Severe Hypoglycemia Information
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 |
|---|---|
| GLUCOSE IS PREFERRED TREATMENT Level 1 | <70 mg/dL(3.9 mmol/L) Requires ingestion of glucose or carbohydrate-containing food |
| ADA RECOMMENDS GLUCAGON BE PRESCRIBED Level 2 | <54 mg/dL (3.0 mmol/L) Requires immediate action to resolve the hypoglycemic event. Cognitive impairment begins to emerge |
| GLUCAGON ADMINISTRATION MAY BE REQUIRED Level 3 | 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
View Description
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.
