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Hypoglycemic unawareness and glucose monitoring

Hypoglycemic unawareness and glucose monitoring

McCrimmon Hypoglycemic unawareness and glucose monitoringSong Z, Hyopglycemic H, McNay Best forms of magnesium supplements, Weikart-Yeckel C, Fan X, Glucpse VH, Sherwin RS. HbA monitofing at Hypoglyccemic months, adjusted for baseline HbA 1c visit 2center and age-group was significantly lower in the continuous glucose monitoring group mean 6. This is especially important before activities like driving a car. Tamborlane WV, Beck RW, Bode BW, et al; Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group.

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Hypoglycemic unawareness and glucose monitoring -

Patients have defective symptomatic and counterregulatory responses, in particular impaired epinephrine response to hypoglycemia. Both defective counterregulatory responses and hypoglycemia unawareness constitute the hypoglycemia-associated autonomic failure associated with recurrent iatrogenic hypoglycemia 2 , — 4.

In adults, it has been demonstrated that as little time as 2 to 3 weeks of avoidance of hypoglycemia reverses hypoglycemia unawareness and improves the attenuated epinephrine component of defective counterregulation in affected patients 5 , — 7. Although strict avoidance of hypoglycemia can restore autonomic symptoms of hypoglycemia and improve counterregulatory responses to hypoglycemia, this is difficult to achieve in practice.

Real-time continuous glucose monitoring CGM allows patients to view their blood glucose levels almost instantaneously and offers potential to reduce hypoglycemia frequency.

This study was designed to determine whether real-time CGM with preset alarms at specific glucose levels would prove a useful tool to achieve avoidance of hypoglycemia and therefore improve the counterregulatory response to hypoglycemia in adolescents with type 1 diabetes with hypoglycemia unawareness.

Adolescents with type 1 diabetes aged 12—18 years with hypoglycemia unawareness attending Princess Margaret Hospital diabetes clinics were invited to participate. Hypoglycemia unawareness score was determined by the use of modified Clarke's questionnaire 8. This questionnaire has been shown to accurately identify patients with impaired awareness of hypoglycemia for both clinical and research purposes 9.

Consent was obtained for all participants. All subjects underwent a hyperinsulinemic hypoglycemic clamp study at baseline to assess hypoglycemic symptoms and hormonal responses.

Subjects were then randomized to either standard therapy standard group or to the use of real-time Medtronic Minimed Paradigm REAL-Time System CGM CGM group for 4 weeks. At the end of the 4-week period, all patients underwent a repeat hypoglycemic clamp study. During this procedure, the antecubital vein was cannulated for insulin and glucose infusion, and blood was sampled from the contralateral hand vein placed in a box heated to 60°C.

Regular insulin Human Actrapid; Novo Nordisk, Crawley, U. Following this, blood glucose was lowered over 30 min to a nadir of 2. The blood glucose concentration of 2. Euglycemia was then restored. For the duration of the clamp procedure, blood glucose was analyzed at the bedside using a glucose oxidase technique YSI ; Yellow Springs Instruments, Yellow Springs, OH.

Additional samples of arterialised venous blood were taken to measure plasma insulin, glucagon, epinephrine, norepinephrine, cortisol, and growth hormone concentrations. The CGM group received an an additional 2 h of instructions regarding sensor insertion and usage.

Sensors were changed every 3 days. The major outcome measure was the epinephrine response to hypoglycemia measured during the hypoglycemia clamp study. Plasma epinephrine levels were measured by ELISA Diagnostika GMBH, Hamburg, Germany and samples were analyzed in duplicate.

Eleven subjects were studied, including five subjects in the standard group age At baseline, the epinephrine response to hypoglycemia was blunted, and there was no difference between subjects randomized to standard or CGM groups percentage change ± vs.

Following the intervention, there was a greater epinephrine response in the CGM group percentage change ± 83 vs. CGM group, respectively as shown in Fig. Peak adrenaline response during hypoglycemia after the intervention was also greater in the CGM group than in the standard group 1, ± vs.

Subjects in the CGM group reported higher adrenergic symptoms scores after the intervention than the standard group 5. The mean A1C at baseline was 7.

Following the intervention, there was no deterioration in glycemic control in the standard or CGM group A1C 7. The glucagon response was absent at baseline and after intervention in both groups. There was no change in cortisol and growth hormone responses to hypoglycemia for both groups.

The epinephrine response to hypoglycemia in patients with type 1 diabetes with hypoglycemia unawareness was greater after the use of real-time CGM with low glucose alarms than with standard medical therapy alone. The use of CGM was not associated with deterioration in A1C. This greater epinephrine response during hypoglycemia suggests that real-time CGM is a useful clinical tool to improve hypoglycemia unawareness in adolescents with type 1 diabetes.

The high risk of associated severe hypoglycemia requires that hypoglycemia unawareness be recognized and treated. This study demonstrates that blunted counterregulatory responses to hypoglycemia do occur in adolescents with a relatively short duration of diabetes. In addition to the blunted epinephrine response, most of these subjects reported no adrenergic symptoms during their baseline hypoglycemic clamp study.

A limitation of this study is the sample size. However, evaluating counterregulatory response with hypoglycemia clamp studies is a robust method, and this technique limits inclusion of a large number of subjects. The costs of publication of this article were defrayed in part by the payment of page charges.

Section solely to indicate this fact. Some people may be used to this level of blood glucose, and they may not have symptoms of hypoglycemia. However, this value alerts people about the risk for a further fall in glucose, so they can be active by consuming some carbohydrates.

These levels are associated with major consequences, such as losing consciousness. If a person treated with insulin or sulfonylureas has these readings often, the treatment should be reevaluated. Level 3 hypoglycemia is when a person experiences episodes that require assistance from another person for recovery because they are confused or unconscious.

A blood glucose level is not required to define hypoglycemia in this setting, but with consumption of carbohydrates, or glucagon if they are unable to take something by mouth, the person will be lucid again or recover consciousness. A: Hypoglycemia unawareness is a condition in which people treated with insulin or sulfonylurea have diminished or no ability to perceive the onset of hypoglycemia level 2.

However, if someone is exposed to recurrent episodes of hypoglycemia, the glucose level that triggers symptoms of hypoglycemia keeps getting lower and lower.

So, the person may not notice their symptoms until it is too late, and they become unconscious. The frequency is so high, many people on insulin have hypoglycemia several times a week.

Q: What are the risk factors for developing hypoglycemia unawareness? A: A person must be taking a medicine that causes hypoglycemia, such as insulin or sulfonylurea. We also see other risk factors such as having diabetes for 20 or 30 years, trying too hard to reach low glucose levels, or having trouble managing their diabetes.

Q: What are the complications of hypoglycemia unawareness? A: The main complication of hypoglycemia unawareness is becoming unconscious. Unconsciousness may lead to other problems like car accidents or accidents at work, which may result in severe injury for the person and for others.

Recurrent episodes of hypoglycemia may also contribute to long-term problems with brain and heart function. For example, people who have an episode of severe hypoglycemia are at a greater risk of having a heart attack or a stroke in the next year. It is not clear if this is only because of the hypoglycemia, or if these are just very frail people.

Health care professionals should keep this in mind and pay close attention to other risk factors for cardiovascular disease in these patients, such as hypertension and high cholesterol.

Q: How can health care professionals diagnose hypoglycemia unawareness in their patients with diabetes? A: Health care professionals should talk to their patients about hypoglycemia at every visit, and they should ask their patients how low their blood sugar has to go before they have symptoms.

This should prompt the health care professional to think about why the patient is experiencing episodes of hypoglycemia. Is the patient using too much insulin? Is the patient skipping meals? Has the patient changed their physical activity level?

This also reminds us that these patients should carry glucagon with them, and someone—a family member, coworker, or teacher—should know how to access and administer it.

Q: How can health care professionals help patients manage hypoglycemia unawareness? A: Continuous glucose monitors are very good tools for patients that are at risk of hypoglycemia unawareness, because the CGM will alert them if their blood glucose level gets too low.

Patients also will know what their blood glucose level is before they drive, and have insights into how food and exercise affect their glycemia. Health care professionals should also make sure that patients understand that they need to be aware of some circumstances that may put them at risk.

The same is true for alcohol—if patients drink alcohol, it increases the risk of hypoglycemia, so they should be reminded to eat food if they are going to drink. Diabetes Care. Cryer PE. The barrier of hypoglycemia in diabetes. Rehni AK, Dave KR.

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Characterizing blood glucose variability using new metrics with continuous glucose monitoring data. Download references.

We would like to give sincere thanks to the research staff who participated in this work and the patients for supporting the program. This work was funded by the Natural Science Foundation of Fujian Province, China No. Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.

The Third Clinical Medical College of Fujian Medical University, Fujian, China. Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.

You can also search for this author in PubMed Google Scholar. QJ and BH wrote the draft of the manuscript. XS performed the statistical analysis. All authors were involved in the study design, interpretation of data, and review of the manuscript.

All authors read and approved the final manuscript. Correspondence to Xiulin Shi or Xuejun Li. This study has been approved by the Ethical Review Authority in The First Affiliated Hospital of Xiamen University Number: Participants gave informed consent to participate in the study before taking part.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Analysis of influencing factors of AH, Level 1 AH, and Level 2 AH by univariate logistic regression model. Open Access This article is licensed under a Creative Commons Attribution 4.

The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Reprints and permissions. Huang, B. et al. Hypoglycemia unawareness identified by continuous glucose monitoring system is frequent in outpatients with type 2 diabetes without receiving intensive therapeutic interventions.

Each Hypoglycemic unawareness and glucose monitoring reaction to unawarenesx is different. As unpleasant as they may be, these symptoms Hypoglucemic useful as unawarenses help let you know that action is unawareeness to correct a Fueling your exercise regimen blood sugar. This is called hypoglycemia unawareness. People with hypoglycemia unawareness are not able to tell when their blood sugar goes too low and may need help from someone else to treat it — this is also known as a severe low. If you or someone you know has hypoglycemia unawareness, it is important to check blood sugar frequently or wear a continuous glucose monitor CGM. Hypoglycemic unawareness and glucose monitoring

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