Hypoglycaemia episodes are a real nightmare for physicians and as well as patients. This article highlights the latest recommendations by the Endocrine Society for managing diabetes in individuals with a high risk of hypoglycaemia.

Hypoglycaemia

Hypoglycaemia is defined by a decrease in blood sugar levels below 70mg/dl with symptoms like tachycardia, cold sweats, hunger, tremor, and other autonomic nervous symptoms. Clinicians should counsel patients regarding hypoglycaemia symptoms and its management to reduce the morbidity and mortality associated with hypoglycaemia episodes.

Definition of levels of hypoglycaemia

• LEVEL 1: Glucose <70 mg/dl and glucose ≥54 mg/dl. Patients are aware of the symptoms associated with hypoglycaemia and are advised to ingest carbohydrates at this level to prevent progressive hypoglycaemia.
• LEVEL 2: Glucose <54 mg/dl. This level of hypoglycaemia is associated with an increased risk for cognitive dysfunction and mortality.
• LEVEL 3: Glucose <40mg/dl. A severe event characterised by altered mental and/or physical status requiring assistance. This level of hypoglycaemia is life-threatening and requires emergent treatment typically with glucagon.

Individuals at risk

The following individuals are at risk of hypoglycaemia:

• Individuals on diabetic medications known to cause hypoglycaemia (eg, insulin, sulfonylureas, meglitinides)
• Individuals with impaired kidney or liver function
• Older-age patients, Preschool-age children
• Individuals with a history of severe hypoglycaemia
• Individuals with cognitive impairment or intellectual disability that may reduce their ability to respond to low blood glucose
• Individuals with impaired awareness of hypoglycaemia
• Individuals with a longer duration of diabetes (including those using insulin for ≥5 y)
• Individuals who use alcohol
• Individuals with eating disorders
• Individuals that are fasting for religious or cultural reasons
• Individuals with a history of untreated pituitary, adrenal, or thyroid insufficiency

Key recommendations by the Endocrine Society 

This article highlights the latest recommendations for managing diabetes in individuals with a high risk of hypoglycaemia.

1. As per recommendation, continuous glucose monitoring (CGM) rather than self-monitoring of blood glucose (SMBG) by fingerstick should be preferred for patients with type 1 diabetes (T1D) receiving multiple daily injections (MDIs).
2. As per recommendation using real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps (ADIPs) rather than multiple daily injections (MDIs) with self-monitoring of blood glucose (SMBG) three or more times daily for adults and children with type 1 diabetes (T1D).
3. As per recommendation, real-time continuous glucose monitoring (CGM) be used rather than no continuous glucose monitoring (CGM) for outpatients with type 2 diabetes (T2D) who take insulin and/or sulfonylureas (SUs) and are at risk for hypoglycaemia.
4. As per recommendation initiation of continuous glucose monitoring (CGM) in the inpatient setting for select inpatients at high risk for hypoglycaemia.
5. As per recommendation continuation of personal continuous glucose monitoring (CGM) in the inpatient setting with or without algorithm-driven insulin pump (ADIP) therapy rather than discontinuation.
6. As per recommendation, inpatient glycemic surveillance and management programs leverage electronic health record (EHR) data to be used for inpatients at risk for hypoglycaemia.
7. As per recommendation long-acting insulin analogues to be used rather than human-neutral protamine Hagedorn (NPH) insulin for adult and pediatric outpatients on basal insulin therapy who are at high risk for hypoglycaemia.
8. As per recommendation rapid-acting insulin analogues to be used rather than regular (short-acting) human insulin for adult and pediatric patients on basal-bolus insulin therapy who are at high risk for hypoglycaemia.
9. As per recommendation a structured program of patient education over unstructured advice is to be used for adult and pediatric outpatients with type 1 diabetes (T1D) or type 2 diabetes (T2D) receiving insulin therapy.
10. As per recommendation glucagon preparations that do not have to be reconstituted over glucagon preparations that do have to be reconstituted (i.e., available as a powder and diluent) be used for outpatients with severe hypoglycaemia.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India. 

About the author of this article: Dr Hitesh Saraogi is a diabetologist, physician and an obesity specialist at Dhanvantari Hospital, Raj Nagar Extension, Ghaziabad.