The Moment
Severe hypoglycemia can happen any day. For Karen, it was today
Salesperson to Karen: “Ma'am? Ma'am, are you all right?” (with ears-ringing sound in background).
Coworker: “I wanted to also pick your brain about the meeting next week.”
Karen: “You know, I'm running really late. Can we talk about it in the morning?”
Coworker: “No problem.”
Karen: “Okay, thanks.”
Karen (on her phone): “Just got here. Looking for a spot.”
Karen: “What the…! This guy!” (with heavy sigh).
Friend: “Karen!”
Karen: “Hi! I'm sorry, I'm late!”
Friend: “It's okay!”
Karen: “I'm starving. Where do you want to eat?”
Friend: “Ooh! The store's going to be closed by the time we finished eating. Could we just do a quick errand? Five minutes?”
Karen (reluctantly): “Umm, okay.”
Salesperson: “Ma'am? Are you all right?” (with ears-ringing sound in background).
Friend: “Karen? What's wrong?”
Cacophony of many voices, expressing concern for Karen's well-being.
Friend: “Could you call for help, please? She's diabetic. So could you look in her purse and see if there's some candy in there…”
American Diabetes Association Recommendations for Severe Hypoglycemia1
As Risk Escalates, Clinicians Should Help Prepare Patients for Severe Hypoglycemia with Glucagon
ADA Classifications of Hypoglycemia
| Recommendation | Glycemia Criteria |
|---|---|
| Recommendation: GLUCOSE IS PREFERRED TREATMENT Level 1 | Glycemia Criteria: <70 mg/dL(3.9 mmol/L) Requires ingestion of glucose or carbohydrate-containing food |
| Recommendation: ADA RECOMMENDS GLUCAGON BE PRESCRIBED Level 2 | Glycemia Criteria: <54 mg/dL (3.0 mmol/L) Requires immediate action to resolve the hypoglycemic event. Cognitive impairment begins to emerge |
| Recommendation: GLUCAGON ADMINISTRATION MAY BE REQUIRED Level 3 | Glycemia Criteria: No specific glucose threshold A severe hypoglycemic event characterized by altered mental and/or physical functioning requiring assistance for recovery |
In type 2 diabetes, endogenous glucagon response can worsen over time―as in type 1 diabetes2,3
Patients with type 2 diabetes are at risk3,4
- Pancreatic α-cell function declines and patients lose their ability to secrete glucagon in response to hypoglycemia4
- In most patients with type 2 diabetes, this impaired glucagon response worsens over time—similar to type 1 diabetes3,4
- Patients on exogenous insulin have a defective counter-regulatory response to decreased blood glucose, increasing the risk for severe hypoglycemia2,4
Patients report a variable range of circumstances that lead to severe hypoglycemia in their everyday lives5
Patient-identified Causes of Severe Hypoglycemic Events
Patients with type 1 diabetes (n equals 319) and patients with type 2 diabetes (n equals 320) reported the following self-identified causes of severe hypoglycemic events:
Irregular/insufficient food intake: 43 percent of type 1 patients; 47 percent of type 2 patients
Physical exercise/overexertion: 24 percent of type 1 patients; 23 percent of type 2 patients
Insulin dose miscalculation: 24 percent of type 1 patients; 16 percent of type 2 patients
Stressful situations: 12 percent of type 1 patients; 17 percent of type 2 patients
Oscillating blood glucose levels: 9 percent of type 1 patients; 8 percent of type 2 patients
Impaired hypoglycemia awareness: 8 percent of type 1 patients; 5 percent of type 2 patients
Study design
- Study to investigate the experiences of people with insulin-treated diabetes who have had severe hypoglycemic events (SHEs), in Germany, Spain, or the UK.
- Patients with insulin-treated type 1 (n=319) or type 2 diabetes (n=320) who had experienced ≥1 SHE in the preceding year were enrolled. Their median age was 53 years (range: 16-94 years).
- Data were collected using a questionnaire developed with the input of diabetes specialists, emergency physicians, and patients from focus groups.
- Patients reported a variable range of circumstances that led to severe hypoglycemia in their everyday lives.
Patients may not tell you about severe hypoglycemia
In the US CRASH Survey, 4 in 10 people with diabetes on insulin reported they did NOT discuss their most recent severe hypoglycemia event with their doctor.6
In the US CRASH Survey, only 4% of people with diabetes reported they obtained a glucagon kit or confirmed that they already had one after their most recent severe hyperglycemia event.6
Study design: Conversations and Reactions Around Severe Hypoglycemia (CRASH) was a cross sectional, online survey using purposive sampling. Participants had to be ≥ 18 years of age at the time of screening, self-report type 1 (n=110) or type 2 (n=109) diabetes, and have experienced a recent severe hypoglycemia event (within the past 3 years) while taking insulin.6
Severe hypoglycemia can't always be avoided, so make sure your patients with diabetes on insulin are prepared7
A1C may not reveal a patient's glucose highs and lows1,8
Fifteen-day glucose traces of two patients with identical A1C of 8.0%8
- Both patients had identical A1C, but Patient 2 had greater glucose variability, resulting in 7 episodes of level 2 hypoglycemia (≤50 mg/dL)
- Patient 1 had no such hypoglycemic episodes
- A1C reflects average glycemia and not glycemic variability, which is a major determinant of hypoglycemia risk
Study design8
- An analysis of acute manifestations of glucose variability (including hypoglycemia) to review a) measures that assessed the amplitude of glucose variability from routine self-monitored blood glucose data and b) timing from continuous glucose monitoring data to determine the relationship of speed and magnitude of rapid glucose fluctuations to clinically relevant outcomes
References:
- American Diabetes Association. 6. Glycemic targets: standards of medical care in diabetes 2022. Diabetes Care. 2022;45(suppl. 1):S83-S96.
- McCrimmon RJ, Sherwin RS. Hypoglycemia in type 1 diabetes. Diabetes. 2010;59(10):2333-2339.
- Edelman SV, Blose JS. The impact of nocturnal hypoglycemia on clinical and cost-related issues in patients with type 1 and type 2 diabetes. Diabetes Educ. 2014;40(3):269-279.
- Cryer PE. Minireview: Glucagon in the pathogenesis of hypoglycemia and hyperglycemia in diabetes. Endocrinology. 2012;153(3):1039-1048.
- Lammert M, Hammer M, Frier BM, Management of severe hypoglycaemia: cultural similarities, differences and resource consumption in three European countries. J Med Econ. 2009;12(4):269-280.
- Snoek FJ, Jiletcovici A, Bushnell III DM, et al. Conversations and Reactions Around Severe Hypoglycemia (CRASH): US results from a global survey of people with T1DM or insulin-treated T2DM and caregivers. Diabetes. 2019;68(suppl 1). doi:10.2337/db19-285-OR.
- Donnelly LA, Morris AD, Frier BM, et al. Frequency and predictors of hypoglycaemia in Type 1 and insulin-treated Type 2 diabetes: a population-based study. Diabet Med. 2005;22(6):749-755.
- Kovatchev B, Corbelli C. Glucose variability: Timing, risk analysis, and relationship to hypoglycemia in diabetes. Diabetes Care. 2016;39:502-510.