Hypoglycemia awareness month -
People with diabetes develop hypoglycemia when they do not have enough sugar glucose in their blood, and it may differ from person to person. The condition is common among people with type 1 diabetes and those with type 2 diabetes who take insulin shots or consume other diabetes medicines.
USA , wellness physician and diabetologist, Lyfstyle Wellness. Hypoglycemia is a much bigger problem than hyperglycemia high sugars because the sympathetic nervous system kicks in increasing adrenaline, cortisol, and growth hormones ultimately resulting in increased heart rate, blood pressure, said Dr Dilip Gude, senior consultant physician, and diabetologist, Yashoda hospitals Hyderabad.
This can lead to uncontrolled diabetes at times, mentioned Dr Ashutosh Goyal, senior consultant, endocrinology, Paras Hospitals, Gurgaon. Shakiness Dizziness Sweating Hunger Fast heartbeat Inability to concentrate Confusion Irritability or moodiness Anxiety or nervousness Headache.
Taking too much insulin or consuming an excess of diabetes medications Postponing or skipping a meal or a snack Not eating enough taking in less glucose Doing too much exercise using up glucose without adjusting diabetes medications Drinking alcohol.
As per MayoClinic. org , one can raise their blood sugar quickly by eating or drinking a simple sugar source, such as glucose tablets or fruit juice.
While mild to moderate hypoglycemia can be easily treated, severe hypoglycemia can cause serious complications like passing out, coma, and rarely death, said Dr Shah.
Dr Shah mentioned that people with diabetes should take the following actions to prevent hypoglycemia. Avoiding sulfonylureas, minimising insulin dose per day, switching to safer second-generation basal insulins, gliptins, SGLT2 inhibitors, GLP1R agonists, metformin, alpha-glucosidase inhibitors, etc with optimal diet and exercise will help one minimise their hypoglycemia risk, recommended Dr Gude.
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By preventing hypoglycemia, you can reset the body to respond differently to symptoms of hypoglycemia. Some health care professionals may prefer to use newer basal insulins in patients at risk of hypoglycemia because these insulins seem to have less risk of hypoglycemia than the older ones, but they can still cause hypoglycemia, and we need to be aware of that.
I think that for many people, it is easier to administer mealtime insulin when they have an insulin pump. It is also important to remember that some patients may be afraid to report episodes of hypoglycemia to their doctors because of legal implications. For example, some states may require people with diabetes to not have a hypoglycemia episode for 6 to 12 months before they can drive a vehicle.
Health care professionals should emphasize to patients that they should know what their blood glucose level is before they drive a car, and that they should have food on hand, so if their glucose level drops, they can manage it. Q: What research is being conducted on hypoglycemia unawareness?
A: Researchers are interested in different aspects of hypoglycemia unawareness such as the cause, complications, and treatments. Some groups are studying why recurrent hypoglycemia leads to impaired awareness.
Is it a problem with brain adaptation to hypoglycemia, or is it only a problem with people who have severe glucagon deficiency? Other groups are doing research on the long-term effects of recurrent hypoglycemia on the function of other organs.
I just finished a study where we gave people naloxone during an episode of exercise to determine if they recognize their hypoglycemia the next day, but the study was just completed, so we do not have results yet.
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In such cases, it is necessary to contact the writer, artist, or publisher to obtain permission for reuse. Q: What is hypoglycemia? Q: What is hypoglycemia unawareness, and how common is it? What is your experience managing hypoglycemia unawareness?
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Patient Communication Research Advancements Complications of Diabetes Medication and Monitoring Practice Transformation Diabetes Prevention Patient Self-Management Obesity and Weight Management Social Determinants of Health New Technologies These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH.
Technological interventions insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact.
Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates. This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.
Hypoglycemia remains the major limiting factor toward achieving good glycemic control 1. Recurrent hypoglycemia reduces symptomatic and hormone responses to subsequent hypoglycemia 2 , associated with impaired awareness of hypoglycemia IAH. IAH occurs in up to one-third of adults with type 1 diabetes T1D 3 , 4 , increasing their risk of severe hypoglycemia SH sixfold 3 and contributing to substantial morbidity, with implications for employment 5 , driving 6 , and mortality.
Although small research studies have shown that meticulous avoidance of hypoglycemia can improve awareness of hypoglycemia 9 , achieving this in clinical practice is difficult and hard to sustain. Strategies used include educational approaches, using biopsychosocial or behavioral therapies; technological interventions, such as continuous subcutaneous insulin infusion CSII , continuous glucose monitoring CGM , and sensor-augmented pumps SAP ; and pharmacotherapies.
This systematic review assessed the clinical effectiveness of treatment strategies for restoring hypoglycemia awareness HA and reducing SH risk in those with IAH and performed a meta-analysis, where possible, for different approaches in restoring awareness in T1D adults.
Interventions to restore HA were broadly divided into three categories: educational inclusive of behavioral , technological, and pharmacotherapeutic. A systematic literature search in the databases of The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL was performed from inception until 1 October Additional studies were identified by hand-searching reference lists of included trials and systematic reviews and contacting experts in the field.
Search terms and their synonyms used were type 1 diabetes mellitus, hypoglycemia, low glucose, hypoglycemia unawareness, impaired awareness of hypoglycemia, avoidance of hypoglycemia, and awareness Supplementary Table 1.
The recommendations of the Centre for Reviews and Dissemination for Systematic Reviews 10 were followed. All randomized controlled trials RCTs , nonrandomized controlled trials, and before-and-after studies that assessed interventions to restore HA were included. Case series and case reports were excluded.
Studies must have described HA status at baseline by validated scoring systems such as the Clarke 12 or Gold 13 scores. In studies that did not use these scores, accuracy of blood glucose BG estimate was allowed as a surrogate measure of awareness status.
Islet and pancreas transplantations were excluded because intractable recurrent severe hypoglycemia is a proven indication for these interventions 14 , Two authors E. and M. independently assessed abstracts and titles for eligibility and extracted data, with differences in interpretation resolved by a third reviewer P.
and consensus after discussion. Full texts of studies that fulfilled inclusion criteria were obtained and data extracted using a standardized data extraction table. Relevant missing information was sought from article author s. Interventions were classified into patient education including diabetes education classes, psychological interventions, behavioral therapy ; use of technology CSII, CGM sensors, retrospective or real-time [RT] , and pharmacological therapies insulin analogs and other pharmacological agents.
For studies with more than one intervention e. Outcome measures were categorized into SH rates defined as events requiring external assistance [ 16 ] , restoration of HA Gold [ 13 ] or Clarke [ 12 ] scores , subjective recognition of low BG by participants or improved autonomic or neuroglycopenic symptoms, responses to hypoglycemia assessed by symptom scores 17 , counterregulatory hormone responses, and changes to glycemic control measured by HbA 1c.
To assess the quality of included studies, Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA guidelines were used for RCTs 18 and Meta-analysis of Observational Studies in Epidemiology MOOSE guidelines for observational studies Instead of a score allocated to each study for quality assessment, we assessed the strength of evidences using the four domains suggested by the Agency for Healthcare Research and Quality guidelines 20 : risk of bias, consistency of effect sizes, directness of link between interventions and outcomes, and precision or the certainty of effect in relation to a specific outcome.
Additional Agency for Healthcare Research and Quality domains include assessment of a dose-response association, existence of confounders, strength of association, and publication bias. The first three of these are more relevant to observational studies than RCTs. The strength of evidence was based on a global assessment of all of these domains and studies graded as high, moderate, low, or insufficient.
A study was considered of high quality if it was a well-conducted RCT, prospective, with a low risk of bias, and accounted for confounders such as age and diabetes duration. If interventions studied had sufficient data, MedCalc software was used to perform a meta-analysis pooling the standardized mean difference SMD.
If studies did not directly report the mean and SD for change from baseline to 12 months for the outcomes of interest, these were calculated. Where outcomes were measured on different scales, SMDs were combined, where possible. Studies reporting outcomes in a measure that was not suitable for inclusion into the meta-analysis are presented as a summary of findings and analyzed in a narrative synthesis.
In the meta-analysis, heterogeneity was assessed using the I 2 statistic. Effect sizes were pooled by using fixed-effects and random-effects models. The two models used different assumptions.
The former assumes there is one true effect size that is shared by all of the included studies, and the latter, by contrast, assumes that the true effect could vary from study to study.
The database search identified 1, abstracts until 1 October Fig. Review of titles and abstracts identified 57 full-text articles meeting the inclusion criteria. A further two articles were retrieved from reference lists of included articles, of which one met inclusion criteria.
Forty-three studies were included in the final systematic review, summarized in Table 1. CG, control group; GH, growth hormone; HU, hypoglycemic-unaware; IG, intervention group; NS, not significant; OR, odds ratio.
Patient education was the primary intervention in 27 included studies 8 RCTs ; 11 6 RCTs were based on technology, and 5 all RCTs examined pharmacotherapeutics.
In four studies combining multiple interventions e. Studies with long-term follow-up or different outcomes were analyzed separately.
Thirteen studies were conducted in North America and Canada, 10 in the U. This represented the largest intervention group: 27 relevant studies used an educational approach to restore HA.
There were 20 studies in this category: 8 in unselected populations with T1D 4 , 21 — 27 and 12 in participants with IAH at baseline 9 , 28 — Eight studies 22 , 23 , 24 , 26 , 29 , 30 , 33 , 34 were long-term, durations ranging between 1 and 3 years.
In unselected populations with T1D, some educational programs were based on well-established structured education in insulin self-management, such as the German Diabetes Treatment and Training Program DTTP , designed in Dusseldorf 39 and adopted elsewhere in Germany 25 ; Dose Adjustment For Normal Eating DAFNE 21 ; and the Tayside insulin management course 4 , an adaptation from Bournemouth type 1 intensive education BERTIE , whereas others were based on psychoeducational programs, such as Blood Glucose Awareness Training BGAT 22 — 24 , 26 , delivered in individual or group settings.
BGAT showed improved ability and accuracy index in recognizing symptoms of low BG The DAFNE 21 and Tayside 4 studies were large-scale registry data with more than 1, patients, followed up for a year, showing generalizability of the interventions. One year after DAFNE, the rate of IAH had fallen from Glycemic control improved or was maintained at target level, uninfluenced by the method of delivery of the structured education individual or group setting.
Only one study assessed effect of education on counterregulatory hormone responses 27 , comparing hypoglycemia rates in intensively treated defined as CSII therapy or multiple daily insulin [MDI] injections, 4—7 BG tests, and weekly contact with the treatment team against conventional insulin therapy defined as twice-daily insulin injections, 1 to 2 daily BG tests, and monthly clinic visits, in five subjects, four being switched to CSII.
This showed that intensive therapy was associated with improved HbA 1c but resulted in a reduction in epinephrine and symptom responses to experimental hypoglycemia, neither of which was fully restored on return to conventional therapy, despite worsening of HbA 1c.
Follow-up was 3—12 months, with longer-term follow-up data of 18 months 29 and 3 years 33 was available for two studies.
Although autonomic and neuroglycopenic symptom scores improved to levels seen in control subjects without diabetes, counterregulatory hormone responses did not improve in two of seven studies 32 , Dagogo-Jack et al.
Reversal of hypoglycemia unawareness was sustained beyond the period of active intervention despite no regular contact with participants, suggesting that skills acquired under supervision for hypoglycemia prevention may become ingrained.
In three studies 32 , 34 , 36 , improvement in HA was at the expense of worsened glycemic control, with HbA 1c rising significantly to suboptimal values, whereas it remained within therapeutic targets in two 35 , 37 and showed no significant change in one 9.
Four of 12 studies with baseline IAH used a psychoeducational approach to restore awareness 28 — BGAT, based on work by Cox et al. The DAFNE-Hypoglycemia Awareness Restoration Training HART pilot study 28 incorporates motivational interviewing and cognitive behavioral therapies to address behavioral issues found to promote and sustain IAH All of these approaches successfully reduced SH and improved awareness.
Although the BGAT studies did not report any prior structured education, the DAFNE-HART program, in particular, recruited people with very high rates of SH, despite having had structured education, and demonstrated success of psychotherapeutic approaches in these people without deterioration in glycemic control.
Neither study assessed counterregulatory hormone responses. Of seven education RCTs 42 — 48 , four recruited unselected patients [BGAT 45 , 47 , 48 and Program for Diabetes Education and Treatment for a Self-Determined Living With Type 1 Diabetes PRIMAS 42 ] and three recruited those with IAH [HyPOS 43 , 44 and Hypoglycemia Anticipation, Awareness and Treatment Training HAATT 46 ].
The longest follow-up was 4. In the U. These studies did not report baseline SH rates 47 , 48 and people with SH in the preceding 2 years of the study were excluded from the Kinsley et al. A head-to-head comparison between PRIMAS 42 , a new German education program with additional aspects of goal-setting, motivation, and greater hypoglycemia focus, against the well-established DTTP 39 showed equivalent reductions in SH in both intervention and control groups.
These differences can be attributed to the different comparator arms: the PRIMAS study 42 , in particular, compared the new educational method with the DTTP, a well-established program Of note, the DTTP structured education program on flexible insulin therapy includes education on hypoglycemia avoidance.
Their principles were adapted into several of the programs included in this analysis. Counterregulatory hormones to hypoglycemia were only measured in one study, with improved epinephrine response to hypoglycemia in the BGAT group despite no between-group differences in hypoglycemia symptom scores Glycemic control improved in the U.
PRIMAS showed improvement in HbA 1c only in the intervention arm Three studies specifically recruited participants with IAH: HyPOS 43 , 44 and HAATT Similar to PRIMAS, HyPOS compared a biopsychosocial education program with a standard education program, specifically in patients with previous SH.
Both groups showed similar reductions in SH at 6 months, but the reduction in SH in the HyPOS group was greater compared with the control group in long-term 2.
There was no difference in long-term glycemic control. The HAATT study compared a psychoeducational program to self-monitoring of blood glucose SMBG in Bulgaria, where SMBG was not routinely available. This study showed a reduction in SH and improved detection of low BG in the intervention group despite no significant change in HbA 1c between the two groups, implying that the psychoeducational component of the study was vital in reducing SH and improving awareness Of five studies that used technology as the primary intervention, two evaluated CSII 52 , 53 and three RT-CGM prospectively 54 and retrospectively 55 , Four of these studies recruited people with SH and IAH at baseline and showed significant reductions in SH postintervention 52 , 54 — In contrast, an earlier study by Hübinger et al.
In Giménez et al. There was improvement in Clarke score for HA, with participants scoring similarly after treatment to controls without IAH, with no deterioration in glycemic control.
The other study 54 showed improvement in hypoglycemia awareness but used a different score, the HYPO-score Six RCTs evaluated technology as the primary intervention 58 — All except one 62 included IAH or prior episodes of SH in their inclusion criteria. Kovatchev et al.
SH was defined according to American Diabetes Association definitions 16 except in the Ly et al. Baseline assessments of HA status were performed using Clarke 58 , 60 or Gold scores 59 , 63 except in Kanc et al.
The Comparison of Optimised MDI versus Pumps with or without Sensors in Severe hypoglycaemia HypoCOMPaSS trial 59 , 63 and Thomas et al. Both studies included a high degree of support and education from the researchers.
Ly et al. In studies that provided structured education or feedback in addition to technology to all participants, SH was reduced and HA status improved in all intervention arms, with technology CSII or RT-CGM having no additional benefit 59 , 60 , In the adults from Ly et al. Despite greater frequency of visits compared with routine care, the follow-up of the participants in all of these studies did not differ between arms.
Use of the HHC and predictive data were associated with reduction in SH, greater in those with hypoglycemia unawareness at baseline, with an increase in the BG estimation accuracy index. Of studies conducting hyperinsulinemic-hypoglycemic clamps, one showed an increase in plasma metanephrine responses to hypoglycemia 59 , and two showed no significant differences in hormone responses 58 , In all studies comparing CSII with insulin analog therapy, there was no deterioration or differences in glycemic control in any of the intervention arms when compared with control despite reductions in SH and improvements in HA status.
In the Kovatchev et al. Five studies were identified, all of which were conducted more than 10 years ago. Four studies compared short-acting and long-acting analog insulin against conventional soluble SI or NPH insulin 64 — One noninsulin study was identified, investigating propranolol to restore HA There was no mention of any change in education between the arms.
SH did not occur in three of these studies 64 , 66 , 68 ; two had no statistically significant change in SH rates between study arms 65 , There was no consistent finding in changes in hypoglycemia symptom scores during hypoglycemic clamp studies between comparator arms in the insulin studies 64 — The study on propranolol reported increased sweating during hypoglycemia with propranolol There was, however, a higher peak plasma epinephrine response when NPH was delivered separately at bedtime compared with a combined SI and NPH with dinner Counterregulatory hormones were not measured in the remaining two studies 65 , There were no significant changes in glycemic control in the three lispro studies 64 , 65 , HbA 1c was lower at the end of the treatment period in the split-NPH dosing Changes in HbA 1c were not reported in the propranolol study, which lasted only 1 month.
A meta-analysis for educational interventions on change in mean SH rates per person per year was performed. We evaluated the active interventions used in the RCTs as individual before-and-after trials, because all included some educational component, a structured curriculum, and information around causes and prevention of hypoglycemia.
For Schachinger et al. Forest plot of meta-analysis of SMDs in SH rates per person per year in each study and the overall pooled estimate.
The horizontal lines represent the SMD. The size of box is proportional to the weight of that study. The diamond indicates the weighted mean difference, and the lateral tips of the diamond indicate the associated SMD.
A random-effects meta-analysis revealed an effect size of a reduction in SH rates of 0. From the RCT studies Hermanns et al. Heterogeneity between studies was significant, with I 2 statistic of Most of the educational interventions were observational and mostly retrospective, with few RCTs.
The overall risk of bias is considered medium to high and the study quality moderate. Most, if not all, of the RCTs did not use double blinding and lacked information on concealment. The strength of association of the effect of educational interventions is moderate. The ability of educational interventions to restore IAH and reduce SH is consistent and direct with educational interventions showing a largely positive outcome.
There is substantial heterogeneity between studies, and the estimate is imprecise, as reflected by the large CIs. The strength of evidence is moderate to high. There were approximately equal numbers of observational and RCTs of technological interventions.
These trials were well conducted, with two RCTs of almost patients selected for hypoglycemia unawareness. The overall risk of bias was considered low to medium, with moderate study quality.
Double blinding was not possible, and there was lack of information on concealment in the RCTs. Combining all of these studies into a single meta-analysis was not appropriate because CSII, RT-CGM, and SAP are all different categories of technological interventions, with variable reporting of outcomes in each category.
Furthermore, provision of education at baseline provides a degree of confounding. In CGM studies, the ability of CGM to reduce SH is consistent and direct, with all included studies showing a positive outcome and reduction in SH rates. The strength of evidence is thus moderate to high. However, the ability to improve or restore hypoglycemia unawareness is uncertain and the strength of evidence is low.
The strength of evidence for the ability of CSII to reduce SH and restore hypoglycemia awareness is moderate to high, with a generally positive effect of CSII. However, when patients were provided education and optimized MDI therapy, CSII appeared not to provide any additional benefit.
All of the pharmacological intervention studies were RCTs. Lack of information on concealment was present, but the overall risk of bias was considered low to medium and the study quality was high.
However, the strength of evidence for insulin analogs to reduce SH was low because SH was an exclusion criterion for many of the included studies.
The strength of evidence of insulin analogs to restore hypoglycemia awareness was low, with no consistent outcome seen. To our knowledge, this study represents the first systematic review and meta-analysis of the different interventions available for reversing IAH in T1D and includes a comprehensive and expansive literature search.
Despite this, there are still limitations. A large proportion of studies did not report the type of diabetes education subjects received before the study intervention, and it is possible that a proportion of patients would have received previous structured education and that some may have had ongoing education given the duration of diabetes in most studies.
Another limitation is study heterogeneity and the inconsistent reporting of outcome measures, in particular, in SH rates and measures of HA status, in noneducation studies, preventing a more comprehensive meta-analysis.
SH rates were reported as mean SD , median interquartile range [IQR] , odds ratios, and proportion of subjects with reduced SH. HA was reported as Gold and Clarke scores, and BG estimation accuracy and the proportion of subjects who had improved awareness was often subjectively assessed.
Some studies reported a modified Gold score with a score from 0 to 10 on a visual analog scale. In studies reporting Gold and Clarke scores, we used Clarke scores as the main reporting outcome.
In studies that reported Gold scores only, we grouped the outcomes, because Gold and Clarke scores have been shown to be well correlated Even so, it was not possible to perform a meta-analysis due to study heterogeneity.
In an unselected population with no prior diabetes education, structured education or BGAT can reduce SH and improve glycemic control. There is early evidence that such programs can also achieve these outcomes when provided as reeducation some years after the initial exposure In patients with established IAH, BGAT and other psychotherapeutic programs, such as HyPOS and HAATT, are also effective.
There was no difference between structured education programs in flexible insulin therapy and programs with a psychological approach when compared head to head, and this may be because in teaching users the basics of insulin pharmacodynamics and how to adjust their insulin regimens around their lifestyles to achieve glucose targets that exclude hypoglycemia, hypoglycemia exposure is lessened.
There is perhaps a need to seek the common factors in successful programs to distill the essential elements of any new programs. Meanwhile, DAFNE-HART had a much higher baseline level of SH than any of the other studies and was the only study that took people who were IAH despite prior education.
Although a small nonrandomized study, it demonstrated that a psychobehavioral therapeutic approach can have a sustained effect on SH and nonsevere hypoglycemic episodes in people whose IAH seems resistant to other interventions Thus, in unselected populations with T1D, structured education in flexible insulin usage reduces SH and may reduce the proportion of people with IAH and SH.
In those with IAH, further education or BGAT reduces SH, with the greatest reductions seen in programs with a behavioral component.
CSII can reduce SH with greater reductions in those with greater SH at baseline 52 , although there was evidence that in an unselected population, CSII and improved control may cause some deterioration of awareness In observational studies, CGM showed a reduction in SH, even in those who remained in IAH despite education and CSII A RCT of LGS compared with CSII in young people with IAH showed improved awareness and reduced SH with LGS-enabled SAP Most studies with technology, such as CSII or CGM, were done in patients who had received prior education.
Thus, in people with IAH despite prior education, CSII, CGM, and, in particular, sensor-augmented pump therapy with LGS provide additional benefits. The HypoCOMPaSS study 63 is in keeping with earlier studies by Cranston et al. HypoCOMPaSS clearly illustrates the value of a holistic approach to the management of people with IAH, using structured education as a core foundation combined with optimized MDI and the use of CSII in selected individuals, to provide far greater advantages than one intervention alone.
We thus propose a stepped-care algorithm that may guide the health care professional in choosing the appropriate intervention when faced with a person with IAH Fig. We would argue that step one—provision of structured education in flexible insulin therapy—should be available to any person with T1D but that additional resources for individuals with higher care needs may be focused in centers where the more intensive interventions combining psychoeducational and technological interventions are available, to which people with IAH and SH posteducation can be referred.
Proposed algorithm for the selection of interventions in patients with IAH and SH. The gray shading indicates recommendation based on expert opinion, with as yet no completed evidence. For future research, we would recommend that outcome measures such as SH rates and HA scores should be reported in a standardized manner to allow future systematic reviews and meta-analyses.
Because incidence and prevalence of SH rates are not normally distributed, the median IQR SH rate may be more appropriate than the mean SD commonly used. Measures of assessment of HA should also be standardized using Gold or Clarke scores because these have been shown to correlate well with clinical and clamp findings and each other.
The proportion of patients with baseline IAH and then improved awareness should be reported as well as Gold or Clarke scores and their change. Future research may be needed to compare structured education, possibly using psychotherapeutic techniques, and optimized MDI using insulin analogs, with comparisons against new diabetes technologies such as LGS-enabled SAP.
Psychotherapeutic techniques may provide additional benefit, in particular in improving HA status, and large RCTs using this approach should be conducted. Use of technology in diabetes, either better warning systems through CGM or through improved insulin delivery via CSII, can reduce SH rates and improve HA without worsening glycemic control, but without restoring counterregulatory hormone responses.
A stepped approach is recommended in the management of people with IAH. The authors thank the authors of the original cited studies who were contacted for sharing the information required from their studies. received fellowship funding as part of the Health Manpower Development Plan award from Khoo Teck Puat Hospital, Alexandra Health Pte, Ltd.
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It can be common in people with diabetes, especially those taking insulin or sulfonylureas. Gvoke HypoPen® is a ready-to-use glucagon rescue pen that you can count on to bring very low blood sugar back up quickly and safely.
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Time for a Diabetes Toolkit Refresh If you take insulin or sulfonylureas, your toolkit should include ready-to-use glucagon, you should carry it at all times, and know when and how to use it. References: McCall AL, Lieb DC, Gianchandani R, et al.
Management of individuals with diabetes at high risk for hypoglycemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes [published correction appears in Diabetes Care.
Looking for easy to read information for your patients to help them manage their diabetes? Self-Care for People with Diabetes. Low Blood Sugar Hypoglycemia. Foot Care for People with Diabetes. Diabetes Canada offers tools, resources and information for health-care providers and Canadians affected by diabetes:.
Diabetes Awareness Month Currently, one in three Canadians have diabetes or prediabetes. Nafisa Merali, B. Pharm , CDE Vancouver, BC Meet Nafisa. Esmond Wong, RPh, CDE, APA Calgary, AB Meet Esmond.
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