Hypoglycaemia in primary care: ask and you will find it
Primary care is an ideal place to identify hypoglycaemia and help patients to avoid it in the future, according to the latest Primary Care Diabetes Europe (PCDE) webinar
If you look at the data and ask enough patients, hypoglycaemia is common in clinical practice, according to Kamlesh Khunti, Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester.
Alongside Pratik Choudhary, Professor of Diabetes at the University of Leicester, Professor Khunti presented a useful webinar for PCDE on how hypoglycaemia can be identified and addressed in primary care.
He began with the data. Figures on prevalence vary, but one of the biggest studies (the 2016 Hypoglycaemia Assessment tool [HAT] study) involved over 25,000 patients using insulin and used four-week prospective diaries in 24 countries. It found that 46.5% of people with type 2 diabetes who were on insulin reported hypoglycaemia, with an average of 20 episodes per person, per year. And they saw a global average of 2.5 severe hypos a year in the type 2 group. This is higher than you would see in randomised controlled trials because the availability of therapies and education programmes varies from country to country.
To be clear on definition, severe hypoglycaemia is a hypoglycaemic event that requires the assistance of another person to recover, with possible hospitalisation; non-severe or mild can be managed by the person themselves but includes symptoms such as pounding heart, sweating and confusion; nocturnal hypoglycaemia happens at night, usually during sleep.
A US study showed that the risk of severe hypoglycaemia was three to five times higher in people on insulin and those on secretagogues, and 10-12 times higher than those on non-secretagogue medications. It also found that higher HbA1c (8-9%) was associated with higher rates.
How do you assess someone for their hypo risk?
It is vital to identify who is at high risk of severe hypoglycaemia in the future and one of the simplest ways to do this is by establishing awareness status.
This is especially important for people on insulin and for those with type 1 diabetes. A simple tool is the Gold Score, which asks: How aware are you that your hypos are commencing? 1 is ‘always’ and 7 is ‘never’. If the patient scores 5, 6 or 7, they have impaired awareness and their risk of a severe event is about five times higher.
Questions you can also ask in primary care include:
- How often are you getting a glucose measurement of <70 mg/dl (3.9 mmol/l)?
- Have you ever needed someone else to help you treat a hypo?
- Do others recognise your hypos before you do?
Every patient has a different level of hypoglycaemia risk and so individualised, risk-appropriate treatment targeting is vital. Professors Khunti and Choudhary looked at this using two hypothetical but fairly typical cases.
The first was a 58-year-old woman, active, no other medical issues, body mass index (BMI) 31.6, blood pressure (BP) 136/78, has had type 2 diabetes for six years, on metformin, GLP-1 receptor agonist, a statin and angiotensin-converting enzyme (ACE) inhibitor, HbA1c 8.7%.
First, said Professor Khunti, what is the individualised HbA1c target you want to reach for this patient? She is young and hasn’t had diabetes for a very long time. She’s overweight. She’s got a lot to gain from a low target of 7%. You might consider basal insulin and so the conversation would be started around this, covering why it’s important to bring sugars down and the only way to get to an HbA1c of 7% is with insulin. You should also check that she’s adherent to other drugs (for example, about 30% of people stop taking GLP-1 receptor agonists within six months).
He emphasised the importance of giving patients time to absorb and consider information – not everyone is immediately ready for insulin and a short consultation is not long enough to discuss a lifelong therapy. She might need time to think about it and come back with more questions or require a further discussion with a specialist nurse. If time is not invested in the patient at this point, adherence can be low.
When it comes to hypoglycaemia, her risk is incredibly low, but does she know what it is? It’s unlikely as she’s not on therapy that puts her at high risk, so it would need explaining. It is often the case that people are completely unaware of what it is or how to avoid it.
Professor Choudhary added here that there is a delicate balance between this person wanting her HbA1c to be lower but not creating too much fear – her fear of hypo might end up outweighing the risk of her actual chance of having one – and this needs to borne in mind when having conversations in primary care because it can affect behaviour, such as avoiding exercise or snacking too much (more on this below).
To demonstrate how a small change in profile would alter the treatment strategy, Professor Choudhary changed the patient’s age to 72. She may now be less fit and active and her ability to recognise hypoglycaemia is different (people in their 70s tend to get symptoms at the same time as the onset of confusion, putting them at higher risk, whereas younger patients tend to get symptoms before the confusion). Professor Khunti said he wouldn’t aim for such a tight HbA1c target in this patient, maybe 7.5% or even 8%.
In the second profile, we had a 67-year-old bus driver, with an HbA1c of 8.7%, already on basal insulin and other medications, but discussion here centred around adding in bolus insulin. As soon as you start this, the risk of hypo increases, but this risk can be reduced with the right equipment, education and therapy.
What may cause greater harm – hypo or fear of hypo?
To expand on his point about how you have the conversation about hypoglycaemia, Professor Choudhary showed a Karolinska Institute survey on fear of hypo in 400 patients, which revealed four groups:
43% had low fear/low risk – a group where the risk and fear of hypo are well matched.
32% had high fear/low risk – these are the people where fear of hypo is pushing the glucose up and they’re not getting to target because they’re constantly eating or under-dosing.
17% had high fear, high risk – a group that are appropriately concerned and take the right precautions and actions.
8% had low fear, high risk – this is the most worrying group as repeated episodes of mild hypoglycaemia can lead to severe events. This is often seen in younger patients.
Which box is your patient in? Do they need education intervention? This is where time is needed with the patient to help them understand their risk.
Professor Khunti presented another slide showing a checklist you can use to find the people with type 2 diabetes who are at high risk of a severe event. Those at the highest risk can be identified by asking about previous admissions for hypoglycaemia – more than three is a major predictor of a future event or one to two if also on insulin. The full checklist can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624849/.
How do you manage hypoglycaemia risk?
If you find someone to be at high risk, discuss ways to reduce it. These include…
- Education on identification and treatment – education programmes have been shown in randomised controlled trials to reduce risk of hypoglycaemia
- Newer agents with lower hypo risk
- De-intensification of therapies
- Risk-appropriate targets
- Use of technology for monitoring
- Social and care support
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.