Rationale:

• Difficulties in predicting calorie absorption, caloric expenditure, and rate of insulin absorption increase the risk of having an imbalance between circulating insulin and glucose levels, which can result in hypoglycemia.
• Mild hypoglycemia with activation of adrenergic counter-regulatory function is common.
• With increasing duration of diabetes, the classic adrenergic signs and symptoms of hypoglycemia may disappear or become muted, which frequently results in neuroglycopenia as the presenting sign.

Evidence:

• Hypoglycemia is the limiting factor in achieving good glycemic control (91).
• Individuals at high risk for severe, life-threatening hypoglycemia can be identified, providing an opportunity for prevention by altering glycemic goals of therapy (97).
• Progressive loss of epinephrine and glucagon response to hypoglycemia with prolonged duration of diabetes contributes to the diminished perception of the adrenergic symptoms of hypoglycemia and increases the risk of severe events. Scrupulous avoidance of hypoglycemia results in at least partial recovery of the adrenergic response and facilitates the recognition of hypoglycemia before the onset of neuroglycopenia (98).
• Patient training can improve the recognition of early signs and symptoms other than the classic ones to avoid neuroglycopenia (99; 100). Risk factors for severe hypoglycemia include a lower HbA_1c and a previous history of severe hypoglycemia (25).

Comments:

• None.