Hypoglycemia in type 2 diabetes: a critical review

Type 2 diabetes patients' views on prevention of hypoglycaemia - a mixed methods study investigating self-management issues and self-identified causes of hypoglycaemia

Background

Hypoglycaemia is a common and potentially avoidable adverse event in people with type 2 diabetes (T2D). It can reduce quality of life, increase healthcare costs, and reduce treatment success. We investigated self-management issues associated with hypoglycaemia and self-identified causes of hypoglycaemia in these patients.

Methods

In this mixed methods study qualitative semi-structured interviews were performed, which informed a subsequent quantitative survey in T2D patients. All interviews were audio recorded, transcribed verbatim and coded independently by two coders using directed content analysis, guided by the Theoretical Domains Framework. Descriptive statistics were used to quantify the self-management issues and causes of hypoglycaemia collected in the survey for the respondents that had experienced at least one hypoglycaemic event in the past.

Results

Sixteen participants were interviewed, aged 59–84 years. Participants perceived difficulties in managing deviations from routine, and they sometimes lacked procedural knowledge to adjust medication, nutrition or physical activity to manage their glucose levels. Grief and loss of support due to the loss of a partner interfered with self-management and lead to hypoglycaemic events. Work ethic lead some participant to overexerting themselves, which in turn lead to hypoglycaemic events. The participants had difficulties preventing hypoglycaemic events, because they did not know the cause, suffered from impaired hypoglycaemia awareness and/or did not want to regularly measure their blood glucose. When they did recognise a cause, they identified issues with nutrition, physical activity, stress or medication. In total, 40% of respondents reported regular stress as an issue, 24% reported that they regularly overestimated their physical abilities, and 22% indicated they did not always know how to adjust their medication. Around 16% of patients could not always remember whether they took their medication, and 42% always took their medication at regular times. Among the 83 respondents with at least one hypoglycaemic event, common causes for hypoglycaemia mentioned were related to physical activity (67%), low food intake (52%), deviations from routine (35%) and emotional burden (28%). Accidental overuse of medication was reported by 10%.

Conclusion

People with T2D experience various issues with self-managing their glucose levels. This study underlines the importance of daily routine and being able to adjust medication in relation to more physical activity or less food intake as well as the ability to reduce and manage stress to prevent hypoglycaemic events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01466-0.

Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study

AIM

To determine the incidence of severe hypoglycaemia and its predictors in community-based patients with type 2 diabetes studied between 2008 and 2013 compared with those in a cohort of patients with type 2 diabetes from the same geographical area assessed a decade earlier.

METHODS

We studied 1551 participants (mean age 65.7 years, 51.9% men) with type 2 diabetes from the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). Severe hypoglycaemia was ascertained as that requiring ambulance attendance, emergency department services and/or hospitalization. Cox proportional hazards modelling was used to determine predictors of a first episode of severe hypoglycaemia, and negative binomial regression was used to identify predictors of frequency.

RESULTS

Sixty-three participants (4.1%) experienced 83 episodes, representing an incidence of 1.34/100 participant-years (95% confidence interval [CI] 1.08 to 1.67; vs 1.67/100 participant-years [95% CI 1.31-2.13] in the Fremantle Diabetes Study Phase I [FDS1]; P = 0.18). Those experiencing severe hypoglycaemia experienced one to four episodes in both cohorts. The independent predictors of incident severe hypoglycaemia in the FDS2 were: older age; higher educational attainment; alcohol consumption; current smoking; sulphonylurea/insulin treatment; prior severe hypoglycaemia; renal impairment; and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP). The same variables except smoking were associated with frequency of severe hypoglycaemia. Most of these risk factors paralleled those in the FDS1, but current smoking and plasma NT-proBNP were novel.

CONCLUSIONS

The incidence and frequency of severe hypoglycaemia did not change between the Fremantle Diabetes Study phases but novel risk factors, including plasma NT-proBNP, were observed in the FDS2.

Real-world prevalence of mild to moderate hypoglycemic episodes in type 2 diabetes in Portugal: Results from the HIPOS-PHARMA study

AIMS

This study aimed to characterize and estimate prevalence and frequency of mild to moderate hypoglycemia and potentially associated factors in a population of type 2 diabetes mellitus (T2DM) patients treated at ambulatory care level.

METHODS

HIPOS-PHARMA was a nationwide observational, cross-sectional, multicenter study conducted in community pharmacies, which surveyed T2DM patients treated for at least 3 months.

RESULTS

Overall, 233 pharmacies recruited 1890 patients (males: 50.6%) with mean 67.1 years. On average, participants reported having diabetes for 11.8 years. A total of 86.9% had at least one chronic illness or complication of diabetes, and 76.8% were usually followed in the primary care setting. Fifty eight percent were treated without a secretagogue or insulin. Overall prevalence of mild to moderate hypoglycemic episodes in the 3 months prior to recruitment was 17.8%. A 3.13% prevalence of severe hypoglycemia was observed in the last 12 months. Results suggested that men and patients on antihyperglycemic therapies excluding secretagogues or insulin were less likely to have mild to moderate hypoglycemic episodes.

CONCLUSIONS

Mild to moderate hypoglycemic episodes were commonly reported, and factors like type of antihyperglycemic therapy, duration of disease and due complications may contribute. Almost half of episodes were not reported. Such factors should be considered in T2DM management.

Optimizing the management of hypoglycaemia in individuals with type 2 diabetes: A randomized crossover comparison of a weight-based protocol compared with two fixed-dose glucose regimens

AIMS

To determine whether an individualized body weight-based glucose treatment in adults with type 2 diabetes (T2DM) is more likely to resolve hypoglycaemia with a single treatment without excessive rebound hyperglycaemia compared to fixed doses of 12 or 30 g of glucose.

METHODS

Adults with T2DM were enrolled in a cross-over study. Each episode of hypoglycaemia (capillary glucose <4.0 mmol/L) was randomly assigned to 1 of 3 treatment protocols: 0.3 g glucose/kg body-weight or a fixed dose of either 12 or 30 g glucose, independent of weight. All participants received each treatment in random order for up to 15 hypoglycaemic episodes. Glucose was re-tested 10 minutes after treatment, with a repeat dose if still <4 mmol/L.

RESULTS

Mean (SD) age of the 30 participants was 68 (8.1) years, mean weight was 91.5 (16.8) kg and mean HbA1c was 58.7 (9.2) mmol/mol. Among a total of 244 episodes of hypoglycaemia, 10 participants had 15 treatment episodes and 18 participants had fewer than 10 treatment episodes. The odds ratio, adjusted for multiple comparisons, for resolution of hypoglycaemia at 10 minutes, comparing weight-based treatment and 12 g treatment was 3.2 (95% CI, 1.1-9.0), P = .009, comparing 30 g treatment and 12 g treatment was 8.9 (95% CI, 2.2-36.6), P < .001, and comparing weight-based treatment and 30 g treatment was 0.36 (95% CI, 0.08-1.67) P = .10.

CONCLUSION

In T2DM, both a weight-based 0.3 g/kg treatment and a fixed 30 g glucose treatment result in higher blood glucose than a 12 g treatment, along with increased probability of resolution of hypoglycaemia after 10 minutes. Both treatments result in an excess of mild rebound hyperglycaemia (>8 mmol/L) at 30 minutes.

Association of diabetes therapy-related quality of life and physical activity levels in patients with type 2 diabetes receiving medication therapy: the Diabetes Distress and Care Registry at Tenri (DDCRT 17)

AIM

To examine the association between diabetes therapy-related quality of life (DTR-QOL) and physical activity levels, and identify factors associated with high diabetes therapy-related quality of life.

METHODS

Cross-sectional data from 2970 patients with type 2 diabetes in a Japanese diabetes registry were assessed for independent correlations between DTR-QOL (domains 1-4) and high physical activity levels. Data collected by the International Physical Activity Questionnaire were analyzed by logistic regression and adjusted for potential confounders.

RESULTS

The mean patient age, BMI and HbA1c level were 65.8 years, 24.7 kg/m² and 7.6% (58.7 mmol/mol), respectively. Univariate analysis showed that DTR-QOL domain 1, 2 and 4 scores were significantly associated with physical activity levels (p = 0.0046, p = 0.0004 and p < 0.001, respectively, but domain 3 score was not (p = 0.5073). In a multivariable-adjusted logistic regression model, odds ratios (ORs) of DTR-QOL domains 1, 3 and 4 were independently associated with high physical activity (ORs for 2nd to 4th quartile and p for trend; [domain 1] 1.16, 1.56, 1.22, p = 0.032; [domain 3] 1.45, 1.55, 1.38, p = 0.049; [domain 4] 1.09, 1.30, 1.51, p = 0.001, respectively), but domain 2 was not (ORs for 2nd to 4th quartile and p for trend; 1.19, 1.26, 1.23, p = 0.096).

CONCLUSION

High diabetes therapy-related QOL scores were associated with high levels of physical activity in patients with type 2 diabetes. Because this is a cross-sectional study, further study is needed to evaluate the causal association between therapy-related QOL and physical activity.

Fears and concerns of Iranian diabetic women: A phenomenological study

This study explored the fears and concerns of 19 Iranian diabetic women using a phenomenological approach. Semistructured individual interviews were conducted; each interview was transcribed verbatim and analyzed simultaneously using Van Manen's method. Data analysis resulted in the emergence of two main themes: (1) "a vague and uncertain future" with sub-themes of "fears of dependency," "loneliness," "disease complications," and "children's future"; and (2) "changing lifestyles" with sub-themes of "dietary restrictions" and "insulin injection." Psychological concerns are common in Iranian diabetic women. These concerns can contribute to poor disease self-management. Thus, it is hoped that identifying these concerns can lead to better management of these issues and a better outcome in diabetic patients.

Incidence of and risk factors for severe hypoglycaemia in treated type 2 diabetes mellitus patients in the UK--a nested case-control analysis

AIMS

To assess incidence rates (IRs) of and identify risk factors for incident severe hypoglycaemia in patients with type 2 diabetes newly treated with antidiabetic drugs.

METHODS

Using the UK-based General Practice Research Database, we performed a retrospective cohort study between 1994 and 2011 and a nested case-control analysis. Ten controls from the population at risk were matched to each case with a recorded severe hypoglycaemia during follow-up on general practice, years of history in the database and calendar time. Using multivariate conditional logistic regression analyses, we adjusted for potential confounders.

RESULTS

Of 130,761 patients with newly treated type 2 diabetes (mean age 61.7 ± 13.0 years), 690 (0.5%) had an incident episode of severe hypoglycaemia recorded [estimated IR 11.97 (95% confidence interval, CI, 11.11-12.90) per 10,000 person-years (PYs)]. The IR was markedly higher in insulin users [49.64 (95% CI, 44.08-55.89) per 10,000 PYs] than in patients not using insulin [8.03 (95% CI, 7.30-8.84) per 10,000 PYs]. Based on results of the nested case-control analysis increasing age [≥ 75 vs. 20-59 years; adjusted odds ratio (OR), 2.27; 95% CI, 1.65-3.12], cognitive impairment/dementia (adjusted OR, 2.00; 95% CI, 1.37-2.91), renal failure (adjusted OR, 1.34; 95% CI, 1.04-1.71), current use of sulphonylureas (adjusted OR, 4.45; 95% CI, 3.53-5.60) and current insulin use (adjusted OR, 11.83; 95% CI, 9.00-15.54) were all associated with an increased risk of severe hypoglycaemia.

CONCLUSIONS

Severe hypoglycaemia was recorded in 12 cases per 10,000 PYs. Risk factors for severe hypoglycaemia included increasing age, renal failure, cognitive impairment/dementia, and current use of insulin or sulphonylureas.

The treatment of type 2 diabetes

BACKGROUND

5% to 8% of adults have type 2 diabetes, a disease that is usually asymptomatic at first. The goals of management are timely diagnosis and the prevention of complications.

METHODS

Selective review of the literature, including guidelines from Germany and abroad.

RESULTS

High caloric intake and lack of exercise are the main contributing causes of type 2 diabetes and the principal targets of intervention. If lifestyle changes do not yield adequate improvement, then drug treatment should be initiated (or intensified) and managed on the basis of the HbA1c fraction. Guidelines recommend an HbA1c target range of 6.5% to 7.5%; the individual target value should be chosen in consideration of patient-specific factors and established in collaboration with the patient. Metformin is recommended for initial drug treatment. If metformin is contraindicated, poorly tolerated, or inadequately effective, many therapeutic alternatives and supplements are available. Clinical trials have shown that sulfonylureas and insulin are beneficial with respect to patient-relevant endpoints, but comparable data from clinical trials are not yet available for any other antidiabetic drug (except metformin). For individual patients, other drugs may have advantages such as a lower risk of hypoglycemia, less weight gain, oral administration, and/or applicability in the setting of renal insufficiency. The treatment is individually oriented, depending on the patient's age, disease stage, body weight, comorbidities, work situation, adherence, and personal priorities. Combining more than two antidiabetic drugs is not recommended.

CONCLUSION

Although there are many treatment options, individualized long-term treatment still presents a challenge in many cases.

Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes

AIMS

This retrospective observational study examined the association between International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-coded outpatient hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes.

METHODS

Data were derived from healthcare claims for individuals with employer-sponsored Medicare supplemental insurance. The study period consisted of two consecutive 1-year periods; the baseline period (1 April 2008 to 31 March 2009) and the evaluation period (1 April 2009 to 31 March 2010). Patients selected for study were at least 65 years of age with evidence of type 2 diabetes during the baseline period, as identified using a Healthcare Effectiveness Data and Information Set algorithm or by at least two prescription claims for oral antidiabetic drugs. The baseline period was used to collect information on the patients' demographics and clinical characteristics. The evaluation period was used to identify the presence of hypoglycaemic events and fall-related fractures. Logistic regression was employed to examine the association between hypoglycaemic events and fall-related fractures occurring during the evaluation period, adjusting for patients' demographics and clinical characteristics.

RESULTS

Of 361 210 included patients, 16 936 had hypoglycaemic events during the evaluation period. Patients with hypoglycaemic events had 70% higher regression-adjusted odds (hypoglycaemic events odds ratio = 1.70; 95% confidence interval = 1.58-1.83) of fall-related fractures than patients without hypoglycaemic events. Multiple sensitivity analyses also yielded results suggesting increased odds of fall-related fractures in patients with hypoglycaemic events.

CONCLUSIONS

ICD-9-CM-coded outpatient hypoglycaemic events were independently associated with an increased risk of fall-related fractures. Further studies of the relationship between hypoglycaemia and the risk of fall-related fractures are warranted.

Hypoglycemia is associated with increased worry and lower quality of life among patients with type 2 diabetes treated with oral antihyperglycemic agents in the Asia-Pacific region

AIMS

We examined the relationship of hypoglycemic symptoms with health-related quality of life and worry about hypoglycemia among type 2 diabetic patients using oral antihyperglycemic agents (AHA) in the Asia-Pacific region.

METHODS

A total of 2257 type 2 diabetic patients with at least 6 months of oral AHA were enrolled in China, Korea, Malaysia, Thailand, and Taiwan. Quality of life was measured with the EuroQol Visual Analog Scale (EQ-VAS) and EuroQol-5 Dimensions questionnaire (EQ-5D), and worry about hypoglycemia with the worry subscale of the Hypoglycemic Fear Survey-II (HFS).

RESULTS

The mean (SD) age was 58.7 (10.2) years and HbA(1c) was 7.5% (1.5). The proportion of patients with an HbA(1c) <6.5% and <7% was 24.9% and 41.8%, respectively. Hypoglycemic symptoms in the prior 6 months were reported by 35.8% of patients. Mean scores on the EQ-VAS and the EQ-5D were significantly lower for patients who had hypoglycemic symptoms compared to those who did not (73.6 vs. 76.9, p<0.001; 0.88 vs. 0.90, p<0.0001, respectively), whereas mean score on the HFS was significantly higher (12.5 vs. 6.3, p<0.001). In multivariate models, hypoglycemic symptoms were independently associated with scores on the EQ-5D, EQ-VAS, and HFS (all p ≤ 0.01-0.001). Symptom severity was positively associated with fear of hypoglycemia (all p ≤ 0.001).

CONCLUSION

Hypoglycemic symptoms were associated with reduced quality of life and increased patient worry in patients with type 2 diabetes treated with AHA.

The Experience of Hypoglycaemia and Strategies Used For Its Management by Community-Dwelling Adults with Diabetes Mellitus: A Systematic Review

BACKGROUND

Hypoglycaemia, a common complication of diabetes drug therapy, has been reported to influence therapy adherence and the quality of life of people with diabetes mellitus. No systematic reviews on the experience of hypoglycaemia have been undertaken. The extant literature has taken a medical model perspective focusing on the causes, prevalence, and impact of hypoglycaemia. To understand the meaningfulness of hypoglycaemia and how this condition impacts on a person with diabetes mellitus, a systematic review was undertaken exploring the experiences of hypoglycaemia in community-dwelling people with diabetes mellitus.

OBJECTIVE

This review aimed to synthesise evidence on the experience of hypoglycaemia, and the strategies used to control it in community-dwelling adults with type 1 and type 2 diabetes mellitus.

INCLUSION CRITERIA

Type of Participants - Community-dwelling adults (18 years of age and over) who had experienced hypoglycaemia from type 1 or type 2 diabetes mellitus and/or who had used self-management strategies for hypoglycaemia were included.Phenomena of Interest - The experiences of hypoglycaemia in community-dwelling adults with diabetes mellitus and the strategies they used to self-manage hypoglycaemia were included.Type of Studies - Qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research were included.

SEARCH STRATEGY

Published and unpublished studies in English from January 2000 to August 2010 were gathered using a three-step search strategy. An initial limited search was conducted in MEDLINE and CINAHL to identify keywords and index terms, which were then used in a second search across the CINAHL, PUBMED, SCOPUS, PsycINFO, PsycARTICLES, Web of Science, JSTOR, EMBASE and MEDNAR databases. Additionally, the reference list of all studies was hand-searched for additional studies.

METHODOLOGICAL QUALITY

Two reviewers independently assessed the retrieved studies for methodological validity, using standardised Joanna Briggs Institute-Qualitative Assessment and Review Instrument (JBI-QARI) critical appraisal instruments. Disagreements that arose between the two reviewers were resolved with the help of a third reviewer.

DATA COLLECTION

Data, in terms of research findings, were extracted from included studies using the standardised JBI-QARI data extraction tool.

DATA SYNTHESIS

These findings were then pooled and assembled into level 1 findings, then level 2 findings (categories), and lastly meta-synthesised to form one level 3 synthesised finding. Meta-aggregation was carried out using JBI-QARI.

RESULTS

Six studies were included in the review. Participants who lived independently in the community and attended primary care or outpatient clinics were included. In total, twenty findings were grouped into three categories, which were synthesised into one overall finding - i.e., "People with diabetes mellitus can self-manage their diabetes and thus prevent hypoglycaemic episodes more effectively when health professionals provide psychological, physiological and spiritual support, and an individually targeted education programme".

CONCLUSIONS

The review findings revealed patient-identified priorities to maintain normality in blood glucose self-management. There is also evidence that some people lack the knowledge to identify and self-manage hypoglycaemia.To enable community-dwelling adults with diabetes mellitus to self-manage hypoglycaemia, healthcare professionals should provide individualised information and emotional support, and regularly discuss and assess the person's level of knowledge, awareness of hypoglycaemia, and their ability to self-manage.There is a lack of data that capture the person's experience and awareness of hypoglycaemia and how they self-manage the condition, particularly in varying cultural contexts. A mixed-method study could be designed to explore the experiences of hypoglycaemia, and to develop and validate a reliable tool that assesses the level of knowledge and awareness of hypoglycaemia, and the ability to self-manage. This study should include people with diabetes mellitus from different cultures and/or geographical locations.

Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study

CONTEXT

There are limited published data characterizing severe hypoglycemia complicating type 2 diabetes.

OBJECTIVE

The objective of the study was to determine the incidence and predictors of severe hypoglycemia in community-dwelling type 2 patients.

DESIGN

This was a longitudinal observational cohort study.

SETTING

This was a community-based study.

PATIENTS

There were 616 patients (mean age 67.0 yr, 52.3% males, median diabetes duration 7.7 yr) assessed in 1998 and followed up to the end of June 2006.

MAIN OUTCOME MEASURES

Severe hypoglycemia defined as that requiring ambulance attendance, emergency department services, and/or hospitalization. Cox proportional hazards modeling was used to determine predictors of first episode, and Poisson, negative binomial, zero-inflated Poisson, and zero-inflated negative binomial regression models identified predictors of frequency.

RESULTS

Fifty-two (8.4%) experienced 66 episodes during 3953 patient-years (incidence 1.7 per 100 patient-years). Those experiencing severe hypoglycemia had one to four episodes. Significant independent predictors of time to first episode were duration of insulin treatment, estimated glomerular filtration rate less than 60 ml/min per 1.73 m(2), peripheral neuropathy, education beyond primary level, and past severe hypoglycemia. The zero-inflated negative binomial provided the best model of severe hypoglycemia frequency. Lower fasting serum glucose and higher glycosylated hemoglobin were significantly associated with frequency, whereas patients at minimal risk of repeated severe hypoglycemia were unlikely to use insulin or to have short-duration insulin treatment, to have renal impairment or peripheral neuropathy, or to be educated beyond primary level.

CONCLUSIONS

Duration of insulin treatment was confirmed as an independent risk factor for severe hypoglycemia. The novel association with educational attainment suggests knowledge-driven intensive glycemic self-management. The positive relationship between frequency and glycosylated hemoglobin may identify patients with unstable glycemic control.

Patient-reported outcomes in a survey of patients treated with oral antihyperglycaemic medications: associations with hypoglycaemia and weight gain

AIM

To examine the association between medication side-effects (SEs) and patient-reported outcomes (PROs) among patients with type 2 diabetes treated with oral antihyperglycaemic agents (OAHAs).

METHODS

A total of 1984 participants responded to an internet-based survey in the United States. Data were collected on hypoglycaemia 6 months and weight gain 12 months prior to the survey. Health-related quality of life (HRQoL) was measured using the EuroQol-5D (EQ-5D). Also administered were the Treatment Satisfaction Questionnaire for Medication v.1.4 (TSQM) and the Hypoglycaemia Fear Survey II (HFS).

RESULTS

Symptoms of hypoglycaemia were reported by 62.9% of participants, and 36.9% reported weight gain. For those reporting hypoglycaemia, mean scores were lower for TSQM and EQ-5D and higher for HFS when compared with those with no symptoms (TSQM: 69.7 vs. 75.1; EQ-5D: 0.78 vs. 0.86; HFS: 17.5 vs. 6.2; all p < 0.0001). The same remained true when accounting for symptom severity, where severity was monotonically related with PRO scores (all p < 0.0001). Similarly, reported weight gain was associated with lower treatment satisfaction (69.0 vs. 73.3) and HRQoL (0.77 vs. 0.83), and increased fear of hypoglycaemia (15.7 vs. 11.8) (all p < 0.0001). In mixed linear regression analysis, the associations between medication SEs and PROs remained significant after adjusting for patient and disease characteristics.

CONCLUSIONS

Among patients with type 2 diabetes treated with OAHAs, self-reported hypoglycaemia and weight gain were associated with decreased treatment satisfaction and HRQoL. In addition, the presence of these SEs was associated with increased fear of hypoglycaemia.

Hypoglycaemia in patients with type 2 diabetes treated with a combination of metformin and sulphonylurea therapy in France

CONTEXT

Hypoglycaemia from antihyperglycaemic drugs may have a significant impact on patients' health-related quality of life. Combination use of metformin and a sulphonylurea has become increasingly common; yet, the impact of hypoglycaemia on quality of life in these patients is not well documented.

OBJECTIVE

To examine patient-reported experience of hypoglycaemia, worry about hypoglycaemic symptoms and the impact of hypoglycaemia on patients' quality of life associated with use of sulphonylurea co-administered with metformin.

DESIGN

This was an observational, cross-sectional, multi-centre study.

SETTING

A total of 98 primary care centres in France during October to December 2005.

PATIENTS

A total of 400 patients with type 2 diabetes, who were > or = 35 years old and who had been treated with metformin and a sulphonylurea for at least 6 months, completed questionnaires during their usual primary care office visit.

MAIN OUTCOME MEASURES

Frequency and severity of hypoglycaemic symptoms in the past 6 months, the Worry subscale of the Hypoglycaemic Fear Survey-II (HFS-II) and the EuroQol-5 Dimensions (EQ-5D) questionnaire.

RESULTS

A total of 136 (34%) patients reported experiencing hypoglycaemia, of whom 78 (58%) experienced mild, 40 (30%) experienced moderate and 16 (12%) experienced severe or very severe symptoms. Mean score on the HFS-II Worry scale was higher for patients who reported having hypoglycaemia than for those who did not (19.0 vs. 10.2; p < 0.0001) and increased with severity of hypoglycaemic symptoms. In linear regression analyses, more severe symptoms of hypoglycaemia were significantly associated with higher scores on the HFS-II Worry scale (p = 0.0162) among patients with hypoglycaemic symptoms. Summary scores on the EQ-5D were lower for patients who reported hypoglycaemia than for those who did not (p = 0.0001) and, in multivariate analysis, the experience of hypoglycaemia was negatively associated with the EQ-5D summary score (p < 0.0001).

CONCLUSION

The occurrence and severity of hypoglycaemic symptoms were associated with increased patient worry about hypoglycaemia and lower health-related quality of life among type 2 diabetic patients being treated with both metformin and a sulphonylurea.

Impact of therapeutic advances on hypoglycaemia in type 2 diabetes

Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' 'clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change.

The benefits of tight glycemic control in type 2 diabetes mellitus

Type 2 diabetes mellitus (DM) is associated with significantly increased risk of microvascular and macrovascular disease. Although most studies have focused on the microvascular complications of diabetes (eg, nephropathy, neuropathy, retinopathy), most patients with type 2 DM die from causes that are related to macrovascular disease (eg, myocardial infarction). Poor glycemic control increases the risk of future cardiovascular events, and prospective studies of patients with type 1 and type 2 DM have demonstrated that the incidence of vascular complications is reduced by lifestyle modifications or medications that reduce blood glucose concentrations.

Age-dependent difference in factors affecting choice of system for self-monitoring of blood glucose

To clarify factors determining the preference for a self-monitoring blood glucose (SMBG) system in patients with diabetes mellitus. A total of 52 Japanese inpatients with diabetes mellitus were recruited into a single-center trial. After the patients got used to one SMBG system, the SMBG system was substituted with another one of the three, and the subjects were given questionnaires. The following parameters were identified as independent factors associated with the preference of SMBG: display (P<0.0001), operation for inserting strips (P=0.0004), and lancing-device operation (P<0.05). When the subjects were divided according to age, the independent variables associated with overall preference in the older group (>or=60 years) were display (P=0.001) and procedure for detaching a used needle (P=0.01), whereas those in the younger group (age<60 years) were operation of the lancing device (P<0.0001), operation to apply blood to strip (P=0.001), and amount of blood (P=0.04). These data suggest that in elderly patients with diabetes, display and detachment of the needle are important factors affecting the choice of SMBG system, whereas younger subjects give weight to skin puncture-related issues in choosing an SMBG system.

Severe hypoglycemia monitoring and risk management procedures in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial

Hypoglycemia is a potentially serious side effect of blood glucose lowering in diabetes mellitus. The intensive glycemia treatment arm of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is designed to treat patients with type 2 diabetes with target glycemia within the normal range (ie, glycosylated hemoglobin <6%). Because it is known that treating glycemia to such a low level in patients with diabetes will result in episodes of hypoglycemia, it is necessary to address prevention and treatment of such episodes to ensure patient safety. Thus, several approaches are being taken in the ACCORD trial to prevent initial episodes of severe hypoglycemia, to monitor the frequency of episodes that do occur, and to prevent recurrence. This report describes the processes used in the ACCORD trial, including the definition of severe hypoglycemia, the type of education provided to participants and staff members to prevent initial and subsequent episodes of severe hypoglycemia, and the monitoring systems implemented to identify severe hypoglycemia and prevent its recurrence. The ACCORD trial conducts review and oversight of individual cases of severe hypoglycemia and monitors rates of severe hypoglycemia by clinical site and treatment arm. If the ACCORD intensive glycemia treatment is found to be efficacious in preventing cardiovascular disease events, assessment of the risk and benefit will be essential. In addition, translation of the principles behind the monitoring of severe hypoglycemia in ACCORD into feasible strategies for use in clinical practice will be needed.

The impact of the angiotensin-converting enzyme insertion/deletion polymorphism on severe hypoglycemia in Type 2 diabetes

The insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme gene (ACE) is associated with altered serum ACE activity. Raised ACE levels and the ACE DD genotype are associated with a 3.2 to 6.8-fold increased risk of severe hypoglycemia in type 1 diabetes. This relationship has not been assessed in type 2 diabetes. We aimed to test for association of the ACE I/D polymorphism with severe hypoglycemia in type 2 diabetes. Patients with type 2 diabetes (n = 308), treated with insulin (n = 124) or sulphonylureas (n = 184), were classified according to whether or not they had previously experienced severe hypoglycemia. Samples of DNA were genotyped for the ACE I/D polymorphism using two alternative polymerase chain reactions to prevent mistyping due to preferential amplification of the D allele. Overall, 12% of patients had previously experienced one or more episodes of severe hypoglycemia. This proportion did not differ between genotype groups (odds ratio (95% confidence limits) for carriers of D allele relative to II homozygotes: 0.79 (0.35-1.78)). This study found no evidence for association of the ACE I/D polymorphism with severe hypoglycemia frequency in patients with type 2 diabetes. However, we cannot rule out a smaller effect (odds ratio </= 1.78). Our results suggest that any effect of ACE genotype on severe hypoglycemia risk in type 2 patients is likely to be smaller than that seen in type 1 diabetes. We recommend future larger-scale studies.