Hypoglycemic unawareness risks -
These episodes mostly happened at night. The patient claims that she was very active during her work shift and did not have time to eat adequately, but she injected insulin at the usual dose.
The injection regimen of the patient consisted of multiple insulin injections day: regular insulin, 10 U before breakfast and dinner, and 6 U before lunch; NPH insulin, 25 U in the morning and 10 U at night. Her dose had been adjusted at her last visit to her endocrinologist 3 months previously, but she has had several severe hypoglycemic attacks during the last 4 weeks.
She was examined by a neurologist in the morning for her focal neurological symptoms, and the examination revealed no deficits.
Her medical history was also concerning for hpoglycemia-associated autonomic failure HAAF , and she was recommended to have this condition evaluated as outpatient. To avoid recurrent hypoglycemia, further laboratory tests and a follow-up evaluation with an endocrinologist were recommended, as well a switch from human insulins to analog insulins.
Hypoglycemia is a common side effect of various diabetes medications, such as insulin and sulfonylureas [ 8 , 11 ]. This condition can cause life-threatening episodes, significant morbidity, and a lack of optimal glycemic control. Many routine activities, such as driving, job performance, and sporting competitions, can be affected by hypoglycemia [ 12 ].
This clinical scenario necessitates additional investigation and a review of the medical regimen. The true prevalence of hypoglycemia in persons with T1DM is unknown [ 2 , 8 , 19 ].
HU happens more often in those who: 1 repeatedly have low blood sugar episodes which can cause the patient to stop sensing the early warning signs of hypoglycemia ; 2 have had diabetes for an extended time; and 3 tightly control their diabetes which intensifies their probabilities of having low blood sugar reactions [ 15 , 16 , 18 ].
Changes to insulin regimen. Decreased glucose that enters the bloodstream. The possible explanation of the hypoglycemia in our patient is expected to be delayed meals due to work shifts and lack of carbohydrates at night before sleeping [ 1 , 2 , 6 , 8 , 11 ].
Increased glucose uptake. Other possible causes, in the present case, are due to increased physical activity following work shifts [ 1 , 2 , 6 , 8 , 11 ]. Decreased endogenous glucose production following alcohol consumption.
The medical history of our patient and test results did not confirm this possibility [ 1 , 2 , 6 , 8 , 11 ]. Decreased renal insulin excretion following renal failure.
The medical history of our patient and test results did not confirm renal insufficiency [ 1 , 2 , 6 , 8 , 11 ]. Increased insulin sensitivity following weight loss or exercise or severe glycemic control. She also mentioned beginning sports activities in the last 6 months [ 1 , 2 , 6 , 8 , 11 ].
Previous studyies have linked both tight glycemic control [ 22 , 23 , 24 ] and attempts to rapidly control hemoglobin A1c HbA1c levels [ 22 , 25 ] to increased hypoglycemic events [ 26 ]. Our patient had an HbA1c of 5.
According to related studies in patients with insulin-dependent diabetes, the incidence of hypoglycemic attacks in patients taking regular insulin is higher than that in patients taking newer insulins, including lispro [ 27 , 28 , 29 ], which is consistent with our reported case.
Our patient had also been given regular insulin and NPH. The risk of hypoglycemia is higher with human insulin than with analog insulin such as Lantus and Novorapid [ 30 ], and therefore the preferred type of insulin in T1DM is analog insulin.
A study by Smith et al. revealed that reduced compliance to changes in insulin regimen in hypoglycemia unawareness is consistent with hypoglycemic stress habituation. These authors concluded that therapies aimed at altering repetitive risky behavior could be beneficial in restoring hypoglycemia awareness and preserving toward severe hypoglycemia [ 31 ].
HAAF is another possible explanation for the hypoglycemic episodes experience by our patient. HAAF is a type of functional sympathoadrenal failure caused most commonly by recent antecedent iatrogenic hypoglycemia and is at least partially reversible by careful avoidance of hypoglycemia. HAAF can be maintained by recurrent iatrogenic hypoglycemia [ 32 ].
It is vital to distinguish HAAF from conventional autonomic neuropathy, which can also be caused by diabetes. Sympathoadrenal activation appears to be inhibited only in response to hypoglycemia, while autonomic activities in organs, such as the heart, gastrointestinal tract, and bladder, are unaffected [ 32 ].
Our case was examined for this possibility due to her long history of severe hypoglycemic attacks, which needed further evaluation to rule out having HAAF after an evaluation of sympathoadrenal response to hypoglycemia. People with HU are unable to detect drops in their blood sugar level, so they are unaware that they require treatment.
Unawareness of hypoglycemia increases the risk of severe low blood sugar reactions when they need someone to help them recover. People who are unaware of their hypoglycemia are also less likely to be awakened from sleep when hypoglycemia occurs at night. People who are hypoglycemic but are unaware of it must take extra precautions to monitor their blood sugar levels regularly.
This is especially true before and during critical tasks, such as driving. When blood sugar levels are low or begin to fall, a CGM can sound an alarm. Such a device can be a great assistance to people with HU [ 12 , 15 ].
With continuous BG monitoring, children and adults with T1DM spend less time in hypoglycemia and simultaneously decrease their HbA1c level [ 33 , 34 ]. A prior study showed that diabetic patients with reduced beta-adrenergic sensitivity may be unaware of hypoglycemia, and the best suggestion for these patients is to strictly avoid hypoglycemia [ 35 , 36 ].
Our patient was also advised to have emergency glucose tablets, intermuscular, or intranasal glucagon injections at her disposal all of the time to avoid hypoglycemic attacks.
The glucagon injection pen was not available in Iran at the time of the episode described here, neither was a CGM, so she was recommended to follow educational sessions on carbohydrate counting and perform excessive SBGM.
The patient was given strict advice based on her job and profession, as well as the need to control her blood sugar level to the extent that it did not interfere with her professional and daily functioning [ 12 ].
She was advised to see her endocrinologist to adjust her insulin dose based on her unawareness of hypoglycemia attacks and her work schedule, which may not allow her enough time to rest and consume enough carbohydrates, potentially leading to life-threatening attacks, especially since her coworkers were unaware of her medical condition.
It is strongly advised that people with diabetes, especially patients like this case, wear some sort of identification, such as a bracelet, or carry a card that state their condition [ 15 ]. Normalization of autonomic response takes 7—14 days on average, but it can take up to 3 months to normalize the threshold of symptoms, neuroendocrine response, and glucagon response although glucagon response is never fully recovered [ 37 , 38 ].
Another suggestion was to switch human insulin to the analog type of insulin. Hypoglycemia is a fairly common complication in diabetic patients receiving oral or insulin therapy.
However, in a subset of patients who are unaware of hypoglycemia for a variety of reasons, these warning signs do not exist, resulting in severe and life-threatening hypoglycemic episodes. As a result, patients who have multiple episodes of HU are advised to raise their blood sugar control threshold for at least 2 weeks and to wear at all times a bracelet or label indicating their medical condition.
In addition, in these patients, the use of CGM equipped with alarms in the occurrence of severely low blood sugar can be a perfect option.
Patient data and information can be accessed for review after obtaining permission from the patient without any disclosure of her name. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care. Article CAS Google Scholar.
Cryer PE. Symptoms of hypoglycemia, thresholds for their occurrence, and hypoglycemia unawareness. Endocrinol Metab Clin North Am. Hoeldtke RD, Boden G. Epinephrine secretion, hypoglycemia unawareness, and diabetic autonomic neuropathy. Ann Intern Med. Greenspan SL, Resnick MN.
Geriatric endocrinology. In: Greenspan FS, Strewler GJ, editors. Basic and clinical endocrinology. Stamford: Appleton and Lange; Mitrakou A, Ryan C, Veneman T, Mokan M, Jenssen T, Kiss I, et al.
Hierarchy of glycemic thresholds for counterregulatory hormone secretion, symptoms, and cerebral dysfunction. Am J Physiol-Endocrinol Metabol. Wilson JD, Foster DW, Kronenberg HM, Larsen PR. The anterior pituitary. Williams textbook of endocrinology.
Philadelphia: WB Saunders Co; Joslin EP, Kahn CR. Ronald Kahn Hypoglycemia: pathophysiology, diagnosis, and treatment. Oxford:: Oxford University Press; Google Scholar. Veneman T, Mitrakou A, Mokan M, Cryer P, Gerich J. Induction of hypoglycemia unawareness by asymptomatic nocturnal hypoglycemia.
Kalra S, Mukherjee JJ, Venkataraman S, Bantwal G, Shaikh S, Saboo B, et al. Hypoglycemia: the neglected complication. Indian J Endocrinol Metabol. Article Google Scholar. Cryer P. Hypoglycemia in diabetes: pathophysiology, prevalence, and prevention.
The Pedersen-Bjergaard method tends to overestimate the prevalence of HU as documented previously by Geddes et al.
A higher prevalence of HU was reported in T2DM patients from Turkey The factors reported to affect HU are not consistent among different studies, and some factors that were demonstrated to increase the risk for HU in some studies were not confirmed in others.
However, long diabetes duration and strict blood sugar control are the most commonly reported factors that raise the risk of HU Nevertheless, in the present study, patients with HU had disease durations and HbA1c levels similar to those of aware subjects, findings that were also documented in other studies However, some studies found that patients with HU have higher HbA1c values Relaxing the glycemic target in patients with HU could explain the higher HbA1c values in those patients.
Similarly, Murata et al. found that inadequate knowledge of diabetes is a risk factor for HU in type 2 diabetes Alanazi et al. also found that poor awareness of hypoglycemic attacks was observed among Another local study found that Diabetes education is a crucial key in diabetes management and should be a continuous process to improve blood glucose control, avoid hypoglycemia, and reduce diabetic complications.
In the current study, we found that macrovascular complications of diabetes, specifically previous stroke and ischemic heart disease, are associated with increased risk for HU, whereas diabetic neuropathy and other microvascular complications of diabetes are not.
Contrary to these results, Murata et al. found that stroke had no effect on hypoglycemia awareness, and intriguingly, the presence of microvascular complications of diabetes was associated with less risk for HU The findings from previous studies revealed that a significant number of patients with T1DM and T2DM were reluctant to discuss their hypoglycemia with their healthcare provider HCP.
There could be many reasons for such a dangerous attitude, including implications for employment, fear of losing driving privileges, or concerns that it discloses poor glycemic control to the HCP 15 — In view of these findings along with the great risk of hypoglycemia associated with HU, regular screening for HU is a crucial element of diabetes care.
For insulin-treated patients with HU, they are advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce the risk of future episodes.
However, we used two validated questionnaires commonly used in other studies for assessing HU 7 , 9. A further limitation of our study is that it was conducted only in one area of Saudi Arabia, so it may not be applicable to other Saudi populations.
Despite these limitations, our findings provide valuable insights into HU in KSA. In addition, this study is among the few studies that investigated HU in Saudi Arabian insulin-treated diabetic patients. The study also provides valuable information on the association between HU and diabetes education.
Further research is needed to confirm and extend our results. In addition, interventions to improve HU should also be explored. Despite the advances in insulin formulations and technologies used to control diabetes, HU continues to affect a significant proportion of patients with diabetes on insulin.
Poor diabetes knowledge is a major risk factor for HU. Structured education for effective self-management of diabetes and screening for impaired awareness of hypoglycemia are of utmost importance to improve glycemic control and reduce the risk of hypoglycemia.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. EA conceptualized the idea of the research, and wrote the manuscript. AS was responsible for the literature search and provided research materials. SB collected and organized the data and references and provided logistic support.
AA was responsible for data collection. All authors contributed to the article and approved the submitted version.
We would like to express our deep and sincere gratitude to the medical students who helped with the data collection. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.
Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al.
Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 36 5 — doi: PubMed Abstract CrossRef Full Text Google Scholar. Martín-Timón I, Del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawareness and implications in diabetic patients.
World J Diabetes 6 7 — Al-Agha AE, Alafif M, Abd-Elhameed IA. Glycemic control, complications, and associated autoimmune diseases in children and adolescents with type 1 diabetes in Jeddah, Saudi Arabia.
Saudi Med J 36 1 Hassounah G, Abdullah Aljohani AE, Al Sharhani R, Al Aljoulni M, Robert AA, Al Goudah AH, et al.
Prevalence of impaired awareness of hypoglycemia and its risk factors among patients with type 1 diabetes in Saudi Arabia. Diabetes Metab Syndr 16 1 Bakatselos SO. Hypoglycemia unawareness. Diabetes Res Clin Pract 93 SUPPL. Ahmed B, Khan MN. Hypoglycemia: its effect on patients with diabetes.
World Fam Med 17 9 — CrossRef Full Text Google Scholar. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia.
Diabetes Care 17 7 — People with hypoglycemia unawareness are not able to tell when their blood sugar goes too low and may need help from someone else to treat it — this is also known as a severe low. If you or someone you know has hypoglycemia unawareness, it is important to check blood sugar frequently or wear a continuous glucose monitor CGM.
This is important for critical tasks such as driving. The only CGM that can alert up to an hour before a high or low so that people with diabetes can get ahead of their lows.
The American Diabetes Association Page. Accessed 1SEP 2 The system is intended to complement, not replace, information obtained from standard blood glucose monitoring devices. All therapy adjustments should be based on measurements obtained from standard blood glucose monitoring devices.
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The system is intended to complement, not replace, information obtained from standard blood glucose monitoring devices, and is not recommended for people who are unwilling or unable to perform a minimum of two meter blood glucose tests per day, or for people who are unable or unwilling to maintain contact with their healthcare professional.
The system requires a functioning mobile electronic device with correct settings. If the mobile device is not set up or used correctly, you may not receive sensor glucose information or alerts. Feeling shaky Being nervous or anxious Sweating, chills and clamminess Irritability or impatience Confusion Fast heartbeat.
Tingling or numbness in the lips, tongue, or cheeks Headaches Coordination problems, clumsiness Nightmares or crying out during sleep Seizures. Hypoglycemia unawareness As unpleasant as they may be, these symptoms are useful as they help let you know that action is needed to correct a low blood sugar.
They are also less likely to wake up from an overnight low. Know before you go low If you or someone you know has hypoglycemia unawareness, it is important to check blood sugar frequently or wear a continuous glucose monitor CGM.
A CGM can sound an alarm when blood sugar levels are low or start to fall quickly. This can be a big help for people with hypoglycemia unawareness. What if you knew an hour before going low? Learn more.
: Hypoglycemic unawareness risks| Hypoglycemia-Signs, Symptoms & Treatment |ADA | Hypoglycemic unawareness risks IDs are usually worn as Hypolgycemic bracelet or unawareneds necklace. Glucose Concentrations of Less Than 3. Poor diabetes knowledge is a major risk factor for HU. Discuss the situation openly with your physician to prevent a reoccurrence. This can help you identify and treat hypoglycemia before it gets too low. |
| Common hypoglycemia symptoms | Diabetes Res Clin Pract 65 1 —7. View Large. Hypoglycemia-associated autonomic failure in healthy humans: comparison of two vs three periods of hypoglycemia on hypoglycemia-induced counterregulatory and symptom response 5 days later. Pedersen-Bjergaard U, Pramming S, Heller SR, Wallace TM, Rasmussen ÅK, Jørgensen HV, et al. Speak with your doctor about whether you should buy a glucagon product, and how and when to use it. Hypoglycemia incidence and awareness among insulin-treated patients with diabetes: the HAT study in Brazil. |
| How To Reverse Hypoglycemia Unawareness | Reduce the frequency of your lows Be especially careful to avoid another low for at least two days following a reaction Test blood sugars often to note dropping numbers and treat them before they become lows Set your target blood sugars slightly higher so that you will experience no more than one or two insulin reactions per week Always match your insulin doses to changes in your lifestyle. Wilson JD, Foster DW, Kronenberg HM, Larsen PR. An evaluation of methods of assessing impaired awareness of hypoglycemia in type 1 diabetes. Read our cautionary story. She also mentioned beginning sports activities in the last 6 months [ 1 , 2 , 6 , 8 , 11 ]. Reprints and permissions. |
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