Strategies and Options for the Management of Hypoglycemic Emergencies - Episode 1
A panel of experts in diabetes builds a discussion on hypoglycemia and shares key insights into its impact on community health by considering overall challenges of glucose management.
Peter Salgo, MD: Hello, and welcome to this HCPLive® Peer Exchange titled “Strategies and Options for the Management of Hypoglycemic Emergencies.” I’m Dr Peter Salgo. I’m a professor of anesthesiology and internal medicine at Columbia University Irving Medical Center in New York City. Joining me in this discussion are my colleagues Dr Elaine Apperson, an associate professor of clinical pediatrics at the University of South Carolina School of Medicine in Greenville, South Carolina; Davida Kruger, a certified nurse practitioner specializing in diabetes at Henry Ford Health System in Detroit, Michigan; Dr Anne Peters, a professor of medicine at the Keck School of Medicine of University of Southern California in Los Angeles; and Dr Jay Shubrook, a professor in the primary care department at the Touro University California College of Osteopathic Medicine [in Vallejo, California].
Our discussion is going to focus on the availability of pharmacological options for the treatment of severe hypoglycemia. We are going to discuss how to facilitate shared decision-making for patients with diabetes, parents, and caregivers regarding the selection of therapies for the treatment of severe hypoglycemia. Let’s get started. Before we even get into hypoglycemia, it’s worth setting the scene. We’re talking about diabetes. Classically, when we talk about diabetes, everybody talks about hyperglycemia. What’s the big deal here? Why are we discussing hypoglycemia at all?
Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: It’s important to remember that the treatments for diabetes try to get the glucose close to, but not right at, the normal range because hypoglycemia is the rate-limiting factor for the treatment of diabetes. We want to optimize treatment without causing lows, and these lows are significant, as we are going to spend some time discussing.
Peter Salgo, MD: I recall in my career, which is getting longer now—everyone’s is by the second; mine just seems longer—that there was a time when we were getting tighter control. Tighter is better. Tighter means a longer life. But then we were seeing more and more hypoglycemia, so was this a direct outgrowth of that movement toward tighter control?
Davida Kruger, MSN, APN-BC, BC-ADM: That’s absolutely true. I mean, hypoglycemia has always been the rate-limiting factor in how we treat diabetes. The Diabetes Control and Complications Trial, in which I participated in the 1980s and 1990s, we were able to say that a better hemoglobin A1C [glycated hemoglobin] prevented a lot of complications, but we were limited by hypoglycemia. Now, in 2021—we’ll talk about it later—we have some great devices that may allow us to help prevent some of that hypoglycemia, as well as better medication.
Peter Salgo, MD: If I’m reading you right, that allows us to get closer to that magic knife edge and get the best hyperglycemic treatment. And if we go toward hypoglycemia, then we can deal with that, too—in a better way than we were able to. Is that right?
Davida Kruger, MSN, APN-BC, BC-ADM: Most definitely.
Peter Salgo, MD: Why don’t we get a definition on the table, then? What’s the clinical definition of hypoglycemia, and what are the effects of hypoglycemia on community health?
Anne Peters, MD: Hypoglycemia is simple. It means the glucose level goes too low. In some cases, it goes so low that a person will lose consciousness because you need glucose for your brain to function. We like to have people check their blood sugar to validate that they’re going low, but people often feel the signs and symptoms of hypoglycemia, which we’re going to discuss later. They know they’re going low. They have some juice or do something to treat it, and that’s good because at least they’re aware of it, but there’s also hypoglycemia that, clinically, a patient doesn’t feel. That’s called hypoglycemia unawareness. That’s much scarier because that can then go untreated and cause a patient to have a severe episode where they lose consciousness and can’t treat themselves.
The real problem with this—in community health, but for everybody—is that fine line we’re talking about. Patients become afraid of hypoglycemia. I work with an underserved population. A lot of my patients do very physically intense jobs in the day. They’re construction workers; they’re field workers. They do all sorts of things that make them move around, and they don’t want to go low. To prevent that, they try to keep their glucose levels higher, and we know that that’s not good because it can result in the complications related to hyperglycemia. Finally, there’s concern about nocturnal hypoglycemia—which we all can see—which means glucose levels go too low at night. The person might be asleep and not know what to do until they wake up from a bad dream where they feel funny and agitated and they’re low—sometimes too low. There’s a lot that goes on clinically. As providers what we want to do is obviously find out if it’s true hypoglycemia, help the patient avoid it, and treat it.
Peter Salgo, MD: Teach me something. When I was a resident back in the days when the pterodactyls flew through the sky, we talked about rebound hyperglycemia, which was a consequence of nocturnal hypoglycemia. Do we still see this, or are people just waking up hypoglycemic these days?
Anne Peters, MD: You’re asking a very complicated question.
Peter Salgo, MD: I’m glad I have experts here. I want to be taught.
Anne Peters, MD: That’s what we used to think back in the old days. We know 2 things. We know that there’s something called the dawn phenomenon. You were talking about something we used to call the Somogyi effect.
Peter Salgo, MD: Yes.
Anne Peters, MD: The dawn phenomenon refers to the fact that most of us have hormones that come out in the early morning. Our hormones include cortisol, a growth hormone that can wake us up for the day. That causes insulin resistance, so for a lot of people, when we do continuous glucose monitoring, we can see that their glucose levels are going up in the early morning, not because they went low at night but because their bodies become more resistant. We’re not giving enough insulin to cover that.
The other thing you’re talking about—which is incredibly important—is that people tend to overtreat their lows. When they do that, their glucose level shoots up in response to treating the lows. Then they see their glucose is 300 mg/dL and they must give a correction dose and boom—they give themselves more insulin and they crash down again. One of the real dangers of hypoglycemia is rebound hyperglycemia—but not this Somogyi effect—overnight. It occurs at any time of day that somebody treats their lows too aggressively. I don’t blame anyone who feels like drinking a carton of juice because feeling low feels bad. They’re doing it because that’s what their body is craving, but we have to teach them how to balance it.
Peter Salgo, MD: In aviation, that’s known as pilot-induced oscillation. Your nose is too high, so you push it down. Then your nose is too low, so you pull it up. These cycles get wilder and wilder until the plane crashes. It sounds identical to me, and you have to break that cycle somewhere. Is that fair?
Anne Peters, MD: I’m not flying on an airplane that you’re piloting. That’s all.
Peter Salgo, MD: We did discuss not flying on an airplane in which you were a passenger, but that’s for another discussion entirely.
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Transcript Edited for Clarity