Evolution in Overcoming Barriers in Management of Diabetes: Hypoglycemia

The main objective of management of diabetes focuses on eliminating symptoms of hyperglycemia, preventing hyperglycemic and other metabolic complications, delaying onset of chronic deleterious microvascular disorders and reducing macrovascular risk. However, iatrogenic hypoglycemia remains a major limiting factor in attaining and maintaining desirable glycemic targets. Hypoglycemia is defined as plasma glucose concentration < 70 mg/dl exposing the individual to potential harm. Hypoglycemia is classified into level 1 being asymptomatic or symptomatic documented by blood sugar 54 - 69 mg/dl; level 2 with blood sugar < 54 mg/dl irrespective of symptoms and level 3 or “severe” requiring secondary assistance for resuscitation. Initial symptoms of hypoglycemia are attributed to catecholamine release whereas more serious manifestations are caused by neuroglycopenia. Moreover, nocturnal hypoglycemia and hypoglycemia unawareness present serious consequences including death. The most important goal is to identify patients at a high risk of hypoglycemia, patient education to be on alert for circumstances provoking hypoglycemia and modify treatment regimen based upon individual characteristics. Strategies to manage hypoglycemia are divided into 3 broad categories: 1) Prevention of hypoglycemia, 2) Use of novel technology such as self-blood glucose monitoring systems, insulin pumps, insulin auto injectors as well as newer therapeutic agents including regimens with low/no occurrence of hypoglycemia, and 3) Education of patients and caregivers in treatment of hypoglycemia e.g. use of oral glucose as well as use of glucagon kits.