or content of the report. Dr. Seaquist and her coauthors have reported no relevant financial relationships.

Diabetes Care. Published online April 15, 2013. Abstract