Technologies such as continuous glucose monitoring and insulin pumps have reduced the threat of hypoglycemia in people with diabetes. The latest Endocrine Society clinical practice guideline on hypoglycemia in diabetes urges greater adoption of these many advances in technology and medications.
The many advances in treating diabetes in recent years range from the technology of continuous glucose monitors and new kinds of insulin pumps to medications such as new insulin analogs. Clinicians and patients should use them. That’s the main message of the newly released “Management of Individuals with Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline.”
The guideline committee reviewed the evidence to confirm the effectiveness of these and other innovations in diabetes treatment, according to committee co-chairs Anthony L. McCall, MD, PhD, professor of medicine and endocrinology (Emeritus), University of Virginia, Charlottesville, and David C. Lieb, MD, the Aaron I. Vinik Professor of Medicine in Endocrinology and Diabetes; associate chair for education, Department of Internal Medicine; and program director, Endocrinology, Diabetes and Metabolism Fellowship, Eastern Virginia Medical School, Norfolk, Va.
More than 10 years have passed since the Endocrine Society published its previous hypoglycemia guideline, and that one covered hypoglycemia in both people with diabetes and those without diabetes. The new version focuses solely on people with diabetes and follows the Society’s newer guideline format, which has a renewed emphasis on the rigorous examination of evidence. The committee identified 10 key clinical questions, conducted systematic literature reviews on each of them, and developed recommendations graded according to the certainty of the evidence. The first questions looked at the glucose monitor and insulin pump technologies that have quickly spread.
Monitors and Pumps
“Continuous glucose monitoring is a powerful weapon against hypoglycemia which allows you to know your glucose levels roughly every minute to every five minutes,” McCall says. “It shows your trajectory, and that is a huge advance. If it is going down, you get alerted that you can do something to make it steady, or if it is going way up, you can give more insulin or do other things like exercise.”
The guideline recommends the use of CGM over self-monitoring with fingersticks in people with type 1 diabetes who receive multiple daily injections of insulin.
“We hope it will get people more access to the new technology and the new ways of dealing with things, and we hope that it will help everybody. People with diabetes, their caregivers, and diabetes specialists will all benefit from our guideline with a better understanding of best practices and interventions.”Anthony L. McCall, MD, PhD, professor of medicine and endocrinology (Emeritus), University of Virginia, Charlottesville, Va.
“A new kind of insulin pump system, which we call hybrid or algorithm-driven systems, are really at the cutting edge, and are commercially available to people with diabetes,” McCall says.
CGM and insulin pumps make such a powerful combination that the guideline suggests their use rather than fingerstick monitoring with multiple daily injections in people with type 1 diabetes.
Those recommendations may seem obvious to those involved in diabetes treatment, but a more controversial area that the committee explored is the use of these technologies in hospital inpatients. The Food and Drug Administration has not formally approved inpatient use of CGM but has allowed it during the covid pandemic as an infection control measure — and the guideline committee now says that the evidence accumulated from this experience has demonstrated the technology’s effectiveness.
Significantly, the guideline not only suggests that patients who are using CGM and insulin pumps prior to admission continue using them during a hospital stay, but that CGM should be initiated in the inpatient setting for select inpatients at high risk for hypoglycemia.
Mining Health Records
In another recommendation related to hospital inpatients, the guideline also endorses higher-tech approaches to managing inpatient glycemic levels by enlisting electronic health records. The guideline recommends that hospitals collect in real time and analyze glycemic data from electronic health records to identify those at risk for hypoglycemic and hyperglycemic episodes and develop mechanisms for managing these events.
This recommendation to leverage electronic health data for glycemic surveillance and management represents a significant change because standard care currently does not include the use of such programs.
New Forms of Insulin
Another area of advance is the introduction of new forms of insulin that much more closely mimic the way natural insulin acts in the body. “Insulin is one of the main medications that people take for treating diabetes,” Lieb says. “It is one of the main causes of hypoglycemia and emergency room visits for low blood sugars, so to have new tools that are more accurate and are less likely to cause hypoglycemia is very important.”
In this regard, the guideline suggests that “long-acting insulin analogs be used rather than human neutral protamine Hagedorn (NPH) insulin for adult and pediatric outpatients on basal insulin therapy who are at high risk for hypoglycemia” and that “rapid-acting insulin analogs be used rather than regular (short-acting) human insulins for adult and pediatric patients on basal-bolus insulin therapy who are at high risk for hypoglycemia.”
New Glucagon Formulations
“We also have new therapies for treating hypoglycemia in the form of new glucagon formulations,” Lieb says. “It used to be that everyone on insulin had a kit at home to get an injection of glucagon from a family member to treat a severe low blood sugar when maybe somebody had passed out. But those kits required reconstitution of the glucagon with saline before they could be injected, and many of those who tried to give it misused it, leading to no glucagon being given or underdosing of the glucagon. There are new forms of glucagon that are much easier to inject. There is even a nasal form that can be inhaled.”
The guideline therefore recommends the use of these newer glucagon formulations that do not have to be reconstituted.
Importance of Being Educated
Most people who have diabetes are not treated by diabetes specialists. “So we wanted to know whether structured education was important for helping to reduce hypoglycemia in people at risk compared with more unstructured advice,” Lieb says. “Not surprisingly, diabetes education is incredibly important in both the outpatient setting and the inpatient setting.”
Therefore, the guideline recommends that “structured education on how to avoid repeated hypoglycemia is critical, and this education should be performed by experienced diabetes clinicians.” It adds that health insurance should cover the cost of this education.
“Insulin is one of the main medications that people take for treating diabetes. It is one of the main causes of hypoglycemia and emergency room visits for low blood sugars, so to have new tools that are more accurate and are less likely to cause hypoglycemia is very important.”David C. Lieb, MD, the Aaron I. Vinik Professor of Medicine in Endocrinology and Diabetes; associate chair for education, Department of Internal Medicine; and program director, Endocrinology, Diabetes and Metabolism Fellowship, Eastern Virginia Medical School, Norfolk, Va.
The guideline has been published online and will appear in the March 2023 print issue of The Journal of Clinical Endocrinology & Metabolism.
The committee included a diverse membership and was co-sponsored by theAmerican Association of Clinical Endocrinology, American Diabetes Association, DiabetesSisters, Pediatric Endocrine Society, and Society for Hospital Medicine. “We had people not only from other disciplines, but people who were representing their disciplines,” McCall says. “We wanted to make this definitive,” in a way that all these disciplines could coalesce around endorsing.
“We hope that these exercises in trying to identify what works and what doesn’t, what is really important to do, gets to everybody who deals with diabetes, and that includes people who have diabetes,” McCall says. “We hope it will get people more access to the new technology and the new ways of dealing with things, and we hope that it will help everybody. People with diabetes, their caregivers, and diabetes specialists will all benefit from our guideline with a better understanding of best practices and interventions.”
Seaborg is a freelance writer based in Charlottesville, Va. He wrote about ENDO 2022 studies that addressed COVID-19’s impact on diabetes in the November 2022 issue.