Treating Hypoglycemia

Denise is a 49 year old woman who has had type 1 diabetes for 22 years. She is on an insulin regimen of regular human insulin 5units with each meal and NPH 12 units at breakfast and bedtime. Her A1C is 5.9%. A review of her meter downloads reveals several blood glucose values of < 3.0 mmol/L per week, including some during the night. On further questioning, you discover that she “still feels them”, but no longer experiences the same symptoms (shaky and sweaty) as she did in the past.

Question 1: Which ONE of the following is NOT a risk factor for Denise's episodes of hypoglycemia?

A.	Her A1C of 5.9%.
B.	That she has hypoglycemic unawareness.
C.	That she is 49 years old.
D.	That she has had diabetes for 22 years.
E.	That she has been diagnosed with autonomic neuropathy, on the basis of a persistent resting sinus tachycardia.

Reveal Answer

Question 3: Which of the following would you NOT recommend to reduce her risk of hypoglycaemia?

A.	Eat more frequently in between meals.
B.	Switch to a long-acting insulin analogue (insulin detemir or glargine).
C.	Switch to a rapid-acting insulin analogue (insulin aspart, glulisine or lispro).
D.	Teaching Denise cognitive exercises to practice hypoglycemia recognition.
E.	Setting a target A1C of 7.5 – 8.5% for the next visit.

Reveal Answer

References for Denise:

Chapter 14: Hypoglycemia

A1C 5.9%.	CORRECT. Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months can reduce the risk of hypoglycemia, and reverse hypoglycemia unawareness. B is also correct.
Hypoglycemic unawareness.	CORRECT. Blood glucose awareness training can improve one's awareness of hypoglycaemia. A is also correct.
Duration of diabetes.	Incorrect. Unfortunately there is nothing to reverse duration of diabetes.
Autonomic neuropathy.	Incorrect. Unfortunately, there is no known treatment or cure for autonomic neuropathy.

Her A1C of 5.9%.	Incorrect. An A1C of < 6.0% is a risk factor for hypoglycemia.
That she has hypoglycemic unawareness.	Incorrect. Denise has hypoglycemia unawareness, as she no longer has the adrenergic symptoms of hypoglycemia; this is a risk factor for hypoglycemia episodes themselves.
That she is 49 years old.	CORRECT. Her age is not a risk factor for hypoglycemia. While older age is a risk for hypoglycemia in type 2 diabetes, young age and adolescence are risk factors for hypoglycemia in type 1 diabetes. Denise is neither. To review hypoglycemia in diabetes see: Chapter 14: Hypoglycemia.
That she has had diabetes for 22 years.	Incorrect. Long duration of type 1 diabetes is a risk factor for hypoglycemia.
That she has been diagnosed with autonomic neuropathy, on the basis of a persistent resting sinus tachycardia.	Incorrect. Autonomic neuropathy is a risk factor for hypoglycaemia; resting tachycardia can be a sign autonomic neuropathy.

Eat more frequently in between meals.	CORRECT. Denise's insulin type or doses should be adjusted if she is having recurrent hypoglycaemia, rather than depending on more frequent snacking. That will just lead to weight gain.
Switch to a long-acting insulin analogue (insulin detemir or glargine).	Incorrect. The use of long-acting insulin analogues can reduce her risk of hypoglycemia (especially nocturnal hypoglycemia), and should be considered for Denise.
Switch to a rapid-acting insulin analogue (insulin aspart, glulisine or lispro).	Incorrect. The use of rapid-acting insulin analogues can reduce the risk of hypoglycemia, and should be considered for Denise.
Teaching Denise cognitive exercises to practice hypoglycemia recognition.	Incorrect. Blood glucose awareness training (BGAT) can improve one's awareness of hypoglycemia, and thus reduce the risk of hypoglycemia.
Setting a target A1C of 7.5 – 8.5% for the next visit.	Incorrect. Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months can improve her hypoglycemia unawareness and reduce her risk of hypoglycaemia; her A1C target should be raised for up to 3 months to try to attain this.