Risk Factors for Frequent and Severe Hypoglycemia in Type 1 Diabetes

Abstract

FOR THE WISCONSIN DIABETES REGISTRY PROJECTOBJECTIVE -To determine the risk of frequent and severe hypoglycemia and the associated demographic and clinical risk factors.RESEARCH DESIGN AND METHODS -Demographic and diabetes self-management factors were measured in 415 subjects followed prospectively for 4 -6.5 years of type 1 diabetes duration as participants in a population-based incident cohort. Blood samples were collected up to three times yearly to test glycosylated hemoglobin (GHb) levels. Reports of frequent (2-4 times/week) and severe (lost consciousness) hypoglycemia as well as other diabetes selfmanagement data were collected by questionnaires.RESULTS -Frequent hypoglycemia was common (33 and 35% of participants reported this on the 4-and 6.5-year questionnaires, respectively), whereas severe hypoglycemia occurred much less often. Better glycemic control (odds ratio [OR] 1.3 per 2% decrease in GHb, 95% CI 1.1-1.5) and more frequent self-monitored blood glucose (1.5 per blood glucose check, 1.3-1.7) were independently related to frequent hypoglycemia. The association of frequent hypoglycemia with intensive insulin therapy increased with age. Better glycemic control (1.5 per 2% decrease in GHb, 1.2-2.0) and older age were related to severe hypoglycemic reactions. No sociodemographic factors other than age increased the risk of hypoglycemia.CONCLUSIONS -Frequent hypoglycemia was common in a population representing the full range of glycemic control in the community. Intensive insulin management and blood glucose monitoring independently predicted frequent but not severe hypoglycemia. This information may be useful for updating patients such that minor changes in diabetes management might decrease the daily burden of this condition while maintaining intensive insulin therapy. Diabetes Care 24:1878 -1881, 2001H ypoglycemia is the most common acute complication of type 1 diabetes (1). Onset is usually rapid, and symptoms range from very mild to severe enough to cause brain damage or death (2,3). Results of the Diabetes Control and Complications Trial (DCCT) (4) increased emphasis on intensive insulin treatment but also drew attention to the accompanying risk of hypoglycemia with such therapy, particularly in adolescents.The frequency of and risk factors for moderate and/or severe hypoglycemia in young adults were described in studies conducted in clinic-or hospital-based samples (5-8), the DCCT (9), one national cross-sectional study from France, and a limited number of populationbased cohort studies (10 -12). From these studies, it is clear that a history of hypoglycemia (6,9,13) and intensive insulin therapy (9) is an important predictor.Findings regarding other factors such as age, sex, duration of diabetes, and glycemic control are not consistent across studies. The frequency of all levels of hypoglycemia has not been reported. Also, no large population-based cohort has been studied prospectively to determine the relationship of both intensive insulin therapy and glycemic control to frequent and severe hy...

Beneficial Effects of Continuous Subcutaneous Insulin Infusion and Flexible Multiple Daily Insulin Regimen Using Insulin Glargine in Type 1 Diabetes

“…Although the cause of severe hypoglycemia in type 1 diabetes is multifactorial, it is usually associated with self-management errors, vigorous physical activities, psychosocial stresses, fewer than 3 injections a day, and a low bolus:basal ratio. 28 Consistent with other studies, 28-30 appropriate physiologic replacement of insulin with CSII or FMDI, frequent blood glucose monitoring, combined with adequate self-management, and active problem-based training were the likely reasons for decreased severe hypoglycemia. However, 1 limitation to our study was bedtime dosing of glargine because a recent study suggested that morning dosing instead would further reduce hypoglycemia frequency.…”

The Impact of a Decade of Changing Treatment on Rates of Severe Hypoglycemia in a Population-Based Cohort of Children With Type 1 Diabetes

“…We have also shown that children from the more disadvantaged socioeconomic groups tend to have a higher risk. Some studies have shown contrasting results, but they used a classification of socioeconomic status that was not comparable with ours (7,18). For example, Allen et al (18) used occupation quartiles and showed no correlation, and Rewers et al (7) used medical insurance as an indicator of low socioeconomic status and did report results similar to our findings.…”

Severe Hypoglycemia and Smoking in a Long-Term Type 1 Diabetic Population

“…The Diabetes Control and Complications Trial showed the benefits of tight glycemic control, but it also showed that individuals receiving intensive insulin treatment had an increased risk of developing severe hypoglycemia. Thus, this complication remains a major challenge in treatment of diabetic patients (1)(2)(3)(4)(5). Age, diabetes duration, history of previous episodes of hypoglycemia, intensive insulin treatment, and lower levels of A1C have been described previously as factors associated with this complication (1)(2)(3)(4)(5).…”

“…Thus, this complication remains a major challenge in treatment of diabetic patients (1)(2)(3)(4)(5). Age, diabetes duration, history of previous episodes of hypoglycemia, intensive insulin treatment, and lower levels of A1C have been described previously as factors associated with this complication (1)(2)(3)(4)(5). Smoking has been reported to be associated with hypoglycemia in previous clinical studies (6 -8), and it has been studied but not related to severe hypoglycemia in population-based studies.…”