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PhD, Olenovych O.A.
Higher State Educational Establishment of
«Bukovinian State Medical University», Chernivtsi, Ukraine
INVESTIGATING
HYPOGLYCEMIC AWARENESS IN TYPE 2 DIABETES
Introduction. Hypoglycemia
is the rate-limiting factor that often prevents patients with diabetes from
safely and effectively achieving their glycemic goals [1, 2]. Hypoglycemic
events can have serious implications for patient health, psychological well
being, and adherence to treatment regimens, can impact the health economics of
the patient, their employer [4]. It is primarily associated with treatment with
insulin and insulin secretagogues, equally common for both types of diabetes [3,
5, 8].
While severe hypoglycemic events are undoubtedly
dangerous to patients, equally important are nonsevere hypoglycemic events,
which are frequently and incorrectly dismissed as unimportant because they can
be asymptomatic [6]. In fact, nonsevere hypoglycemic events are actually much
more common than severe hypoglycemic events, yet, nonsevere ones may go
unrecognized. Even if they are recognized, they may not be significant enough
to be remembered by the patient and to be mentioned to the primary care
physician and are therefore also significantly under-reported [6]. Recurrent
episodes of untreated hypoglycemia can lead to hypoglycemia-associated
autonomic failure, an impaired ability of the body to counter-regulate
subsequent and more serious events, which leads to unawareness of hypoglycemia
[8]. Hypoglycemia also commonly goes undetected when it occurs during the
night. Nocturnal hypoglycemia can lead to serious clinical consequences,
including sudden death during sleep, thought to be a result of cardiac rate and
rhythm disturbances in response to prolonged nocturnal hypoglycemia [6].
Considering that, the purpose of this study was to discuss
the importance of all hypoglycemic events in the successful management of
patients with diabetes, emphasizing data regarding the incidence of
hypoglycemia in type 2 diabetes patients taking insulin and/or oral
hypoglycemic agents to estimate the prevalence of hypoglycemia and try to
prevent it from happening.
Materials
and methodology. To accomplish this, 15 patients with
diabetes mellitus type 2 (47% men and 53% women, mean age
– 60,9±1,44 years), hospitalized
to Chernivtsi Regional Endocrinological Center, participated
in the study.
The
verification of the diagnosis and disease severity was based on the acting
national and international regulating documents. All patients underwent
standard general clinical and laboratory-instrumental examination. Glucose
blood concentration was determined by glucose oxidase method before
and 2 hours after meal (pre- and postprandial glycemia) to assess carbohydrate metabolism.
Detection of glycated haemoglobin (HbA1C) was used as informative criterion of continuous
glycemic control (by colorimetric method).
In 40% of participating patients the
duration of diabetes was less than 5 years, in
20% – 6-10 years, in 40% of patients had diabetes
longer than 10 years. Among all examined patients 40% were treated by
oral hypoglycemic agents, 60% were on combined hypoglycemic therapy.
Except standard clinical patients’
examination findings and information from medical records, self-report 10-item
Hypoglycemia questionnaire, provided by the Hypoglycemic Health Association of
Australia, was used in order to reveal unrecognized hypoglycemic episodes and
to identify the probability of hypoglycemic events in the examined patients [7].
Individual’s risk profile was calculated according to scoring scheme by the
assessment of hypoglycemia signs as «rarely», «occasionally», and «usually»,
being assigned a certain number of points. If total score was less than 8
points, hypoglycemia was considered as «unlikely», between 8 to 15 points – as
«possible», in case of total score above 15 – as «present». Despite this
questionnaire is easy to fill in, the researcher accompanied the patients while
they completed the questionnaires to aid quality control during data
collection.
Results and discussion. The
analysis of carbohydrate metabolism parameters evidenced a
poor compensation of the disease in patients of the examined cohort.
According to
the obtained findings, the probability of hypoglycemia development was assessed
as «possible» only in 20% of the enrolled patients; all of them were on
combined hypoglycemic therapy. In the majority of cases (80%) the «present»
hypoglycemia was defined in the patients treated by various types of
hypoglycemic therapy. Our analysis demonstrated, that the
gradient for risk according to the age and duration of diabetes as well as to
the level of its compensation was noticeable.
Thus, the
frequency of hypoglycemia in people with type 2 diabetes, mostly middle aged or
elderly, is usually underestimated and much higher than documented. Impaired
awareness of hypoglycemia, more prevalent in type 2 diabetes than is
appreciated, is associated with increased risk of a variety of adverse clinical
outcomes, including microvascular events (nephropathy, retinopathy,
neuropathy), macrovascular events (heart failure, peripheral vascular disease,
myocardial events, stroke), and death. Accompanied by such factors, as age, a
past history of vascular disease, interactions with other drugs, alongside with
treatment either by sulfonylureas or insulin, hypoglycemia poses particular
problems and the mortality may be unrecognized.
Though the
risk of therapy-induced hypoglycemia is highest among patients treated with
insulin, there are risks associated with other treatments. Sulfonylurea
therapy, which increases insulin output from the pancreas, is one of the key
contributors to hypoglycemia in patients with type 2 diabetes who are early in
the progression of the disease. The risk of hypoglycemia with oral antidiabetes
drugs is variable and, as with sulfonylureas, depends upon their respective
pharmacokinetic and pharmacodynamic profiles. It is important to remember that
if insulin or insulin secretagogues, such as a sulfonylurea, are added into the
treatment regimen as the disease progresses, the risk of hypoglycemia will
increase.
The incidence
of type 2 diabetes is projected to increase in coming years, while the average
age of patients with type 2 diabetes is decreasing; therefore, the number of
patients with advanced type 2 diabetes, for whom sulfonylureas and oral
antidiabetes drugs will not provide sufficient glycemic control, and who will
require the addition of insulin to their treatment regimen, is also likely to
increase dramatically. Combined with increasingly tighter glycemic targets,
this may contribute to an increasing prevalence of hypoglycemia in the future.
Conclusion. A recent
inquiry emphasised the benefits of using charts or scores for hypoglycaemia
risk assessment in getting treatment decisions made alongside realistic
estimates of patient susceptibility to hypoglycemia
as the rate-limiting factor for the achievement of glycemic treatment goals.
Such approach to the individual patient has daily practice implications, as it
provides a useful tool for primary care physicians, who are responsible for
guiding therapy to achieve euglycemic control in patients with diabetes. It
helps to recognize asymptomatic hypoglycemia and to optimize management and
outcomes in patients who are initially categorized as at hypoglycemia risk.
REFERENCES:
1.
Defining and Reporting Hypoglycemia in Diabetes. A
report from the American Diabetes Association Workgroup on Hypoglycemia // Diabetes
care. – 2005. –Vol.28, ¹5. – P.1245-1249.
2.
3.
Matza L.S. Validation of two generic patient-reported
outcome measures in patients with type 2 diabetes / L.S.Matza, K.S.Boye,
N.Yurgin // Health Qual Life Outcomes. – 2007. – ¹5. – P.47.
4.
Quilliam B.J. The Incidence and Costs of Hypoglycemia
in Type 2 Diabetes / B.J.Quilliam, J.C.Simeone, A.B.Ozbay // Am J Manag Care. – 2011. – Vol.17, ¹10. – P.673-680.
5.
Seaquist E.R. Hypoglycemia and Diabetes: A Report of a
Workgroup of the American Diabetes Association and The Endocrine Society / E.R.Seaquist,
J.Anderson, B.Childs // Diabetes Care. – 2013. – ¹36. – P.1384-1395.
6.
Unger J. Uncovering undetected hypoglycemic events /
J.Unger // Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. –
2012. – ¹5. – Ð.57-74.
7. What is
Hypoglycemia questionnaire?
[http://www.hypoglycemia.asn.au/2012/hypoglycemia-questionnaire/]
8.
Zammitt N.N. Hypoglycemia in
Type 2 Diabetes / Nicola N.Zammitt, Brian M.Frier // Diabetes Care. – 2005. –
Vol.28, ¹12. – P.2948-2961.