Strategies and Options for the Management of Hypoglycemic Emergencies - Episode 3
Expert panelists provide an overview of health complications associated with mild and severe hypoglycemic episodes and emphasize the importance of patient awareness and early recognition to improve quality of life and health-related outcomes.
Peter Salgo, MD: Why do we care? Why is early recognition and understanding of the causes of hypoglycemia so important for appropriate treatment? For that matter, so what? You get some hypoglycemic episodes, you treat them, and the sugar comes up. What’s the big deal? Why are we discussing this?
Anne Peters, MD: We’re discussing it not because relatively mild hypoglycemia is so bad for you—I mean, I don’t think it’s good to feel as if you’re always about to go low, psychologically. But in terms of physiology, once you start going below 54 mg/dL is when you can get into an area where you may have cognitive dysfunction. That is a severe episode, which means you lose consciousness. People who have recurrent, severe lows—as you heard—have an adaptation. Their body stops sensing lows. They lose those adrenergic signs and symptoms, and they just develop the neuroglycopenic symptoms. Then they can be on a ladder and fall off or be in a car and crash into another car, or simply have seizures and lose consciousness. That kind of hypoglycemia is bad. If you think about it, we’ve given somebody a shot of insulin in 1 way or another that’s external. We’ve put it into the body, and we can’t take it back out. It’s in there, so as someone starts plummeting, if they don’t stop that plummet somehow, then they’re going to go way too low.
Basically, we need systems. They’re trying to develop these closed-loop systems in which they give glucagon and insulin to balance each other. But we have no balance. People lose their ability to secrete glucagon as they have diabetes for longer, so there’s no internal balance. That’s why people need to be able to recognize this and treat this always and as early as they can. In the clinic, I always have a patient show me that they have simple carbohydrates with them. If somebody comes into the clinic and they don’t have it in their purse or in their pocket, you have to reinforce that they always need to carry something to treat hypoglycemia with because they’re not always going to know when they’re going to get it.
It’s really important, as I said, to prevent the severe episodes. The older population—these people are near and dear to my heart because they’ve lived for 50 years with type 1 diabetes. Sadly, diabetes gets harder to manage as you get older, not easier, because there’s more variability and your food intake may vary. They found that recurrent episodes of severe hypoglycemia lead to or are associated with more cognitive dysfunction. It’s also likely true that more cognitive dysfunction leads to more hypoglycemic episodes because when you treat diabetes, it’s inherently numeric. You have to figure out what dose to give, and if you’re losing cognitive function, maybe you give 6 units instead of 3, so you can’t see to measure it up. Older adults get into real trouble with recurrent severe hypoglycemia, so we need to make sure people don’t get severe lows. That’s why we have to treat the mild lows. Besides, you don’t want them to feel weak and shaky all the time. It is not a good feeling.
Peter Salgo, MD: Sure. I guess the question really is, every time you get low, are you knocking off neurons? In other words, does every hypoglycemic episode leave you a little more impaired than the previous 1, even if you can’t feel it at first?
Anne Peters, MD: Not in mild cases. In the DCCT [Diabetes Control and Complications Trial], which Davida knows more about than I do because she participated in it, they didn’t have a cognitive decline related to hypoglycemia. I don’t think mild hypoglycemia knocks off neurons, but I do think recurrent episodes of severe hypoglycemia, especially with seizures, can cause ongoing damage. There are studies looking at patients who had episodes of severe hypoglycemia, and they can see clear cerebral abnormalities. You don’t really want to have severe hypoglycemia. It’s not that people should be terrified; I don’t want that to be the message. Mild hypoglycemia is relatively benign, but not if it leads to severe hypoglycemia.
Elaine Apperson, MD: I would also add that, when you look at the total distress on the part of parents—the amount of effort that goes into managing diabetes in a child, the disruption to their day, the disruption to their ability to learn and to play with peers—if you have a low, then almost invariably you will then have a high, which means you will have to treat the high. It sets up a roller coaster for the next 12 hours, almost invariably. You look at those 12 hours as a lost 12 hours for the caretaker, usually the mom. It’s a boomerang effect if you have a severe low that you’ve had to treat. The quality of life is lost. It’s a severe blow. It’s not negligible.
Peter Salgo, MD: Davida?
Davida Kruger, MSN, APN-BC, BC-ADM: You must also look at quality of life. When I think of my patients, I think of a teenager who said to me, “It’s hard to run with the crowd if you’re fearing hypoglycemia,” or some of my executive patients who say, “How do we get up on the stage in front of an audience unless my blood sugar is higher? I can’t risk hypoglycemia in front of a crowd.” I think of a school teacher who’s trying to run a classroom, or an auto worker who’s getting in and out of cars all day trying to put them together. It has to do with quality of life as well and how you appear to other people and the vulnerability it causes. On the family side, I have patients whose family members are so afraid. Joe had an event at 3 o’clock 6 months ago, so every day at 3 o’clock, that spouse runs up to the patient and wants them to eat, so it never happens again.
Then I think about what it would be like to go to bed at night worrying about having unassisted hypoglycemia. In addition to when we think of what goes on in the body with hypoglycemia, we have to think of quality of life, how people perceive these individuals with diabetes and their fears of and concerns with hypoglycemia as well.
Peter Salgo, MD: I don’t want to leave this topic without discussing the 800-pound gorilla in the room, which is death. How many of these episodes of hypoglycemia kill people? Is it a real fear? Is it something that patients know about? Is it something they have to worry about?
Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: Yeah. You’ve heard very clearly that hypoglycemia can be a nuisance if you’re eating something for non-nutritional purposes, and then it gets to all the way to the point where you could die, right? Something like 4% of people with diabetes can die from hypoglycemia, at least concerning people with type 1. There’s entropy in the management of diabetes. Because you can’t explain every glucose value, that uncertainty amplifies the fear for so many families: “I don’t know why they drop low, but I just know I’m never going to let that happen again.” You can see parents. They don’t want their kid to drop low—they might even not have the kid go out and do activities. Or someone may say, “I’m never going to be low before I get behind a wheel again because I don’t want to crash a car.” There’s a real concern—although we’ve really found ways to reduce hypoglycemia with new agents and with technology—that it’s an issue. The perceived fear is also very important, and the more we can educate our providers and our patients to understand the things that contribute to glucose variability, the less mysterious these concepts will become. They can say, “I realize that sometimes I’m going to be going faster than I thought I was going, but I have a way I can handle that.” The more awareness we have about where we are, the more we’re going to be able to have actionable items to prevent that from beginning so severely.
Peter Salgo, MD: I want to thank all of you for watching this HCPLive® Peer Exchange. If you enjoyed the content, I want you to subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box.
Transcript Edited for Clarity