Hypoglycemia in Diabetes

Hypoglycemia, caused by treatment with insulin, a sulfonylurea, or a glinide coupled with compromised defenses against falling plasma glucose concentrations, is the limiting factor in the glycemic management of diabetes. It causes recurrent morbidity in most people with type 1 diabetes and many with advanced type 2 diabetes, and is sometimes fatal. Caused by recent antecedent hypoglycemia, prior exercise, or sleep, perhaps among other mechanisms, the compromised defenses are loss of a decrease in insulin and loss of an increase in glucagon and attenuation of an increase in epinephrine as glucose levels fall, resulting in defective glucose counter-regulation and impaired awareness of hypoglycemia resulting from an attenuated sympathoadrenal response. These comprise the clinical syndrome of hypoglycemia-associated autonomic failure in diabetes. Minimizing hypoglycemia includes acknowledging the problem, considering each of the risk factors for hypoglycemia—those resulting in absolute or relative insulin excess and those resulting in comprised defenses against hypoglycemia—and application of the principles of glycemic control. The latter include drug selection and application of diabetes treatment technologies along with individualized glycemic goals and structured patient education, typically coupled with short-term scrupulous avoidance of hypoglycemia. With these methods, hypoglycemia can be reduced in most affected patients.