Hypoglycaemia and its management in primary care setting

Abstract

Hypoglycaemia is common in patients with type 1 diabetes and type 2 diabetes and constitutes a major limiting factor in achieving glycaemic control among people with diabetes. While hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L), symptoms may occur at higher blood glucose levels in individuals with poor glycaemic control. Severe hypoglycaemia is defined as an episode requiring the assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions to assure neurologic recovery. Hypoglycaemia is the most important safety outcome in clinical studies of glucose lowering agents. The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan. A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycaemic goals and promote new therapies to improve quality of life of patients. Data from recent large clinical trials reported low risk of hypoglycaemic events with the use of newer anti‐diabetic drugs. Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas. Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of “frailty.” Many of such patients may be better treated by the use of GLP‐1 receptor agonists or SGLT2 inhibitors rather than insulin. Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia. Patients with impaired awareness of hypoglycaemia benefit from real‐time CGM. The diabetes educator is an invaluable resource and can devote the time needed to thoroughly educate the individual to reduce the risk of hypoglycaemia and integrate the information within the entire construct of diabetes self‐management. Conversations about hypoglycaemia facilitated by a healthcare professional may reduce the burden and fear of hypoglycaemia among patients with diabetes and their family members. Optimizing insulin doses and carbohydrate intake, in addition to a short warm up before or after the physical activity sessions may help avoiding hypoglycaemia. Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy including administration of rapid‐acting insulin analogues rather than human insulin, pre‐conception initiation of insulin analogues, and immediate postpartum insulin dose reduction.

Nocturnal Hypoglycaemia in Patients with Diabetes Mellitus: Database Analysis of a Cohort Using Telemedicine Support for Self-Monitoring of Blood Glucose over a 10-Year-Long Period

“…Our data indicate that nocturnal hypoglycaemia carries a significant risk for daily clinical practice, even in recent years. Bearing this in mind, antihyperglycaemic agents with a lower risk of hypoglycaemia (in patients with type 1 diabetes: insulin analogues, especially second-generation basal insulin analogues; in patients with type 2 diabetes: SGLT-2-inhibitors, GLP-1-recepetor agonists, or DPP-4-inhibitors) should be preferred [45,46]. Importantly, the clinical significance of medical nutrition therapy should also be emphasized as dietary carbohydrate restriction could frequently lead to a reduction or elimination of different antihyperglycaemic medications with hypoglycaemic side effects [47,48].…”

Glucose‐lowering pharmacotherapies in Chinese adults with type 2 diabetes and cardiovascular disease or chronic kidney disease. An expert consensus reported by the Chinese Diabetes Society and the Chinese Society of Endocrinology

“…Immediate management should be given if hypoglycaemia occurs and the glucose-lowering treatment regimen should be adjusted. 1,75 Furthermore, it has been shown that glycaemic variability is associated with an increased risk of adverse cardiovascular outcomes due primarily to hypoglycaemia. 76,77 Therefore, the use of new antihyperglycaemic drugs (such as GLP-1RAs or SGLT2 inhibitors), which can reduce glycaemic variability and have no an increased risk of hypoglycaemia, may be better than the use of insulin or insulin secretagogue in patients with T2DM and ASCVD, HF or CKD who are at risk of severe hypoglycaemia.…”

“…76,77 Therefore, the use of new antihyperglycaemic drugs (such as GLP-1RAs or SGLT2 inhibitors), which can reduce glycaemic variability and have no an increased risk of hypoglycaemia, may be better than the use of insulin or insulin secretagogue in patients with T2DM and ASCVD, HF or CKD who are at risk of severe hypoglycaemia. 75 Figure 1 shows the anti-hyperglycaemic treatment algorithm for patients with T2DM and ASCVD or very high cardiovascular risk, HF or CKD.…”

Identifying patients at increased risk of hypoglycaemia in primary care: Development of a machine learning‐based screening tool

“… 31 , 32 In primary care, stratifying patients based on hypoglycaemia risk can provide an approach in which treatment, glycaemic goals and education are tailored to the individual, which ultimately helps to reduce hypoglycaemia. 33 Previous research has shown that pharmacy‐led interventions can be effective in reducing the number of hypoglycaemic events in T2D patients. 34 , 35 Using routinely available pharmacy data to screen for patients at increased risk of hypoglycaemia can improve the effectiveness and efficiency of these interventions.…”