May 5, 2016

Diabetes Education Must Include Hypoglycemia

This was not anything that was included in any meetings with a certified diabetes educator. If it were not for Gretchen Becker and her book The First Year - Type 2 Diabetes, New York, Marlow & Company, 312 pages, by Gretchen Becker, and the information in this book - Diabetes Type 2 Complete Food Guide Management Program, New York, Three Rivers Press, 350 pages, by Sherri Shafer, I might not have known what to do to treat hypoglycemia and how to prevent it.

In addition, these two resources helped with hyperglycemia.

Elizabeth R. Seaquist, MD talks about hypoglycemia and gets serious about it. In this case, I can say that she is doing those of us using insulin a good service. She says this is an enormous problem for our patients, because it really limits how well they can control their blood sugars. Every patient with diabetes knows that he/she needs to keep their blood sugars at a near-normal level to reduce their risk for microvascular complications, but this frequently comes at the cost of hypoglycemia, which is really the factor that limits how well they control their blood sugars.

People can have episodes of hypoglycemia that cause them to lose consciousness, have seizures, and die from hypoglycemia. Elderly people with type 2 diabetes who have an episode of severe hypoglycemia that requires the assistance of another person have an increased risk for mortality in the subsequent year.

Even though all of us should know this, Dr. Seaquist repeats this. When you see any patient who is on insulin or a sulfonylurea, you need to wonder about their risk for hypoglycemia. You need to ask them about their hypoglycemia: when it happens, if it is happening. Don't assume that those patients with a high A1c, who you know frequently have high sugars, are free of hypoglycemia. People with very high A1c's have the same risk for hypoglycemia as people with low A1c's. We need to be aware of it at all times.

What do we do when we talk with our patients about hypoglycemia? First, I usually look at their glucose logs, meters, or CGM (continuous glucose monitor) to see if they are having hypoglycemia. Hurrah for her! However, I also ask them about undocumented episodes of hypoglycemia, because they don't always check.

I then ask them how low their blood sugar has to get before they have symptoms of hypoglycemia. That's a very important question, because if people have to get down to 50 or 40 before they have any symptoms, and that tells me that they have experienced frequent episodes of hypoglycemia. This tells me, we need to make a change. People who experience recurrent hypoglycemia in a short period of time develop "hypoglycemia unawareness." There is a real problem that you need to address.

We need to help our patients understand how to pick a rational dose of insulin for every mealtime, every time they're eating, and how to best adjust their insulin for exercise. If we can do that and use the tools that are available to us, we can help avoid hypoglycemia. As doctors, we need to sit down and talk with our patients, and think about what tools we can give them to help manage this problem of hypoglycemia.

If we can avoid hypoglycemia, we can prevent patients from developing hypoglycemia unawareness, which really puts them at risk for mortality, accidents, and disruptions to their everyday life. If we can avoid hypoglycemia, we can help patients achieve better glucose control because they won't be so fearful, which will help them control their diabetes overall.

Her approach to hypoglycemia is more rational and thought out than any doctor that I have dealt with and she carefully says what doctors need to do, questions to ask, and how to deal with patients positively. You may want to read the full article here.

1 comment:

lisadavid said...

Hi!!! Great post, thanks for sharing it is more informative and beautifully articulated.