Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia.

Abstract

Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3-6 months. If targets are not met, one diabetes technology-continuous subcutaneous insulin infusion or continuous glucose monitoring-should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.

• Authors: Pratik Choudhary, Michael R Rickels, Peter A Senior, Marie-Christine Vantyghem, Paola Maffi, Thomas W Kay, Bart Keymeulen, Nobuya Inagaki, Frantisek Saudek, Roger Lehmann, Bernhard J Hering
• Journal: Diabetes care (Diabetes Care) Vol. 38 Issue 6 Pg. 1016-29 (Jun 2015) ISSN: 1935-5548 [Electronic] United States
• PMID: 25998294 (Publication Type: Journal Article, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't, Review)
• Copyright: © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

Chemical References

• Blood Glucose
• Hypoglycemic Agents
• Insulin

Topics

• Algorithms
• Awareness
• Blood Glucose (metabolism)
• Blood Glucose Self-Monitoring
• Diabetes Mellitus, Type 1 (prevention & control)
• Evidence-Based Medicine
• Humans
• Hypoglycemia (prevention & control)
• Hypoglycemic Agents (therapeutic use)
• Insulin (therapeutic use)
• Insulin Infusion Systems
• Pancreas Transplantation
• Patient Education as Topic (methods)