Hypoglycemia is the most common side effect of treatment with insulin and to a lesser
extent is associated with the use of insulin secretagogues such as the sulfonylureas.
While generally unpleasant and inconvenient, most episodes of hypoglycemia are readily
self-treated and pose little risk to the individual, unless they are performing a
complex task such as driving. However, severe hypoglycemia, defined by requiring help
for recovery, causes significant cognitive impairment and can be associated with significant
morbidity or even be life threatening. Early identification of the onset of hypoglycemia,
which was redefined recently as a blood glucose of <3.0 mmol/L (54 mg/dL),[[1]] is therefore essential if appropriate action is to be taken by the affected individual
or by carers to avoid progression to severe hypoglycemia.
Hypoglycemia (severe and nonsevere) is three times more frequent in people with Type
1 diabetes than in those with insulin-treated Type 2 diabetes.[[2]] Severe events are experienced by 30%–40% of adults with Type 1 diabetes annually
and in around 20%–25% of people with insulin-treated Type 2 diabetes.[[3]],[[4]] The large global HAT study (Hypoglycemia Among insulin-Treated patients with diabetes)
demonstrated that the frequency of severe hypoglycemia is much higher in Type 2 diabetes
than had been appreciated previously,[[5]] and the rates in HAT are consistent with those reported by other real-world studies
of hypoglycemia in insulin-treated Type 2 diabetes.[[6]] Many people with Type 2 diabetes progress to insulin dependence with time, and
the frequency of hypoglycemia increases with duration of insulin therapy.[[3]] In Middle Eastern countries where Type 2 diabetes predominates, the frequency of
hypoglycemia is therefore likely to be escalating, because of increasing longevity
of people with Type 2 diabetes, the rising need for insulin replacement therapy, and
the overall improvement in glycemic control associated with intensification of therapy.
Two papers in the present issue of the journal are of relevance to the burgeoning
problem of hypoglycemia in the Middle East. One highlights the current lack of knowledge
about hypoglycemia within a population who have mainly Type 2 diabetes and the other
describes a novel and user-friendly method of delivering glucagon to treat severe
hypoglycemia that can be used both in community and hospital settings.
A questionnaire study in Saudi Arabia of 361 adults with diabetes, 95% of whom had
Type 2 diabetes, and 40% of whom were receiving insulin therapy, has demonstrated
that knowledge about hypoglycemia and the management of this problem is limited, and
this included the identification of the symptoms, the causes, treatment options, and
ways to avoid developing a low blood glucose.[[7]] As people with diabetes who were being treated with diet alone or with oral glucose-lowering
medications (with the exception of sulfonylureas) would seldom have encountered hypoglycemia,
their lack of knowledge of hypoglycemia in the survey is not surprising. However,
the deficiencies in knowledge in those treated with insulin are disturbing and suggest
that their education about hypoglycemia has either been inadequate or was poorly understood
by the patients. Whatever the reason, this suggests that a serious communication gap
exists between many patients and their health-care providers (HCPs). The latter have
a responsibility to discuss hypoglycemia during routine consultations, but surveys
of insulin-treated patients in Europe have demonstrated that HCPs seldom review, or
even mention, hypoglycemia.[[8]],[[9]] This lack of focus on hypoglycemia and evidence of deficiencies in education about
its recognition and management, particularly in people with Type 2 diabetes, is a
widespread phenomenon and not one confined to Saudi Arabia. Educational deficiencies
are particularly problematical in older people and their relatives, whose ability
to identify and manage hypoglycemia has been shown to be very limited[[10]] and if they have some degree of cognitive impairment, education about hypoglycemia
needs to be reinforced regularly. This problem is easily overlooked in specialist
care when several other medical issues, such as diabetic complications, may be demanding
attention. The present study observed that younger people and particularly those who
had experienced hypoglycemia previously were better informed about the presentation,
causes, and treatment of this side effect of insulin. Regular discussion about hypoglycemia
is essential in all people receiving insulin and the provision of information about
hypoglycemia should be a fundamental part of the diabetes education package, which
may have to be repeated and updated at intervals.
Severe hypoglycemia is a serious medical emergency that requires urgent treatment
and may be associated with coma and/or seizures. The methods of treating severe hypoglycemia
have been reviewed recently.[[11]] When a person with severe hypoglycemia is comatose or is semi-conscious but profoundly
neuroglycopenic and unable to swallow, the usual rescue treatment is to inject either
intravenous dextrose or intramuscular (i.m.) glucagon. The parenteral administration
of glucose requires intervention by medical or paramedical staff and is not an option
for lay people who are required to treat severe hypoglycemia in the community, which
is where most severe episodes are managed.[[12]] Although glucagon is a long-standing and well-established rescue treatment for
severe hypoglycemia and is provided in emergency kits that can be kept at home, it
is not an easy preparation to use and has to be given by injection. Immediate reconstitution
of a powdered form of glucagon is necessary by dissolving it in a diluent to allow
its injection as a solution.[[10]] Thus, the parenteral administration of glucagon requires several careful steps
to be followed, often by a person who is inexperienced in administering medications
by injection and who is confronted by a stressful situation that is prone to induce
panic and distress. A clumsy procedure leads to mistakes and inadequate administration
of glucagon.
In the present issue, Heba et al. have reviewed a novel form of glucagon that is now
available to treat severe hypoglycemia.[[13]] A different route of delivery has been developed for glucagon to be administered
into the nose. The drug is available in the form of a dry powder (3 mg) that is introduced
into a nostril using a single-use puffer device and is passively absorbed through
the nasal mucosa with no need for the recipient to inhale. When compared with i.m.
glucagon, it is approximately 3 min slower in restoring normoglycemia, which is not
considered to be clinically relevant.[[11]] It can be used successfully in the presence of nasal congestion or rhinorrhea such
as when a person has an upper respiratory infection such as a common cold.[[14]] It is therefore as effective as i.m. glucagon and the principal benefit of nasal
glucagon is the ease of administration with no skill being required and with no need
for reconstitution before administration. Family members, who live with the fear of
having to manage unpredictable episodes of severe hypoglycemia in a relative (especially
the parents of young children) and carers who look after patients with insulin-treated
diabetes, are much more confident in giving nasal glucagon to treat severe hypoglycemia
and less likely to make mistakes.[[11]] This product simplifies the treatment of a serious metabolic emergency and so represents
a significant therapeutic advance.
Authors' contribution
Single author.
Compliance with ethical principles
No ethical approval is required.
