From the Guidelines
Repeated hypoglycemia is a major cause of hypoglycemia unawareness, a condition where the body stops producing warning symptoms of low blood sugar, and can lead to severe hypoglycemia, cognitive impairment, and even death. When a person experiences frequent episodes of hypoglycemia, their body adapts by reducing the threshold at which counterregulatory hormones (like adrenaline and glucagon) are released, and the brain becomes less sensitive to low glucose levels 1. This adaptation means patients no longer experience typical warning signs such as shakiness, sweating, or hunger when their blood sugar drops, putting them at risk for severe hypoglycemia, seizures, loss of consciousness, or even death.
Some of the key factors that contribute to repeated hypoglycemia include:
- Older age
- Multimorbidity
- Cognitive impairment
- Chronic kidney disease and end-stage kidney disease
- Cardiovascular disease (CVD)
- Depression
- Neuropathy
- Female sex
- Food insecurity
- Low annual household incomes
- Socioeconomic deprivation
- Lack of insurance or being underinsured
- Homelessness
Additionally, certain populations are particularly vulnerable to hypoglycemia, including:
- Young children with type 1 diabetes
- The elderly, including those with type 1 and type 2 diabetes
- Individuals with reduced ability to recognize hypoglycemic symptoms and effectively communicate their needs
To prevent repeated hypoglycemia, it is essential to individualize glycemic goals, provide patient education, and implement nutrition intervention, physical activity management, medication adjustment, glucose monitoring, and routine clinical surveillance 1. Furthermore, cognitive function should be routinely assessed among older adults with diabetes, and clinicians should be aware of cultural practices that may influence glycemic management. By taking a comprehensive approach to managing diabetes and preventing hypoglycemia, clinicians can help reduce the risk of hypoglycemia unawareness, cognitive impairment, and other complications associated with repeated hypoglycemia.
From the FDA Drug Label
Hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy expenditure, or both. The time of occurrence of hypoglycemia depends on the action profile of the insulins used and may, therefore, change when the treatment regimen or timing of dosing is changed In patients being switched from other intermediate or long-acting insulin preparations to once- or twice-daily LEVEMIR, dosages can be prescribed on a unit-to-unit basis; however, as with all insulin preparations, dose and timing of administration may need to be adjusted to reduce the risk of hypoglycemia Patients must be instructed on handling of special situations such as intercurrent conditions (illness, stress, or emotional disturbances), an inadequate or skipped insulin dose, inadvertent administration of an increased insulin dose, inadequate food intake, or skipped meals.
The causes of repeated hypoglycemia (low blood sugar) include:
- Excess insulin: relative to food intake or energy expenditure
- Changes in treatment regimen: switching from other intermediate or long-acting insulin preparations
- Inadequate or skipped insulin dose
- Inadvertent administration of an increased insulin dose
- Inadequate food intake
- Skipped meals
- Intercurrent conditions: such as illness, stress, or emotional disturbances 2, 2, 2
From the Research
Causes of Repeated Hypoglycemia
- Some therapies for diabetes, such as insulins and insulin secretagogues (including glinides and sulfonylureas), increase the risk of hypoglycemia 3
- Uncritical prescription of sulfonylureas, neglecting crucial contraindications (particularly renal insufficiency), and deficiencies in diabetes care contribute to the risk of severe hypoglycemia 4
- Repeated insulin-induced hypoglycemic episodes can lead to weight gain, even in the absence of diabetes, due to a multifaceted deficit in metabolic regulation rather than increased caloric intake 5
- Hypoglycemia is a limiting factor for achieving ambitious glucose targets, and its management is crucial in the treatment of diabetes mellitus 6
- While not a direct cause of hypoglycemia, diabetic ketoacidosis (DKA) is a related complication of diabetes that requires prompt management, and its prevention is closely tied to the management of hypoglycemia and overall diabetes care 7
Risk Factors for Repeated Hypoglycemia
- Type 1 diabetes and insulin-treated type 2 diabetes increase the risk of hypoglycemia 3
- Geriatric patients with type 2 diabetes are at higher risk of severe hypoglycemia due to factors such as renal insufficiency and polypharmacy 4
- Intensified therapy to achieve glycaemic targets can increase the risk of hypoglycemia, particularly in patients with a history of severe hypoglycemia 3