COMMENTARY

Hypoglycemia Warnings Essential in Diabetes Education

Elizabeth R. Seaquist, MD; Mark Harmel, MPH

Disclosures

April 27, 2016

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The Consequences of Hypoglycemia

I'm here today to talk about hypoglycemia in patients with type 1 or type 2 diabetes. This is an enormous problem for our patients, because it really limits how well they can control their blood sugars. Every patient with diabetes knows that they need to keep their blood sugars at a near-normal level to reduce their risk for microvascular complications, but this frequently comes at the cost of hypoglycemia, which is really the factor that limits how well they control their blood sugars.

The consequences of hypoglycemia vary. In addition to being inconvenient and uncomfortable, people can lose consciousness, have seizures, and die from hypoglycemia. Older people with type 2 diabetes who have an episode of severe hypoglycemia that requires the assistance of another person have an increased risk for mortality in the subsequent year. This is really something that every doctor taking care of patients with diabetes needs to think about.

When you see any patient who is on insulin or a sulfonylurea, you need to wonder about their risk for hypoglycemia. You need to ask them about their hypoglycemia: when it happens, if it is happening. Don't assume that those patients with a high A1c, who you know frequently have high sugars, are free of hypoglycemia. The current literature shows that there isn't a strong relationship between high or low A1c and hypoglycemia risk. That is, people with very high A1c's have the same risk for hypoglycemia as people with low A1c's. We need to be aware of it at all times.

Patients' Perspectives

What do we do when we talk with our patients about hypoglycemia? First, I usually look at their glucose logs, meters, or CGM (continuous glucose monitor) to see if they are having hypoglycemia. However, I also ask them about undocumented episodes of hypoglycemia, because they don't always check.

I then ask them how low their blood sugar has to get before they have symptoms of hypoglycemia. That's a very important question, because if people have to get down to 50 or 40 before they have any symptoms, that tells me that they have experienced frequent episodes of hypoglycemia. That also tells me that they frequently have more insulin than they need for their metabolic requirements, and we need to make a change.

People who experience recurrent hypoglycemia in a short period of time develop "hypoglycemia unawareness." If you ask your patients at what glucose level do they experience hypoglycemic symptoms, people who have never seen it before usually get symptoms in the 60s. If they are only experiencing symptoms down in the 50s, 40s, or lower, there is a real problem that you need to address.

If the problem arises because people have too much insulin for the metabolic needs of the moment, how as physicians do we manage that? It takes a lot of time talking to your patient. You really need to understand how they make decisions about taking insulin. How do they make those decisions before mealtime? Do they use an insulin-to-carb ratio? Do they use a correction scale? Are they checking their blood sugar? Are they taking their insulin at the beginning of the meal or after the meal?

You need to understand all of those variables, and then understand that what they tell you may not always be what they actually do. You have to ask them about certain changes in situation. For example, "This is what you would normally do, but what would you do if you were going for a walk after lunch? Would you change your insulin—yes or no?" That helps you understand the patient's thinking.

It is also very important to ask them why they think they got hypoglycemic. They may have a very clear idea, and it may have arisen because of concerns about having too high of a sugar count. They may say, "I went to Starbucks and had the really high-calorie drink, so I said I am going to give myself 20 units of insulin because I just don't want to be that high." That is a patient who you know is perhaps more fearful of hyperglycemia than hypoglycemia.

You probably need to spend some time reminding them that hypoglycemia is dangerous, that glucose-control parameters linked to reducing microvascular risk are A1c levels rather than a single blood sugar that is above target. It takes a lot of time talking to our patients to understand this problem.

The Tools for Managing Diabetes

Exercise is the other variable that we really need to talk about with our patients who have hypoglycemia. Hypoglycemia can occur during or after exercise. You need to understand what the patient's exercise pattern is, what they like to do, as different forms of exercise have different effects. To manage this problem with patients, you really need to understand how they live their life and how they make choices about diabetes management.

We need to help our patients understand how to pick a rational dose of insulin for every mealtime, every time they're eating, and how to best adjust their insulin for exercise. If we can do that and use the tools that are available to us, we can help avoid hypoglycemia. In recent years, different techniques like CGM and low glucose suspend pumps have come on the market and been helpful. However, they're only helpful if your patient finds them helpful. As doctors, we need to sit down and talk with our patients, and think about what tools we can give them to help manage this problem of hypoglycemia.

If we can avoid hypoglycemia, we can prevent patients from developing hypoglycemia unawareness, which really puts them at risk for mortality, accidents, and disruptions to their everyday life. If we can avoid hypoglycemia, we can help patients achieve better glucose control because they won't be so fearful, which will help them control their diabetes overall.

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