A Conversation with Roma Gianchandani, MD
The body mounts a stress response when glucose levels start to drop which also depends on how fast it is dropping. Symptoms experienced include nervousness, sweating, palpitations, confusion, irritability, hunger, visual changes. These occur due to our body’s hormones fighting hypoglycemia with glucagon, adrenaline, and cortisol. Since the brain needs glucose for fuel the rest of the body works hard to conserve it making this response extremely important. If levels of glucose drop and deprive the brain of glucose this can lead to seizures, coma and rarely even death.
Patients with DM take oral medications, which increase secretion of body’s own insulin or they take insulin by injection. When insulin dose is mismatched to the requirement of the body as with increased physical activity, low intake of food, nausea, diarrhea etc., the excessive insulin drops blood glucose very fast. The body’s checks and balances cannot overcome this excessive insulin dose and causes hypoglycemia. So it is important to adjust medications for periods of no food intake, illness, intense exercise etc. Every patient with diabetes especially on insulin should have a Sick Day plan.
In healthy patients without diabetes and normal insulin production, glucose values can run lower especially for young women when they wake up. This can be corrected by the body’s counterresponses and prevents any major consequences.
Patients who are at risk of hypoglycemia include those on insulin and drugs like sulfonylureas (glipizide, glyburide), older individuals, those with kidney dysfunction especially dialysis, liver failure, alcoholism, those who with longstanding diabetes who cannot always tell when their glucose is dropping, pregnant women, children and those who have had several episodes of hypoglycemia
Hypoglycemia if untreated, deprives the brain of glucose and can lead to seizures, coma, and death. There is diversion of glucose to the brain and stress on liver to produce glucose. This in addition to the stress hormones poses significant strain on the heart and can lead to abnormal beats (arrhythmias), angina and sudden cardiac death.
If patients have repeated episodes of hypoglycemia, the body stops recognizing this event and its response is to hypoglycemia is blunted. A person is unable to tell that their glucose is low. This leads to a severe episode of hypoglycemia in which a person needs assistance from others to overcome the low glucose episode by glucagon, EMS, emergency room visit etc..
A CPG is a framework for treatment and care of a subset of individuals laid out by their expert societies. These CPG process helps to gather, evaluate, and publicize recent evidence to improve and standardize care of a subset of patients. CPGs also help doctors keep up with the new literature and provide better care without the burden of intense review of papers.
In this new hypoglycemia guideline the committee calls out diabetes patients who are at high risk for low blood glucose, and some of the interventions and management issues to help reduce episodes of hypoglycemia. It targets specific groups e.g. T1, on insulin injections, pumps, T2 on insulin or sulfonylureas and lays out the data in the literature to come up with best practices. It also evaluates a significant body data over the last decade of technology and how it can contribute to improve the lives of patients with diabetes. The CPG also discusses the newer glucagon preparations and their importance in this group.
In the next few years devices will be much more accurate, accessible, and coverage will improve. This CPGs also evaluates the importance of these devices and their contribution to glucose control and hypoglycemia reduction. In time things will change and in the meanwhile, if someone has multiple episodes of hypoglycemia it may be possible to appeal for coverage or find some other routes to get the device.
An alternative use of these devices is as a diagnostic CGM trial. Here the device is put on patient in clinic and stays on the body for 10 to 14 days. The patient returns the device and we use the data obtained in that period to identify patterns of hypo and hyperglycemia and alter therapy. This can be done a few times and can help titrate medications and improve the diabetes regimen. This is widely covered by insurances so can be requested by patients..
These devices can be lifechanging for some. For most patients CGMs improve their QOL. They help predict highs and lows and warn of hypoglycemia before it occurs, They also help plan activity and help one get through an activity. I have patients who have resisted CGMs for years and when they eventually are convinced to get one they cannot believe they waited this long.
As preferences vary, few patients find CGMs an intrusion on their body and they or family members are bothered by the alarms and the disturbance and attention they draw. Also CGMs can lag behind glucose levels by finger pokes and this discordance in glucose levels between the meter and CGM is very concerning for some patients.
All insulins if mismatched with need will cause hypoglycemia. Some insulins have shorter duration of action or slow absorption and can therefore do not overlap with next dose and cause less hypoglycemia. These are usually the newer and engineered insulins.
In pregnancy the baby is taking a lot of the mother’s nutrition. Additionally glucose goals are very tight during pregnancy to prevent abnormalities in the baby. Nausea, indigestion etc. are a part of pregnancy and curtail food intake. The combination of these factors raises the hypoglycemia risk.
Hypoglycemia is an area of intense research at this moment. We still need data in different areas – clinical medicine, patient education, best practices evaluation, devices etc. One area to evaluate urgently is the cost of hypoglycemia. When patients get a CGM the cost of BG monitoring goes up. How does that compare with the cost of an ER visit, an EMS call or a hospital admission, loss of productivity and other associated issues. This I believe is one of the most urgent questions to answer that will change the landscape of device utilization and coverage.
Developed For Patients Based on Management of Individuals with Diabetes at High-Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline
Dr. Gianchandani is Professor of Medicine and Director of Diabetes Quality and Vice Chair of Medicine for Quality and Innovation at Cedars Sinai. She has spent her career in building and evaluating new and innovative programs, protocols, and guidelines for improving quality of diabetes management in the hospital. She is passionate about integrating diabetes technology into both the inpatient and outpatient setting. She chairs the National Epic Endocrinology Steering Board to help translate some of these practices for the endocrinology community. In her free time she enjoys spending time with family, cooking, music and reading.
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