REVIEW : Avoiding or coping with severe hypoglycemia in patients with type 2 diabetes

( Jae Seung Yun ),( Seung Hyun Ko ) 대한내과학회 2015 The Korean Journal of Internal Medicine Vol.30 No.1

Hypoglycemia is a major barrier to achieving the glycemic goal in patients with type 2 diabetes. In particular, severe hypoglycemia, which is defined as an event that requires the assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions, is a serious clinical concern in patients with diabetes. If severe hypoglycemia is not managed promptly, it can be life threatening. Hypoglycemia-associated autonomic failure (HAAF) is the main pathogenic mechanism behind severe hypoglycemia. Defective glucose counter- regulation (altered insulin secretion, glucagon secretion, and an attenuated increase in epinephrine during hypoglycemia) and a lack of awareness regarding hypoglycemia (attenuated sympathoadrenal activity) are common components of HAAF in patients with diabetes. There is considerable evidence that hypoglycemia is an independent risk factor for cardiovascular disease. In addition, hypoglycemia has a significant inf luence on the quality of life of patients with diabetes. To prevent hypoglycemic events, the setting of glycemic goals should be individualized, particularly in elderly individuals or patients with complicated or advanced type 2 diabetes. Patients at high-risk for the future development of severe hypoglycemia should be selected carefully, and intensive education with reinforcement should be implemented.

Patient Understanding of Hypoglycemia in Tertiary Referral Centers

조난희,김남경,한유진,홍준화,전언주,문준성,서미혜,이지은,서현애,김미경,김혜순 대한당뇨병학회 2018 Diabetes and Metabolism Journal Vol.42 No.1

Background: Hypoglycemia is an important complication in the treatment of patients with diabetes. We surveyed the insight by patients with diabetes into hypoglycemia, their hypoglycemia avoidance behavior, and their level of worry regarding hypoglycemia. Methods: A survey of patients with diabetes, who had visited seven tertiary referral centers in Daegu or Gyeongsangbuk-do, Korea, between June 2014 and June 2015, was conducted. The survey contained questions about personal history, symptoms, educational experience, self-management, and attitudes about hypoglycemia. Results: Of 758 participants, 471 (62.1%) had experienced hypoglycemia, and 250 (32.9%) had experienced hypoglycemia at least once in the month immediately preceding the study. Two hundred and forty-two (31.8%) of the participants had received hypoglycemia education at least once, but only 148 (19.4%) knew the exact definition of hypoglycemia. Hypoglycemic symptoms identified by the participants were dizziness (55.0%), sweating (53.8%), and tremor (40.8%). They mostly chose candy (62.1%), chocolate (37.7%), or juice (36.8%) as food for recovering hypoglycemia. Participants who had experienced hypoglycemia had longer duration of diabetes and a higher proportion of insulin usage. The mean scores for hypoglycemia avoidance behavior and worry about hypoglycemia were 21.2±10.71 and 23.38±13.19, respectively. These scores tended to be higher for participants with higher than 8% of glycosylated hemoglobin, insulin use, and experience of emergency room visits. Conclusion: Many patients had experienced hypoglycemia and worried about it. We recommend identifying patients that are anxious about hypoglycemia and educating them about what to do when they develop hypoglycemic symptoms, especially those who have a high risk of hypoglycemia.

Influencing Factors on Hypoglycemia Fear Behavior and Hypoglycemia Anxiety among Type 1 Diabetes Mellitus Patients

Mi-Kyoung Cho,Mi Young Kim 위기관리 이론과 실천 2020 Crisisonomy Vol.16 No.2

The purpose of this study was to identify the factors affecting hypoglycemia fear behavior and hypoglycemia anxiety among type 1 diabetes mellitus patients. A cross-sectional survey was conducted with 101 type 1 diabetes mellitus patients in South Korea via online survey. The data were analyzed by descriptive statistics, correlation and multiple regression analysis using IBM SPSS Statistics 23.0 program. The mean age of the participants was 28.31±11.68 years and 61.4% of the participants experienced hypoglycemia more than four times per month. The scores for hypoglycemia fear behavior and hypoglycemia anxiety were 29.55±6.70 (range: 13-43) and 41.11±16.39 (range: 16-80), respectively. The explanatory power of the hypoglycemia fear behavior model including three variables of age, depression, and hypoglycemia anxiety was 19.0% (F=8.75, p<.001), while that of the hypoglycemia anxiety model including only two variables of depression and hypoglycemia fear behavior was 36.2% (F=29.03, p<.001). Considering that the most common factor affecting hypoglycemia anxiety was depression, efficient management of hypoglycemia is recommended to decrease the fear of hypoglycemia. 본 연구의 목적은 제 1 형 당뇨병 환자에서 저혈당공포 행위와 저혈당 염려에 영향을 미치는 요인을 확인하는 데 있었다. 본 연구의 설계는 횡단면 조사이었고, 연구의 참가자는 제 1 형 당뇨병 환자 101명으로 자료수집은 온라인 설문을 실시하였다. 수집된 자료는 PCWS 23.0 프로그램을 이용하여 기술통계, 상관관계, 단계적 다중회귀분석방법으로 분석하였다. 대상자의 평균 연령은 28.31±11.68세였으며 한 달에 4회 이상의 저혈당을 경험하는 빈도는 61.4%이었다. 저혈당공포 행위와 저혈당 염려 점수는 각각 29.55±6.70(범위:13-43), 41.11±16.39 (범위:16-80)이었다. 연령, 우울, 저혈당 염려의 세 변수로 구성된 저혈당공포 행위 모델의 설명력은 19.0% (F=8.75, p<.001)이었고, 우울과 저혈당공포 행위의 두 변수로 구성된 저혈당 염려 모델의 설명력은 36.2%이었다(F=29.03, p<.001). 제 1형 당뇨병 환자의 저혈당 공포행위와 저혈당 염려에 공통적으로 영향을 미치는 부정적인 정서인 우울에 대한 중재와 저혈당에 대한 올바른 인식과 대처방법에 대한 교육이 필요하겠다.

1,5-Anhydro-D-Glucitol Could Reflect Hypoglycemia Risk in Patients with Type 2 Diabetes Receiving Insulin Therapy

Kim, Min Kyeong,Jung, Hye Seung,Kwak, Soo Heon,Cho, Young Min,Park, Kyong Soo,Kim, Seong Yeon Korean Endocrine Society 2016 Endocrinology and metabolism Vol.31 No.2

<P><B>Background</B></P><P>The identification of a marker for hypoglycemia could help patients achieve strict glucose control with a lower risk of hypoglycemia. 1,5-Anhydro-D-glucitol (1,5-AG) reflects postprandial hyperglycemia in patients with well-controlled diabetes, which contributes to glycemic variability. Because glycemic variability is related to hypoglycemia, we aimed to evaluate the value of 1,5-AG as a marker of hypoglycemia.</P><P><B>Methods</B></P><P>We enrolled 18 adults with type 2 diabetes mellitus (T2DM) receiving insulin therapy and assessed the occurrence of hypoglycemia within a 3-month period. We measured 1,5-AG level, performed a survey to score the severity of hypoglycemia, and applied a continuous glucose monitoring system (CGMS).</P><P><B>Results</B></P><P>1,5-AG was significantly lower in the high hypoglycemia-score group compared to the low-score group. Additionally, the duration of insulin treatment was significantly longer in the high-score group. Subsequent analyses were adjusted by the duration of insulin treatment and mean blood glucose, which was closely associated with both 1,5-AG level and hypoglycemia risk. In adjusted correlation analyses, 1,5-AG was negatively correlated with hypoglycemia score, area under the curve at 80 mg/dL, and low blood glucose index during CGMS (<I>P</I>=0.068, <I>P</I>=0.033, and <I>P</I>=0.060, respectively).</P><P><B>Conclusion</B></P><P>1,5-AG level was negatively associated with hypoglycemia score determined by recall and with documented hypoglycemia after adjusting for mean glucose and duration of insulin treatment. As a result, this level could be a marker of the risk of hypoglycemia in patients with well-controlled T2DM receiving insulin therapy.</P>

내인성 고인슐린혈증에 의한 저혈당증에서의 포도당 길항호르몬 반응

정진욱,조동혁,정동진,정민영 대한내분비학회 2009 Endocrinology and metabolism Vol.24 No.3

Background: In patients with hypoglycemia due to endogenous hyperinsulinemia such as insulinoma or insulin autoimmune syndrome, little is known about the counterregulatory hormone response to spontaneous hypoglycemia. We therefore compared hormone responses during spontaneous hypoglycemia due to endogenous hyperinsulinemia with those at the end of a 72-hour fast. Methods: We measured glucagon, epinephrine, cortisol, and growth hormone responses during spontaneous hypoglycemia in 8 patients with insulinoma and 18 patients with insulin autoimmune syndrome. We also assessed these responses in 13 normal control subjects who underwent a 72-hour fast. Results: In patients with insulinoma (median serum glucose level, 35.0 mg/dL), plasma glucagon levels (median, 42.9 vs. 76.2 pg/mL, respectively; P < 0.05) were lower than those in control subjects (serum glucose level, 62.5 mg/dL), whereas, there were no statistically significant differences in the other hormone responses between the two groups. In contrast, in the patients with insulin autoimmune syndrome (median serum glucose level, 34.5 mg/dL), plasma glucagon levels (median, 73.7 vs. 76.2 pg/mL, respectively) were lower than those in the control subjects, but there was no statistically significant difference between the two groups. There were no statistically significant differences in counterregulatory hormone responses during spontaneous hypoglycemia between patients with insulinoma and patients with insulin autoimmune syndrome. Conclusion: Our results suggest that defective glucagon secretion in patients with insulinoma rather than insulin autoimmune syndrome may contribute to hypoglycemia in addition to hyperinsulinemia. Background: In patients with hypoglycemia due to endogenous hyperinsulinemia such as insulinoma or insulin autoimmune syndrome, little is known about the counterregulatory hormone response to spontaneous hypoglycemia. We therefore compared hormone responses during spontaneous hypoglycemia due to endogenous hyperinsulinemia with those at the end of a 72-hour fast. Methods: We measured glucagon, epinephrine, cortisol, and growth hormone responses during spontaneous hypoglycemia in 8 patients with insulinoma and 18 patients with insulin autoimmune syndrome. We also assessed these responses in 13 normal control subjects who underwent a 72-hour fast. Results: In patients with insulinoma (median serum glucose level, 35.0 mg/dL), plasma glucagon levels (median, 42.9 vs. 76.2 pg/mL, respectively; P < 0.05) were lower than those in control subjects (serum glucose level, 62.5 mg/dL), whereas, there were no statistically significant differences in the other hormone responses between the two groups. In contrast, in the patients with insulin autoimmune syndrome (median serum glucose level, 34.5 mg/dL), plasma glucagon levels (median, 73.7 vs. 76.2 pg/mL, respectively) were lower than those in the control subjects, but there was no statistically significant difference between the two groups. There were no statistically significant differences in counterregulatory hormone responses during spontaneous hypoglycemia between patients with insulinoma and patients with insulin autoimmune syndrome. Conclusion: Our results suggest that defective glucagon secretion in patients with insulinoma rather than insulin autoimmune syndrome may contribute to hypoglycemia in addition to hyperinsulinemia.

당뇨 입원 환자의 저혈당 위험 인자 연구

신윤정 ( Uoon Jeong Shin ) 이화여자대학교 간호과학연구소 2014 Health & Nursing Vol.26 No.1

Purpose: Intensive treatment regimens including early initiation of insulin treatment are important to prevent late complications in type 2 diabetes. The assumed risk of hypoglycemia is a major barrier to initiation of insulin treatment. We aimed to determine risk factors associated with hypoglycemia during hospitalization with diabetes. Methods: To assess the relevance of this risk we evaluated the risk factors from previous researches. Using RISS, KISS, CINAHL we identified 13 clinical studies (8 domestic and 5 overseas) studying risk factors and causes of hypoglycemia. Results: The risk factors of hypoglycemia in clinical studies varied from “Subjects” “Purpose”. Over use of insulin, duration of diabetes, HbA1c(%), nutritional interruption, old ages, hypoglycemia unawareness, type 1 diabetes, infections, excessive exercise, alcoholic, gastrointestinal diseases are important risk factors of hypoglycemia for the patients with diabetes. Conclusion: The present knowledge of risk factors in hypoglycemia is limited due to the lack of data from the patients with hypoglycemia shock. Long term studies about the patient with mild and moderate hypoglycemia as primary endpoint are needed to clarify the hypoglycemia occurrence for inpatient patients and to classify high risk group of hypoglycemia.

Risk Factors for Recurrent Hypoglycemia in Hospitalized Diabetic Patients Admitted for Severe Hypoglycemia

Yen-Yue Lin,Chin-Wang Hsu,Wayne Huey-Herng Sheu,Shi-Jye Chu,Chin-Pyng Wu,Shih-Hung Tsai 연세대학교의과대학 2010 Yonsei medical journal Vol.51 No.3

Purpose: Severe hypoglycemia can result in neural damage, impaired cognitive function, coma, seizures, or death. The decision to admit diabetic patients after initial treatment in the emergency department remains unclear. Our purpose is to identify risk factors for developing recurrent hypoglycemia in diabetic patients admitted for severe hypoglycemia. Materials and Methods: We reviewed the records of 233 subjects (92 males, 141 females; mean age, 74.1 ± 9.8 years) with type 2 diabetes treated at a tertiary care teaching hospital and hospitalized for severe hypoglycemia. Results: Seventy-four (31.8%) patients were categorized with recurrent hypoglycemia and 159(68.2%) with non-recurrent. Multivariate logistic regression analysis revealed that patients with loss of a recent meal, coronary artery disease, infection, and poor renal function (lower estimated glomerular filtration rate) were at risk for recurrent hypoglycemia. The use of calcium-channel blockers appeared to be a protective factor for the development of recurrent hypoglycemia. Conclusion: There may be a subset of patients with severe hypoglycemia and certain risk factors for recurrent hypoglycemia that should be admitted.

1,5-Anhydro-D-Glucitol Could Reflect Hypoglycemia Risk in Patients with Type 2 Diabetes Receiving Insulin Therapy

김민경,정혜승,곽수헌,조영민,박경수,김성연 대한내분비학회 2016 Endocrinology and metabolism Vol.31 No.2

Background: The identification of a marker for hypoglycemia could help patients achieve strict glucose control with a lower riskof hypoglycemia. 1,5-Anhydro-D-glucitol (1,5-AG) reflects postprandial hyperglycemia in patients with well-controlled diabetes,which contributes to glycemic variability. Because glycemic variability is related to hypoglycemia, we aimed to evaluate thevalue of 1,5-AG as a marker of hypoglycemia. Methods: We enrolled 18 adults with type 2 diabetes mellitus (T2DM) receiving insulin therapy and assessed the occurrence ofhypoglycemia within a 3-month period. We measured 1,5-AG level, performed a survey to score the severity of hypoglycemia,and applied a continuous glucose monitoring system (CGMS). Results: 1,5-AG was significantly lower in the high hypoglycemia-score group compared to the low-score group. Additionally,the duration of insulin treatment was significantly longer in the high-score group. Subsequent analyses were adjusted by the durationof insulin treatment and mean blood glucose, which was closely associated with both 1,5-AG level and hypoglycemia risk. In adjusted correlation analyses, 1,5-AG was negatively correlated with hypoglycemia score, area under the curve at 80 mg/dL,and low blood glucose index during CGMS (P=0.068, P=0.033, and P=0.060, respectively). Conclusion: 1,5-AG level was negatively associated with hypoglycemia score determined by recall and with documented hypoglycemiaafter adjusting for mean glucose and duration of insulin treatment. As a result, this level could be a marker of the risk ofhypoglycemia in patients with well-controlled T2DM receiving insulin therapy.

Hypoglycemia Revisited in the Acute Care Setting

Shih-Hung Tsai,Der-Ming Chu,Yen-Yue Lin,Chin-Wang Hsu,Chien-Sheng Cheng 연세대학교의과대학 2011 Yonsei medical journal Vol.52 No.6

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

Blood electrolyte disturbances during severe hypoglycemia in Korean patients with type 2 diabetes

강미연 대한내과학회 2015 The Korean Journal of Internal Medicine Vol.30 No.5

Background/Aims: To investigate abnormalities in blood electrolyte levels during severe hypoglycemia in Korean patients with type 2 diabetes mellitus (T2DM) in a clinical setting. Methods: Blood electrolyte levels in adult T2DM patients during severe hypoglycemia were collected from January 1, 2008 to December 31, 2012. Patients who maintained normal serum creatinine and blood urea nitrogen levels were utilized in the study. Severe hypoglycemia was defined as a condition requiring medical assistance, such as administering carbohydrates when serum glucose levels less than 70 mg/dL were observed, in conjunction with other symptoms of hypoglycemia. Results: A total of 1,068 patients who visited the emergency room with severe hypoglycemia were screened, of which 219 patients were included in this study. The incidence of abnormal levels for any electrolyte was 47%. Hypokalemia (< 3.5 mmol/L) was the most common type of electrolyte disturbance observed at 21.9%. A decrease in serum potassium levels was associated with decreases in blood glucose levels (r = 0.151, p = 0.025). During severe hypoglycemia, median blood glucose levels, incidence of tachycardia (> 100 beats per minute) and severe hypertension (≥ 180/120 mmHg) were 30 mg/dL (range, 14 to 62) and 35 mg/dL (range, 10 to 69; p = 0.04), 18.8% and 7.2% (p = 0.02), and 20.8% and 10.2% (p = 0.05) in the hypokalemia and normokalemia groups, respectively. Conclusions: During severe hypoglycemia, hypokalemia occurred in 21.9% of T2DM patients and was associated with tachycardia and severe hypertension. Therefore, the results suggest that severe hypoglycemia may increase cardiovascular events in T2DM.