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Risk Factors for Hypoglycemia and Strategies for Avoidance

Minimizing hypoglycemia in type 2 diabetes patients….

Hypoglycemia is a common problem among patients taking combinations of insulin and sulfonylureas and may be a limiting factor in diabetes therapy management. Hypoglycemia is defined by the American Diabetes Association (ADA) as a plasma glucose of 79mg/dL. (3.9mmol/L) or less; however most people begin to feel symptoms of hypoglycemia around a concentration of 61mg/dl-64mg.dL) or 3.4-3.6mmol/L. Since the majority of hypoglycemia episodes are reported based on symptoms and not on glucose levels, the ADA Workgroup on Hypoglycemia distinguished five subsets of hypoglycemia:

  1. severe hypoglycemia: requiring outside assistance regardless of glucose levels
  2. documented symptomatic hypoglycemia: symptoms of hypoglycemia and a confirmed glucose of 3.9mmol/L or less
  3. asymptomatic hypoglycemia: no symptoms with a glucose level of 3.9mmol/L or less
  4. probable symptomatic hypoglycemia: symptoms without confirmed glucose levels
  5. relative hypoglycemia: symptoms with a glucose level greater than 3.9mmol/L.

Symptoms of hypoglycemia may include tachycardia, anxiety, shaking, irritability, feelings of hunger, weakness, tiredness, dizziness, headache, confusion, and trouble concentrating.

The incorrect dosing of glucose-lowering medications such as sulfonylureas and insulins can cause hypoglycemia. Skipping meals, eating smaller meals, and having irregular eating patterns were also identified as risk factors for hypoglycemia. Increased physical activity may increase hypoglycemia by increasing insulin sensitivity. Additional factors identified included drug or alcohol consumption, older age, longer duration of diabetes, renal disease, peripheral neuropathy, obesity, and cognitive dysfunction. Other medications may also act to mask hypoglycemia symptoms such as beta blockers, and ACE inhibitors.

The authors concluded that hypoglycemia can occur in both type 1 and type 2 diabetic patients and leads to reduced quality of life and increased financial burden, as well as long-term complications. They conclude that the best strategies to reduce hypoglycemia risk are likely the ones that will be cost-saving strategies.

Plausible strategies to combat and prevent hypoglycemia in the type 2 diabetes population include:

  • Educate patients, family and health care providers about hypoglycemia, including symptoms, risk factors, self-monitoring and glucagon handling.
  • Focus not only on glycemic control, but also on decreasing the risk for hypoglycemia, when discussing glucose-lowering treatments.
Practice Pearls:
  • There are many risk factors for hypoglycemia in type 2 diabetic patients, including increased age, duration of diabetes, skipping meals or erratic eating patterns, and certain concurrent medications that can mask the symptoms of hypoglycemia such as beta blockers.
  • Hypoglycemia reduces quality of life and is very costly; the most successful strategies to reduce its occurrence will likely be cost-saving strategies.
  • Strategies to educate patients, family and providers about hypoglycemia, its causes, and appropriate mitigation techniques through medication use should be used.

Ahren, Bo. Avoiding hypoglycemia: A key to success for glucose-lowering therapy in type 2 diabetes.

Vascular Health and Risk Management Diabetes Metabolism Research & Reviews 2013;9:155-163.