From the Guidelines
Autonomic instability and recurrent hypoglycemia can be caused by impaired glucose counterregulation, hormonal deficiencies, and certain medical conditions such as diabetic neuropathy and hypothyroidism 1.
Key Factors Contributing to Autonomic Instability and Recurrent Hypoglycemia
- Medications: Certain medications like beta-blockers and alpha-2 adrenergic agonists can impair the body's ability to respond to hypoglycemia 1.
- Long-acting insulin analogues and sulfonylureas: These can increase the risk of hypoglycemia, particularly when used in combination with other glucose-lowering agents 1.
- Hypoglycemia unawareness: This condition, characterized by deficient counterregulatory hormone release and a diminished autonomic response, can severely compromise stringent diabetes control and quality of life 1.
- Age and disease duration: Older adults and those with long-standing diabetes are more vulnerable to hypoglycemia due to reduced ability to recognize hypoglycemic symptoms and effectively communicate their needs 1.
- Social and economic factors: Food insecurity, low annual household incomes, and being underinsured or homeless can increase the risk of hypoglycemia-related emergency department visits and hospitalizations 1.
- Cognitive impairment: This has a strong bi-directional association with hypoglycemia, and recurrent severe hypoglycemic episodes can lead to a greater decline in psychomotor and mental efficiency 1.
Management and Prevention
To manage and prevent autonomic instability and recurrent hypoglycemia, it is essential to:
- Individualize glycemic goals: Set targets based on the patient's specific needs and circumstances 1.
- Monitor glucose levels: Regularly check blood glucose levels to detect hypoglycemia early 1.
- Adjust medications: Modify medication regimens as needed to minimize the risk of hypoglycemia 1.
- Provide patient education: Teach patients to recognize hypoglycemic symptoms, balance insulin use and carbohydrate intake, and exercise safely 1.
From the FDA Drug Label
The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal Other factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to concomitant drugs Patients with renal or hepatic impairment may be at higher risk of hypoglycemia
The causes of autonomic instability are not directly addressed in the provided drug labels. The causes of recurrent hypoglycemia include:
- Changes in meal pattern
- Changes in level of physical activity
- Changes to concomitant drugs
- Renal or hepatic impairment
- Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis
- Sudden change in the injection site (to unaffected area)
- Duration of action of the insulin 2
From the Research
Causes of Autonomic Instability and Recurrent Hypoglycemia
- Autonomic instability and recurrent hypoglycemia can be caused by various factors, including:
- Opioid receptor activation, which can impair hypoglycemic counterregulation in humans 3
- Intensive glycemic control, which can lead to hypoglycemia-associated autonomic failure (HAAF) 3
- Cardiac autonomic neuropathy (CAN), which is associated with an increased risk of severe hypoglycemia in individuals with type 2 diabetes 4
- Insulin antibodies, which can cause hypoglycemia in rare cases of type 1 diabetes mellitus 5
- Imbalance between food intake and insulin injections, which is a common cause of hypoglycemia in patients with diabetes mellitus 6
Risk Factors for Recurrent Hypoglycemia
- Certain factors can increase the risk of recurrent hypoglycemia, including: