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Impact & impaired awareness

Impact of hypoglycaemia

An episode of severe hypoglycaemia can lead to confusion, loss of consciousness and seizures,7 with a concomitant increase in the risk of falls, injuries, and hospitalisation. Nocturnal hypoglycemia may impair sleep quality and quantity, thus reducing well-being on the following day.8 Fear of hypoglycaemia, in turn, can compromise adherence to medical treatment.9

Recurrent hypoglycaemia has been shown to lower the glucose level that triggers the counterregulatory physiological response, leading to a significantly greater risk of subsequent severe hypoglycaemia.7 [See section on Impaired Awareness of Hypoglycaemia.]

Long-term clinical impact

  • Type 1 diabetes: Data from the DCCT (adult) cohort did not find a link between past episodes of severe hypoglycaemia and decreased cognitive function,7 but children may be at greater risk of hypoglycaemia-related cognitive deficits.10
  • Type 2 diabetes: The ACCORD, ADVANCE and VADT trials found an association between severe hypoglycaemia and subsequent mortality.7 Symptomatic hypoglycaemia (whether mild or severe) has also been linked to an increased risk of cardiovascular events.11

Impaired awareness of hypoglycaemia

Impaired awareness of hypoglycaemia (IAH) is a reduced ability to perceive the onset of hypoglycaemia while cognition is still intact. It affects 20-25% of patients with type 1 diabetes and about 10% of those with insulin-treated type 2 diabetes.6

IAH arises when repeated episodes of hypoglycaemia raise the glycaemic threshold for symptom generation (i.e. symptoms are only triggered at a lower blood glucose level). Symptoms that would make people aware of impending hypoglycaemia, such as sweating or anxiety, no longer occur above the new threshold. A careful clinical history is often sufficient to identify IAH.7

In addition to significantly increasing the risk of severe hypoglycaemia,8 IAH increases people’s reliance on others to manage their diabetes and can even lead to loss of driving privileges and employment. Scrupulous avoidance of hypoglycaemia can reverse IAH, though this strategy runs the risk of compromising glycaemic control.7

References

  1. Edelman SV, Blose JS. the impact of nocturnal hypoglycemia on clinical and cost-related issues in patients with type 1 and type 2 diabetes. Diabetes Educ 2014;40:269.
  2. Schneider G. Exorcising the specter of night-time hypoglycemia. Diabetes self-management. http://www.diabetesselfmanagement.com/managing-diabetes/blood-glucose-management/exorcising-the-specter-of-nighttime-hypoglycemia/
  3. King P et al. Well-being, cerebral function, and physical fatigue after nocturnal hypoglycemia in IDDM. Diabetes Care 1998;21:341.
  4. Walz L et al. Impact of symptomatic hypoglycemia on medication adherence, patient satisfaction with treatment, and glycemic control in patients with type 2 diabetes. Pat Pref Adher 2014;8:593.
  5. Hannonen R et al. Neurocognitive functioning in children with type-1 diabetes with and without episodes of severe hypoglycaemia. Dev Med Child Neurol 2003;45:262.
  6. Hsu et al. Association of Clinical Symptomatic Hypoglycemia With Cardiovascular Events and Total Mortality in Type 2 Diabetes. Diabetes Care 2013; 36: 894.
  7. Cryer PE. Elimination of hypoglycemia from the lives of people affected by diabetes. Diabetes 2011;60:24.
  8. Gold AE et al. Frequency of severe hypoglycemia in patients with type 1 diabetes with impaired awareness of hypoglycemia. Diabetes Care 1994;7:697.

John Borthwick

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