Interventions That Restore Awareness of Hypoglycemia in Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis

Abstract

OBJECTIVEImpaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D. RESEARCH DESIGN AND METHODSWe searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control. RESULTSForty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates. CONCLUSIONSThis review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.

Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association

“…FoH and hypoglycemia unawareness often co-occur, and interventions aimed at treating one often benefit both (69). FoH may explain avoidance of behaviors associated with lowering glucose such as increasing insulin doses or frequency of monitoring.…”

“…If FoH is identified and a person does not have symptoms of hypoglycemia, a structured program, Blood Glucose Awareness Training, delivered in routine clinical practice can improve A1C, reduce the rate of severe hypoglycemia, and restore hypoglycemia awareness (70,71). Such improvements in disease state have been shown to reduce diabetes distress and improve psychological well-being (69,72,73). …”

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

“…The majority of patients experiencing a SH episode attended by Ambulance Crew in the UK do not have evidence of further contact with primary or secondary care diabetes services [18,27] Many SH patients feel they have had only limited education in hypoglycaemia avoidance and management [1] and the lack of further education and support means patients do not have an opportunity to have an individualised glycaemic target reviewed (29), or access education and advice on hypoglycaemia avoidance [1,2,29 -31]. There may also be reluctance on the part of patients to let their normal diabetes team know about SH events, in case they feel clinical teams will be critical, or that it may effect holding a driving license [6].…”

Managing hypoglycaemia

“…There are a few individuals (thankfully rare) who fail to improve after those approaches and in these cases, when available, islet transplantation can be transformational. A recent metaanalysis recently endorsed a similar clinical approach pointing out that the steps in this pathway were largely supported by reasonably high quality evidence (121).…”