DIABETES MANAGEMENT GUIDELINES

American Diabetes Association (ADA) and The Endocrine Society Consensus Report on Hypoglycemia and Diabetes

New Recommendations!

Source: Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and The Endocrine Society. Diabetes Care. 2013. Epub ahead of print.

Recommendations

Slides

Definition of hypoglycemia in diabetes

Iatrogenic hypoglycemia in patients with diabetes Abnormally low plasma glucose concentration that exposes the patient to potential harm

Glycemic thresholds for symptoms of hypoglycemia can shift As such, a single threshold value for plasma glucose that defines hypoglycemia in diabetes cannot be assigned

Patients taking a sulfonylurea, glinide, or insulin are at risk for hypoglycemia Alert these patients to risk when plasma glucose 70 mg/dL (3.9 mmol/L)

ADA/Endocrine Society: Definition of Hypoglycemia in Diabetes

Classification of hypoglycemia in diabetes

Alert value for hypoglycemia 70 mg/dL (3.9 mmol/L) plasma concentration

Severe hypoglycemia: Requires assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions Plasma glucose concentrations may not be available during an event Neurological recovery following plasma glucose levels returning to normal considered sufficient evidence that event was induced by low plasma glucose concentration

Documented symptomatic hypoglycemia Typical hypoglycemia symptoms accompanied by measured plasma glucose 70 mg/dL (3.9 mmol/L)

Asymptomatic hypoglycemia Not accompanied by typical hypoglycemia symptoms but with measured plasma glucose 70 mg/dL (3.9 mmol/L)

Probable symptomatic hypoglycemia Typical hypoglycemia symptoms not accompanied by plasma glucose determination but likely caused by plasma glucose 70 mg/dL (3.9 mmol/L)

Pseudo-hypoglycemia Reports of typical hypoglycemia symptoms with measured plasma glucose >70 mg/dL (>3.9 mmol/L) but approaching that threshold

ADA/Endocrine Society: Classification of Hypoglycemia in Diabetes

Impact of hypoglycemia on glycemic targets

Individualize targets based on: Age, life expectancy, comorbidities, preferences, assessment of hypoglycemia impact on patients life

Healthy adults with diabetes: Lowest A1C that does not cause severe hypoglycemia Preserves hypoglycemia awareness Results in acceptable number of documented episodes of symptomatic hypoglycemia

Type 1 diabetes:

Achieve glucose levels low enough to prevent hypoglycemia symptoms; strategies that completely avoid hypoglycemia may not be possible Relax goals with advanced complications, limited life expectancy, or long-standing disease

Type 2 diabetes: Risk is related to types of medications used A1C <7.0% may be appropriate for recent-onset type 2 diabetes; less-aggressive goals as disease progresses, or with known CVD, extensive comorbidities, or limited life expectancy

ADA/Endocrine Society: Impact of Hypoglycemia on Glycemic Targets

More on individualization of treatment targets: ADA/EASD Position Statement on Management of Hyperglycemia in Type 2 Diabetes

Strategies for preventing hypoglycemia

Patient education:

Discuss hypoglycemia risk factors and remediation regularly with patients taking insulin or sulfonylurea/glinides Educate patients and domestic companions/caregivers on how to recognize and treat hypoglycemic episodes Educate patients on pharmacokinetics of medications Consider enrolling patients with frequent hypoglycemia in a blood glucose awareness training program Dietary intervention:

Encourage patients on long-acting secretagogues and fixed insulin regimens to follow predictable meal plan; patients on flexible insulin regimens should couple insulin injections with meal times Patients on any hypoglycemia-inducing medication should carry carbohydrates at all times for hypoglycemia treatment Exercise management:

Patients should carefully monitor glucose before and after exercise, and take preemptive actions to prevent or minimize postexertional hypoglycemia Patients should eat pre-exercise snacks if blood glucose levels indicate declining glucose Patients should carry readily absorbable carbohydrates when starting any exercise, including house or yard work For patients with well controlled diabetes and history of exercise-related hypoglycemia, may be appropriate to adjust insulin doses on exercise days Medication adjustment:

Review blood glucose patterns to determine if medication adjustments are needed. Adjustments may include substitution of rapid-acting insulin (lispro, aspart, glulisine) for regular, or basal insulin glargine or detemir for NPH Sulfonylureas have greatest hypoglycemia risk; consider substitution with another class for troublesome hypoglycemia Adjust treatment regimen to avoid frequent hypoglycemia/hypoglycemia unawareness Glucose monitoring:

Patients on insulin, sulfonylureas, glinides: check blood glucose when hypoglycemia symptoms are present to confirm need for ingestion of carbohydrates and collect information for reporting to healthcare provider for adjustment of treatment regimen Patients on basal-bolus insulin: check blood glucose before each meal; figure value into calculation of rapid-acting insulin dose Clinical surveillance:

Patients on insulin, insulin secretagogues: assess hypoglycemia risk at all visits Consider having patient complete hypoglycemia questionnaire and review responses together Ask patients to keep a glucose log, including date, time, and circumstances surrounding hypoglycemic episodes, and review at each visit

ADA/Endocrine Society: Strategies for Prevention of Hypoglycemia (1 of 2)

ADA/Endocrine Society : Strategies for Prevention of Hypoglycemia (2 of 2)

CVD=cardiovascular disease

Related content:

Expert webcast: Burton E. Sobel, MD: Glycemic Control: How Low Should You Go?

Overview: The impact of frequent and unrecognized hypoglycemia on mortality in the ACCORD study

April 2013

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