Author: Sparticus

Diabetologists and endocrinologists always used to insist that patients achieve excellent glucose control while avoiding hypoglycemic episodes, but research has now established that those two goals are incompatible for most patients, since intensive glucose control triples the number of instances of severe hypoglycemia, with ‘severe hypoglycemia’ being defined as hypoglycemia so incapacitating that it requires help from by-standers — if there happen to be any. Good blood sugar control sets up a vicious cycle, since intensively controlled patients become less able to detect hypoglycemia and can fall much deeper into hypoglycemia before recognizing its symptoms. (V. Briscoe and S. Davis, "Hypoglycemia in type 1 and type 2 diabetes," Clinical Diabetes, vol. 24, no. 3, p. 115 (2006)) For young children, there is a 60% increase in the risk of hypoglycemia per 10% decrease in the HbA1c value. (H. Chase, "Glycemic control in the prepubertal years," Diabetes Care, vol. 26, p. 1304 (2003))

Hypoglycemia is often difficult to detect and to correct, since 55% of all hypoglycemic episodes in intensively controlled diabetics were found to occur during sleep, while 21% of hypoglycemic events could not be explained. ("Epidemiology of severe hypoglycemia in the DCCT," American Journal of Medicine, vol. 92, no. 3, p. 339 (1992); S. Turpik, et al, "Severe hypoglycemia in children and adolescents during multiple dose therapy," Diabetes Medicine, vol. 15, no. 8, p. 695 (1998))

With the increased emphasis on intensive control of blood sugar levels, there has been a correspondingly increased number of admissions to hospital to treat severe hypoglycemia. From the period 1990-1993, before strict control was very widely practised, to the period 1997-2000, when it was standard practice, the number of diabetics hospitalized for hypoglycemia increased by 50%. (M. Asuncion, et al, "Increase in hypoglycemia admissions," Ethnicity and Diabetes, vol. 17, no. 3, p. 536 (2007) From 1989 to 1991, there were an average of 48,500 hospitalizations per year for diabetic hypoglycemia in the U.S., or about one hospitalization per 30 type 1 diabetics. (H. Fischbein and P. Palumbo, ‘Acute Metabolic Complications in Diabetes, ch. 13 (Bethesda: National Diabetes Data Group, 2nd edition, 1995))

Hypoglycemia has several serious effects on the diabetic, the most obvious being its cost in terms of social disruption and the fear and uncertainty of future episodes. (S. Nordfeldt and J. Ludvigsson, "Fear and other disturbances of severe hypoglycemia," Journal of Pediatric Endocrinology and Metabolism, vol. 18, no. 1, p. 83 (2003)) Hypoglycemia can precipitate as well as worsen neuropathy in diabetics, and if excessive amounts of insulin are taken to achieve good glucose control, this can itself lead to microangiopathy. (K. Sugimoto, et al, "Peripheral neuropathy and microangiopathy," Diabetes and Metabolism Research Review, vol. 19, no. 5, p. 392 (2003)) Even frequent but moderate hypoglycemia can damage the peripheral as well as the central nervous system. (M. Wysocka-Micewicz, et al, "Impact of hypoglycemic episodes on nerve conduction," Endokrynolgia Diabetologia Choroby Prezemiany, vol. 13, no. 1, p. 17 (2007) [summary in English] Brain damage can also result from diabetic hypoglycemia, and even a single episode of severe hypoglycemia in an old type 2 diabetic can increase the risk of dementia by 26%. (M. Figola, et al, "Specific changes in human brain after hypoglycemic injury," Stroke, vol. 28, p. 584 (1997); R. Whitmer, et al, "Hypoglycemic episodes and risk of dementia," Journal of the American Medical Association, vol. 301, no. 15, p. 1565 (2009))

The worst risk of diabetic hypoglycemia is death, and the U.S. Department of Health and Human Services ("Hypoglycemia in Patients with Tpe 1 Diabetes," August 14, 2003, RFA-DK-03-017) has determined that 2% to 4% of all diabetic deaths are caused by hypoglycemia.