Preventing and treating hypoglycemia in patients with type 2 diabetes

Advise following the mantra, "test, treat, test, eat." Advise TESTing blood glucose when patients have symptoms of hypoglycemia...
Abdelwahab Ward, BS Pharm, PharmD

As a pharmacist, you'll see more emphasis on preventing and treating hypoglycemia in patients with type 2 diabetes, not just type 1. We all know that hypoglycemia can lead to confusion, seizures, and emergency room visits. But it can also impact driving, sleep, or work. Help your diabetes patients prevent and manage hypoglycemia...

PREVENTION

Tailor the A1C goal to your patient. An A1C < 7% is appropriate for many patients but suggest an A1C up to 8% for those at risk for severe hypoglycemia or with multiple comorbidities. When needed, suggest medications that may cause less hypoglycemia. For example, 

  • Suggest rapid-acting insulin (Humalog) instead of regular, or a long-acting basal insulin (Lantus, Levemir) instead of NPH (Insulitard). 
  • Or for an add-on to metformin (Glucophage), suggest a gliptin (Januvia), GLP-1 agonist (Byetta), or pioglitazone (Actos) if appropriate. 
  • If a sulfonylurea is needed, suggest glipizide or glimepiride (Amaryl). They're shorter-acting and accumulate less in renal impairment. Discourage using sulfonylureas with insulin, this combo doesn't add much benefit and may increase hypoglycemia risk.

TREATMENT

Advise following the mantra, "test, treat, test, eat." Advise TESTing blood glucose when patients have symptoms of hypoglycemia (shaking, sweating, palpitations, dizziness, etc). Recommend TREATing if glucose is 70 mg/dL or lower, or below 80 to 90 mg/dL in the elderly. Suggest 15 to 20 g of simple carbohydrates (about 3-4 glucose tabs, 5-6 hard candies, 4 oz REGULAR soda, etc). Advise re-TESTing after 15 min and repeating if needed. Advise EATing small meal once glucose is back in range.

Recommend glucagon for patients at risk of severe hypoglycemia. Glucagon indicated for severe hypoglycemic reactions in patients with diabetes treated with insulin. Dose of glucagon is 1 mg (1 unit) IM/SC/IV if no IV for dextrose and repeat q15min once or twice; give dextrose as soon as it is available and if no response. Administer supplemental carbohydrate to replete glycogen stores. Advise patients to train family and friends how to use it.

REFERENCES

  • Seaquist, E.R., Anderson, J., Childs, B., Cryer, P., Dagogo-Jack, S., Fish, L., Heller, S.R., Rodriguez, H., Rosenzweig, J. and Vigersky, R. (2013). Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society. Diabetes Care, 36(5), pp.1384–1395. Available at: https://care.diabetesjournals.org/content/36/5/1384

    Barendse, S., Singh, H., Frier, B.M. and Speight, J. (2012). The impact of hypoglycaemia on quality of life and related patient-reported outcomes in Type 2 diabetes: a narrative review. Diabetic Medicine, 29(3), pp.293–302. Available at: https://pubmed.ncbi.nlm.nih.gov/21838763

    Cryer, P.E. (2008). The Barrier of Hypoglycemia in Diabetes. Diabetes, 57(12), pp.3169–3176. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2584119
Abdelwahab Ward, BS Pharm, PharmD