Fatalities in Insulin Therapy of the Psychoses

Scheflen, Albert E.; Reiner, Elliot R.; Jetter, Walter W.

doi:10.1001/archneurpsyc.1952.02320130038003

Cited by 5 publications

(1 citation statement)

References 8 publications

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“…Deaths of patients with diabetes from "insulin reactions" were reported in 1923 (29). Deaths during or shortly after insulin coma therapy for psychiatric disorders were reported in 1952 (30). In addition, high mortality rates characterize experimental hypoglycemia (31)(32)(33).…”

Section: Downside Of Glycemic Control: Hypoglycemic Morbidity and Mormentioning

confidence: 99%

Glycemic Goals in Diabetes: Trade-off Between Glycemic Control and Iatrogenic Hypoglycemia

2014

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The selection of a glycemic goal in a person with diabetes is a compromise between the documented upside of glycemic control-the partial prevention or delay of microvascular complications-and the documented downside of glycemic control-the recurrent morbidity and potential mortality of iatrogenic hypoglycemia. The latter is not an issue if glycemic control is accomplished with drugs that do not cause hypoglycemia or with substantial weight loss. However, hypoglycemia becomes an issue if glycemic control is accomplished with a sulfonylurea, a glinide, or insulin, particularly in the setting of absolute endogenous insulin deficiency with loss of the normal decrease in circulating insulin and increase in glucagon secretion and attenuation of the sympathoadrenal response as plasma glucose concentrations fall. Then the selection of a glycemic goal should be linked to the risk of hypoglycemia. A reasonable individualized glycemic goal is the lowest A1C that does not cause severe hypoglycemia and preserves awareness of hypoglycemia, preferably with little or no symptomatic or even asymptomatic hypoglycemia, at a given stage in the evolution of the individual's diabetes.Iatrogenic hypoglycemia is the limiting factor in the glycemic management of diabetes (1). It causes recurrent morbidity in most people with type 1 diabetes and many with advanced (absolutely endogenous insulin deficient) type 2 diabetes and is sometimes fatal. It generally precludes maintenance of euglycemia over a lifetime of diabetes and thus full realization of the benefits of glycemic control. It impairs defenses against subsequent falling plasma glucose concentrations and causes a vicious cycle of recurrent hypoglycemia. The problem of iatrogenic hypoglycemia will be solved by the prevention or cure of diabetes, or the provision of precise insulin replacement or secretion-the former by a closed-loop system or the latter by transplantation of insulin-secreting tissue or b-cell expansion (2). Pending those treatments, we need to better understand the pathophysiology of hypoglycemiaassociated autonomic failure (HAAF) in diabetes if we are to lower the barrier of hypoglycemia in diabetes (2).The concept of HAAF in diabetes posits that iatrogenic hypoglycemia is the result of the interplay of therapeutic hyperinsulinemia, caused by treatment with a sulfonylurea, a glinide, or insulin, and compromised physiologic and behavioral defenses against the resulting falling plasma glucose concentrations (1,2). HAAF includes both defective glucose counterregulation, caused by an attenuated adrenomedullary epinephrine response in the setting of loss of a decrement in circulating insulin and loss of an increment in glucagon secretion, and impaired awareness of hypoglycemia, caused by an attenuated sympathoadrenal, largely sympathetic neural, response. The attenuated adrenomedullary and sympathetic neural responses are most often caused by recent antecedent hypoglycemia (1,2).The practice of hypoglycemia risk reduction in people with diabetes at risk for iatrogenic ...

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