Managing diabetes patients at high risk for hypoglycemia: Endocrine Society guidelines
USA: Advances in medications and technology should be leveraged to reduce the risk for hypoglycemia for people with diabetes, according to a clinical practice guideline issued by the Endocrine Society and published online December 7 in the Journal of Clinical Endocrinology & Metabolism.
The article reports Endocrine Society's clinical practice guideline on management of individuals with diabetes at high risk for hypoglycemia.
Patients with diabetes commonly face the problem of hyperglycemia, especially it occurs in those taking medications such as sulfonylureas (SU) and insulin that place them at elevated risk. Hypoglycemia is linked with distress in those with distress in people affected by diabetes and ther families, disruption of work and life, and medication nonadherence, and leads to costly ED (emergency department) visits and hospitalizations, mortality and morbidity.
Anthony L McCall, University of Virginia, Charlottesville, VA, USA, and colleagues reviewed and updated the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and addressed developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.
The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to assess the certainty of evidence and develop recommendations. A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes for which 10 recommendations were made. The recommendations are given below:
Recommendation 1
Continuous glucose monitoring (CGM) rather than self-monitoring of blood glucose (SMBG) by fingerstick is recommended for patients with type 1 diabetes (T1D) receiving multiple daily injections (MDIs).
Recommendation 2
The panel suggests real-time CGM and algorithm-driven insulin pumps (ADIPs) rather than multiple daily injections (MDIs) with self-monitoring of blood glucose three or more times daily for adults and children with type 1 diabetes (T1D).
Recommendation 3
The panel suggest the use of real-time continuous glucose monitoring rather than no CGM for outpatients with type 2 diabetes (T2D) who take insulin and/or sulfonylureas (SUs) and are at risk for hypoglycemia.
Recommendation 4
Initiation of continous glucose monitoring is suggested in the inpatient setting for select inpatients at high risk for hypoglycemia.
Recommendation 5
The panel suggests continuation of personal continuous glucose monitoring in the inpatient setting with or without algorithm-driven insulin pump (ADIP) therapy rather than discontinuation.
Recommendation 6
The panel recommends inpatient glycemic surveillance and management programs leveraging electronic health record (EHR) data be used for inpatients at risk for hypoglycemia.
Recommendation 7
The use of long-acting insulin analogs is suggested rather than human neutral protamine Hagedorn (NPH) insulin for adult and pediatric outpatients on basal insulin therapy who are at high risk for hypoglycemia.
Recommendation 8
The panel suggests the use of rapid-acting insulin analogs rather than regular (short-acting) human insulins for adult and pediatric patients on basal-bolus insulin therapy who are at high risk for hypoglycemia.
Recommendation 9
The panel recommends a structured program of patient education over unstructured advice be used for adult and pediatric outpatients with type 1 diabetes (T1D) or type 2 diabetes (T2D) receiving insulin therapy.
Recommendation 10
The panel recommends that glucagon preparations that do not have to be reconstituted over glucagon preparations that do have to be reconstituted (ie, available as a powder and diluent) be used for outpatients with severe hypoglycemia.
"These recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes," the authors wrote. "These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes."
Reference:
Anthony L McCall, David C Lieb, Roma Gianchandani, Heidemarie MacMaster, Gregory A Maynard, M Hassan Murad, Elizabeth Seaquist, Joseph I Wolfsdorf, Robin Fein Wright, Wojtek Wiercioch, Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, 2022;, dgac596, https://doi.org/10.1210/clinem/dgac596
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