Consensus statement offers strategies for preventing hypoglycemia

Consequences of hypoglycemia and strategies to prevent this condition in patients with diabetes were discussed in a recent consensus statement from the American Diabetes Association (ADA) and The Endocrine Society.

The statement updated a 2005 ADA workgroup report. Experts from both specialty organizations considered data from recent clinical trials and other studies and also used expert opinion to develop their conclusions. The statement was published in Diabetes Care and the Journal of Clinical Endocrinology and Metabolism on April 15.

The consensus statement confirmed previous definitions of hypoglycemia and noted several challenges of accurately measuring blood glucose (such as the inaccuracies of point-of-care meters in critical care settings). Although hypoglycemia occurs more frequently in patients with type 1 diabetes, the greater prevalence of type 2 diabetes means that most episodes occur in type 2 patients, the consensus authors noted. Recent evidence (including the ACCORD, ADVANCE and VADT trials) indicates that hypoglycemia may negatively affect mortality and cognitive function, especially in patients with type 2 disease.

Elderly patients are particularly vulnerable to hypoglycemia, the consensus statement noted. Therefore, for these patients, the experts recommended careful education and regular reinforcement regarding the symptoms and treatment of hypoglycemia, assessment of functional status to properly apply individualized goals, avoidance of arbitrary short-acting insulin sliding scales and glyburide, simplification of complex regimens, and education about hypoglycemia for caregivers and staff in long-term care facilities.

In general, glycemic targets should be based on a patient's age, life expectancy, comorbidities, preferences and an assessment of how hypoglycemia might impact his or her life, the statement said. For healthy adults with diabetes, a reasonable goal might be the lowest hemoglobin A1c level that does not cause severe hypoglycemia, preserves awareness of hypoglycemia and doesn't result in an unacceptable number of hypoglycemic episodes. For patients with long-standing disease and advanced complications or limited life expectancy, the goals may be relaxed.

Strategies to prevent hypoglycemia include patient education (for both the patient and any domestic companions, possibly including interviewing to help identify precipitating factors of hypoglycemic episodes), dietary interventions (such as carrying carbohydrates at all times), exercise management, medication adjustment (substitution of rapid-acting insulin for regular insulin or other oral agents for sulfonylureas), and glucose monitoring. Clinicians should also assess the risk of hypoglycemia at every visit with patients on insulin or insulin secretagogues (an example questionnaire is provided in the consensus statement) and carefully review the patient's glucose log for date, time and circumstances of any hypoglycemia episodes.