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ADA proposes general goals that are ap-\npropriate for many people but empha-sizes the importance of individualizationb a s e do nk e yp a t i e n tc h a r a c t e r i s t i c s .G l y -\ncemic goals must be individualized in the\ncontext of shared decision-making to ad-dress individual needs and preferencesand conside... | [
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ence risks and bene fits of therapy; this\napproach may optimize engagement andself-ef ficacy.\nThe factors to consider in individualiz-\ning goals are depicted in Fig. 6.2 . This\nfigure is not designed to be applied rig-\nidly in the care of a given individual butto be used as a broad framework to guide\nclinical decisi... | [
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clinical decision-making (36) and engage\npeople with type 1 and type 2 diabetes inshared decision-making. More aggressivegoals may be recommended if they can\nbe achieved safely and with an acceptable | [
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be achieved safely and with an acceptable\nburden of therapy and if life expectancy issufficient to reap the benefi ts of stringentgoals. Less stringent goals (e.g., A1C up to8% [64 mmol/mol]) may be recommendedif the individual ’s life expectancy is such\nthat the bene fits of an intensive goal may\nnot be realized or if... | [
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not be realized or if the risks and burdens\noutweigh the potential benefi ts. Severe or\nfrequent hypoglycemia is an absolute indi-\ncation for the modi fication of treatment\nplans, including setting higher glycemic\ngoals.\nDiabetes is a chronic disease that pro-\ngresses over decades. Thus, a goal that | [
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gresses over decades. Thus, a goal that\nmight be appropriate for an individualearly in the course of their diabetes may\nchange over time. Newly diagnosed indi-\nviduals and/or those without comorbiditiesthat limit life expectancy may benefi tf r o m\nintensive glycemic goals proven to prevent\nmicrovascular complicati... | [
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microvascular complications. Both DCCT/\nEDIC and UKPDS suggested that there ismetabolic memory, or a legacy effect, inwhich a finite period of intensive glucose\nlowering yielded bene fits that extended | [
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lowering yielded bene fits that extended\nfor decades after that period ended. How-ever, there are few recent data on the ef-fects of long-term glucose lowering usingmodern treatment strategies. Thus, a fi-\nnite period of intensive treatment tonear-normal A1C may yield enduring ben-efits even if treatment is subsequently... | [
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intensifi ed as characteristics change. Over\ntime, comorbidities may emerge, decreas-ing life expectancy and thereby decreas-ing the potential to reap bene fits from\nintensive treatment. Also, with longer dis-ease duration, diabetes may become\nmore dif ficult to control, with increasing\nrisks and burdens of therapy. T... | [
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risks and burdens of therapy. Thus, glyce-\nmic goals should be reevaluated overtime to balance the risks and bene fits.\nAccordingly, clinicians should continue\nto evaluate the balance of risks and ben-efits of diabetes medications for individu-\nals who have achieved individualizedglycemic goals, and they should deint... | [
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sify (decrease the dose or stop) diabetes\nmedications where their risks exceedtheir bene fits. Hypoglycemia is the major\nrisk to individuals treated with insulin,\nsulfonylureas, or meglitinides, and it is\nappropriate to deintensify these medica-\ntions where there is a high risk for hypo-glycemia (see\nHYPOGLYCEMIA ... | [
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HYPOGLYCEMIA RISK ASSESSMENT ,\nbelow). Switching a high-hypoglycemia-risk\nmedication to lower-hypoglycemia-risk\ntherapy (see Section 9, “Pharmacologic\nApproaches to Glycemic Treatment ”)\nshould be considered if needed to achieve\nindividualized glycemic goals or where in- | [
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individualized glycemic goals or where in-\ndividuals have evidence-based indicationsdiabetesjournals.org/care Glycemic Goals and Hypoglycemia S117\n©AmericanDiabetesAssociation | [
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for alternative medications (e.g., use of\nSGLT2 inhibitors in the setting of heartfailure or diabetic kidney disease and useof GLP-1 receptor agonists in the settingof CVD or obesity). Clinicians should alsoconsider medication burdens other thanhypoglycemia, including tolerability, dif ficul- | [
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ties of administration, impact on educationor employment, and financial cost. These\nfactors should be balanced against bene-fits from glycemic lowering and disease-\nspeci ficb e n e fits of newer medications\nthat may be independent of glycemiclowering (Section 9, “Pharmacologic\nApproaches to Glycemic Treatment ”). | [
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Approaches to Glycemic Treatment ”).\nMultiple trials have shown that deinten-sification of diabetes treatment can be\nachieved successfully and safely (65 –68).\nIt is important to partner with peoplewith diabetes during the deintensi fication\nprocess to understand their goals of diabe-tes treatment and agree upon appr... | [
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ate glycemic monitoring, glucose levels,\nand goals of care (69).\nHYPOGLYCEMIA ASSESSMENT,\nPREVENTION, AND TREATMENT\nRecommendations\n6.11a History of hypoglycemia should\nbe reviewed at every clinical encoun-\nter for all individuals at risk for hypo-glycemia and evaluated as indicated. C\n6.11b Clinicians should s... | [
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6.11b Clinicians should screen all in-\ndividuals at risk for hypoglycemiafor impaired hypoglycemia aware-ness. E\n6.11c Clinicians should consider an\nindividual ’s risk for hypoglycemia\n(see Table 6.5) when selecting diabe-\ntes medications and glycemic goals. E\n6.11d Use of CGM is bene ficial and | [
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6.11d Use of CGM is bene ficial and\nrecommended for individuals at highrisk for hypoglycemia. A\n6.12 Glucose is the preferred treat-\nment for the conscious individual withglucose <70 mg/dL ( <3.9 mmol/L),\nalthough any form of carbohydratethat contains glucose may be used.Fifteen minutes after initial treat-\nment, r... | [
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ment, repeat the treatment if hy-\npoglycemia persists. B\n6.13 Glucagon should be prescribed\nfor all individuals taking insulin or athigh risk for hypoglycemia. Family, care-givers, school personnel, and others\nproviding support to these individuals\nshould know its location and be edu-cated on how to administer it.... | [
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have to be reconstituted are pre-ferred. E\n6.14 All individuals taking insulin A\nor at risk for hypoglycemia Cshould\nreceive structured education for hy-\npoglycemia prevention and treat-ment, with ongoing education forthose who experience hypoglycemicevents.\n6.15 O n eo rm o r ee p i s o d e so fl e v e l2\nor 3 h... | [
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or 3 hypoglycemia should prompt\nreevaluation of the treatment plan, in-\ncluding deintensifying or switching dia-\nbetes medications if appropriate. E\n6.16 Refer individuals with impaired\nhypoglycemia awareness to a trained\nhealth care professional to receiveevidence-based intervention to helpreestablish awareness ... | [
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6.17 Ongoing assessment of cognitive\nfunction is suggested with increased vig-\nilance for hypoglycemia by the clinician,\npatient, and caregivers if impaired or\ndeclining cognition is found. B\nHypoglycemia Defi nitions and Event\nRates\nHypoglycemia is often the major limiting\nfactor in the glycemic management of\n... | [
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type 1 and type 2 diabetes. Recommen-\ndations regarding the classi fication of\nhypoglycemia are outlined in Table 6.4\n(70). Level 1 hypoglycemia is de fined as\na measurable glucose concentration\n<70 mg/dL ( <3.9 mmol/L) but $54 mg/dL\n($3.0 mmol/L). A blood glucose con-\ncentration of 70 mg/dL (3.9 mmol/L)\nhas been... | [
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has been recognized as a threshold for\nneuroendocrine responses to falling glu-\ncose in people without diabetes. Symp-\ntoms of hypoglycemia include, but are\nnot limited to, shakiness, irritability, con-\nfusion, tachycardia, sweating, and hunger\n(71). Because many people with diabetes\ndemonstrate impaired counter... | [
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demonstrate impaired counterregulatory\nresponses to hypoglycemia and/or expe-\nrience impaired hypoglycemia awareness,a measured glucose level <70 mg/dL\n(<3.9 mmol/L) is considered clinically im-\nportant, regardless of symptoms. Level 2\nhypoglycemia (de fined as a blood glucose\nconcentration <54 mg/dL [ <3.0 mmol/L... | [
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concentration <54 mg/dL [ <3.0 mmol/L])\nis the threshold at which neuroglycopenicsymptoms begin to occur and requires im-mediate action to resolve the hypoglyce-\nmic event. If an individual has level 2\nhypoglycemia without adrenergic or neu-roglycopenic symptoms, they likely haveimpaired hypoglycemia awareness (dis-... | [
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HYPOGLYCENMIA RISK ASSESSMENT ,\nbelow). This clinical scenario warrants inves-tigation and review of the treatment plan\n(72,73). Lastly, level 3 hypoglycemia is de-\nfined as a severe event characterized by al-\ntered mental and/or physical functioningthat requires assistance from another per-son for recovery, irrespe... | [
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Hypoglycemia has a broad range of\nnegative health consequences (74). Level 3\nhypoglycemia may be recognized or un- | [
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hypoglycemia may be recognized or un-\nrecognized and can progress to loss ofconsciousness, seizure, coma, or death.Level 3 hypoglycemia was associated withmortality in both the standard and the in-tensive glycemia arms of the ACCORD trial,but the relationships between hypoglyce-\nmia, achieved A1C, and treatment inten... | [
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mia, achieved A1C, and treatment inten-\nsity were not straightforward (75). Anassociation of level 3 hypoglycemia withmortality was also found in the ADVANCEtrial and in clinical practice (76,77). Hypo-glycemia can cause acute harm to the per-son with diabetes or others, especially if it\ncauses falls, motor vehicle a... | [
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causes falls, motor vehicle accidents, or\nother injury (78). Hypoglycemia may alsocause substantial anxiety that can reducethe quality of life of individuals with dia-betes and their caregivers and may con-tribute to problems with diabetes self-management and treatment (79 –81). | [
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Recurrent level 2 hypoglycemia and/orlevel 3 hypoglycemia is an urgent medi-cal issue and requires intervention withmedical treatment plan adjustment, be-havioral intervention, delivery of diabetes\nTable 6.4 —Classi fication of hypoglycemia\nGlycemic criteria/description\nLevel 1 Glucose <70 mg/dL ( <3.9 mmol/L) and $5... | [
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0.005376911256462336,
0.018862368538975716,
0.02917320281267166,
-0.04794236272573471,
-0.04505692422389984,
-0.009203057736158371,
0.07227655500173569,
-0.05104031041264534,
-0.059218648821115494,
-0.021074814721941948,
-0.05084903538227081,
-0.0021287323907017708,
-0... |
Level 1 Glucose <70 mg/dL ( <3.9 mmol/L) and $54 mg/dL ( $3.0 mmol/L)\nLevel 2 Glucose <54 mg/dL ( <3.0 mmol/L)\nLevel 3 A severe event characterized by altered mental and/or physical status requiring\nassistance for treatment of hypoglycemia, irrespective of glucose level | [
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0.06829867511987686,
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0.05415354669094086,
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0.06383626908063889,
0.12130363285541534,
-0.03138583153486252,
0.0006068966467864811,
-0.04618636891245842,
-0.04332110658288002,
-0.05065436288714409,
0.00815... |
Reprinted from Agiostratidou et al. (70).S118 Glycemic Goals and Hypoglycemia Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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0.030342310667037964,
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0.07736773043870926,
0.02416490763425827,
0.03828227519989014,
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0.060450658202171326,
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0.041913773864507675,
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self-management education and support,\nand use of technology to assist with hypo-\nglycemia prevention and identi fication\n(73,82 –85).\nStudies of rates of hypoglycemia pre-\ndominantly rely on claims data for hospi-\ntalizations and emergency department\nvisits (86 –89). These studies do not cap- | [
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0.047041699290275574,
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0.02859831042587757,
-0.022822316735982895,
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0.022016... |
visits (86 –89). These studies do not cap-\nture the level 1 and level 2 hypoglycemiathat represent the vast majority of hypo-\nglycemic events, and they also substan-\ntially underestimate level 3 hypoglycemia\n(86,90). Nevertheless, they reveal a sub-\nstantial burden of hypoglycemia-related\nhospital utilization in ... | [
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0.04100318253040314,
0.02007085271179676,
0.09482687711715698,
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0.08741725981235504,
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0.01067... |
hospital utilization in the community (86 –89).\nLevel 1 and level 2 hypoglycemia can be as-certained from patient self-report (91) and\nare strong risk factors for subsequent level 3\nhypoglycemia.Hypoglycemia Risk Assessment\nAssessment of an individual’ sr i s kf o rh y p o -\nglycemia includes evaluating clinical r... | [
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0.02... |
glycemia includes evaluating clinical risk\nfactors as well as relevant social, cultural,and economic factors ( Table 6.5 ). Recom-\nmendations 6.11 –6.17 group individuals\nwith diabetes into two hypoglycemia riskcategories with clinical signi ficance. Indi- | [
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0.04459591209888458,
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0.033995985984802246,
0.07831498235464096,
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0.009449847973883152,
-0.017096221446990967,
-0.0060428050346672535,
-0.05750304460525513,
-0.05... |
viduals at risk for hypoglycemia are thosetreated with insulin, sulfonylureas, or me-glitinides; clinically signi ficant hypoglyce- | [
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0.0616486594080925,
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0.0834389179944992,
0.10728106647729874,
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-0.018824752420186996,
-0.013628759421408176,
-0.0... |
mia is rare among individuals taking otherdiabetes medication classes (92,93). Indi-viduals at high risk for hypoglycemia arethe subset of individuals at risk for hypogly-cemia who either have a major hypoglyce-mia risk factor or have multiple other riskfactors (determined by the health care pro-fessional incorporating... | [
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0.048357848078012466,
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0.022976942360401154,
0.12958639860153198,
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0.032536279410123825,
-0.05211227387189865,
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... |
health care pro-fessional incorporating clinical judgment)(Table 6.5 ). This risk strati fication is based | [
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0.10306932032108307,
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0.0008340463973581791,
0.029692260548472404,
0.07602810859680176,
0.0691371038556099,
0.14179381728172302,
-0.03143329545855522,
0.013147655874490738,
0.02780560590326786,
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0.0029504760168492794,
0.02936640... |
on epidemiologic studies of hypoglycemia\nrisk (87,88,92,94– 97). Validated tools have\nbeen developed to estimate hypoglyce-mia risk using predominantly electronic\nhealth record data (98 –100). However,\nthese tools do not include all of the im-\nportant hypoglycemia risk factors, andmore research is needed to determ... | [
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0.08160751312971115,
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0.039750147610902786,
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0.05668148398399353,
0.12677186727523804,
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how they can best be incorporated into\nclinical care.\nAmong individuals at risk for hypoglyce-\nmia, prior hypoglycemic events, especiallylevel 2 or 3 events, are the strongest risk\nfactors for hypoglycemia recurrence and\nseverity (96,101 –103). Hypoglycemia his-\ntory should be assessed at every clinicalencounter ... | [
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0.002384814200922847,
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0.0083... |
mic event frequency, severity, precipi-\ntants, symptoms (or lack thereof), andapproach to treatment. It is essential tocorrelate home glucose readings, bothfrom glucose meters and CGM systems,\nwith symptoms and treatment, as individ- | [
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0.0026723... |
with symptoms and treatment, as individ-\nuals may experience and treat hypoglyce-mic symptoms without checking theirglucose level (104), treat normal glucose\nvalues as hypoglycemic, or tolerate hypo-\nglycemia without treatment either be-cause of lack of symptoms or to avoidhyperglycemia.\nIndividuals at risk for hyp... | [
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0.056123897433280945,
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0.03768201917409897,
0.08548212051391602,
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0.0... |
Individuals at risk for hypoglycemia\nshould also be screened for impaired hy-poglycemia awareness (also called hypo-glycemia unawareness or hypoglycemia-associated autonomic failure) at least\nyearly. Impaired hypoglycemia awareness\nis defined as not experiencing the typical | [
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0.01739433966577053,
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0.052474044263362885,
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0.009242705069482327,
0.09085281193256378,
0.07837751507759094,
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0.012195935472846031,
0.012736493721604347,
-0.06750670820474625,
-0.007... |
is defined as not experiencing the typical\ncounterregulatory hormone release atlow glucose levels or the associated symp-toms, which often occurs in individuals\nwith long-standing diabetes or recurrent\nhypoglycemia (105). Individuals with impairedhypoglycemia awareness may experienceconfusion as the first sign of hypo... | [
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0.030230039730668068,
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0.015224617905914783,
0.05394566431641579,
0.07682540267705917,
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0.02332882024347782,
0.013505140319466591,
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which can create fear of hypoglycemia andseverely impact quality of life (106). Impairedhypoglycemia awareness dramatically in-creases the risk for level 3 hypoglycemia\n(107). The Clark and Gold scores are vali- | [
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0.019230375066399574,
-0.07168374210596085,
0.11909706890583038,
0.023610413074493408,
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0.0762096494436264,
0.05741725489497185,
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-0.05248986557126045,
0.009174409322440624,
0.0138591593131423,
-0.041257... |
(107). The Clark and Gold scores are vali-\ndated questionnaires to assess impaired hy-poglycemia awareness (108,109). However,these questionnaires may be impractical forroutine clinical use. A recommended strat-\negy is to screen for impaired hypoglycemia | [
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0.02400309219956398,
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0.07508975267410278,
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0.017687814310193062,
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-0.01520... |
egy is to screen for impaired hypoglycemia\nawareness by asking individuals whetherthey ever have low blood glucose withoutfeeling symptoms, or by asking at what\nblood glucose levels they typically begin to\nfeel symptoms (and what those symptomsTable 6.5 —Assessment of hypoglycemia risk among individuals treated with | [
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0.08302918821573257,
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0.04875898361206055,
0.03044445998966694,
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0.070626400411129,
0.11162301152944565,
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-0.017988761886954308,
-0.08268693089485168,
-0.055084824562072754,
-0.03401020... |
insulin, sulfonylureas, or meglitinides\nClinical/biological risk factors Social, cultural, and economic risk factors\nMajor risk factors\n/C15Recent (within the past 3 –6 months) level 2\nor 3 hypoglycemia\n/C15Intensive insulin therapy*\n/C15Impaired hypoglycemia awareness\n/C15End-stage kidney disease | [
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0.016150403767824173,
0.0004809956008102745,
0.011886890977621078,
0.009532496333122253,
0.08183297514915466,
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-0.03580709546804428,
-0.016277920454740524,
-0.01461371686309576,
-0.03695295378565788,
0.... |
/C15Impaired hypoglycemia awareness\n/C15End-stage kidney disease\n/C15Cognitive impairment or dementiaMajor risk factors/C15Food insecurity\n/C15Low-income status§\n/C15Homelessness\n/C15Fasting for religious or cultural reasons\nOther risk factors/C15Multiple recent episodes of level 1hypoglycemia\n/C15Basal insulin ... | [
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0.02750527299940586,
0.08494649827480316,
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-0.03522... |
/C15Basal insulin therapy*\n/C15Age$75 years †\n/C15Female sex\n/C15High glycemic variability ‡\n/C15Polypharmacy\n/C15Cardiovascular disease\n/C15Chronic kidney disease (eGFR <60 mL/min/\n1.73 m\n2or albuminuria)\n/C15Neuropathy\n/C15Retinopathy\n/C15Major depressive disorderOther risk factors/C15Low health literacy\n... | [
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-0.0178... |
/C15Alcohol or substance use disorder\nMajor risk factors are those that have a consistent, independent association with a highrisk for level 2 or 3 hypoglycemia. Other risk factors are those with less consistent evidenceor a weaker association. These risk factors are identi fied through observational analyses | [
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0.03354617580771446,
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0.0470904968... |
and are intended to be used for hypoglycemia risk strati fication. Individuals considered at\nhigh risk for hypoglycemia are those with $1 major risk factor or who have multiple other | [
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0.09078051149845123,
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0.000550... |
risk factors (determined by the health care professional incorporating clinical judgment)(87,88,92,94 –97,113,146). Proximal causes of hypoglycemic events (e.g., exercise and sleep)\nare not included. eGFR, estimated glomerular filtration rate. *Rates of hypoglycemia are | [
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0.1088392436504364,
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0.012566904537379742,
-0.03121885471045971,
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0.005162507761269808,
0.0131951... |
highest for individuals treated with intensive insulin therapy (including multiple daily injectionsof insulin, continuous subcutaneous insulin infusion, or automated insulin delivery systems), fol-\nlowed by basal insulin, followed by sulfonylureas or meglitinides. Combining treatment with insu- | [
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0.03752424567937851,
0.08291170746088028,
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0.04741... |
lin and sulfonylureas also increases hypoglycemia risk. †Accounting for treatment plan and\ndiabetes subtype, the oldest individuals (aged $75 years) have the highest risk for hypogly-\ncemia in type 2 diabetes; younger individuals with type 1 diabetes are also at very high | [
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0.06620260328054428,
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risk. ‡Tight glycemic control in randomized trials increases hypoglycemia rates. In observa-\ntional studies, both low and high A1C are associated with hypoglycemia in a J-shaped rela-\ntionship. §Includes factors associated with low income, such as being underinsured or living | [
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in a socioeconomically deprived area.diabetesjournals.org/care Glycemic Goals and Hypoglycemia S119\n©AmericanDiabetesAssociation | [
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-0.048... |
are), and follow up positive responses with\na more detailed evaluation (105,110).\nOther notable clinical and biological risk\nfactors for hypoglycemia are older age, mul-timorbidity, cognitive impairment, chronic\nkidney disease and end-stage kidney dis- | [
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0.0038825368974357843,
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0.0021509509533643723,
-0.021895132958889008,
... |
kidney disease and end-stage kidney dis-\nease in particular, CVD, depression, andneuropathy (92,93). Female sex has alsobeen found to be an independent risk fac-\ntor for hypoglycemia in multiple studies, al- | [
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0.03512829169631004,
-0.020406953990459442,
0.07186214625835419,
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0.07074883580207825,
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0.05963548645377159,
-0.0547664612531662,
0.031439755111932755,
-0.029411153867840767,
0.... |
tor for hypoglycemia in multiple studies, al-\nthough the mechanisms of this relationshipare unclear and require further research(92). Cognitive impairment has a strong bi-directional association with hypoglycemia,\nand recurrent severe hypoglycemic epi-\nsodes were associated with a greater de-cline in psychomotor and... | [
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0.017406783998012543,
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0.011698948219418526,
0.01645021140575409,
0.018... |
after long-term follow-up of the DCCT/EDIC\ncohort (111). Therefore, cognitive function\nshould be routinely assessed among olderadults with diabetes.\nThere are a number of important social,\ncultural, and economic hypoglycemia risk\nfactors that should considered. Food inse- | [
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0.011946134269237518,
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0.03025498241186142,
0.029051031917333603,
0.03896846994757652,
-0.08333659172058105,
0.0238167420... |
factors that should considered. Food inse-\ncurity is associated with increased risk ofhypoglycemia-related emergency depart-ment visits and hospitalizations in low-\nincome households, and this was shown\nto be mitigated by increased federal nutri-tion program benefi ts (112). In general, in-\ndividuals with low annual... | [
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0.0348622165620327,
0.11214292049407959,
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0.016503557562828064,
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dividuals with low annual household\nincomes (93), individuals who live in so-\ncioeconomically deprived areas (96), andindividuals who are underinsured (97) orhomeless (113) experience higher rates ofemergency department visits and hospital-\nizations for hypoglycemia. Clinicians should | [
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izations for hypoglycemia. Clinicians should\nalso be aware of cultural practices thatmay in fluence glycemic management\n(which are discussed in detail in Section 5,\n“Facilitating Positive Health Behaviors ”),\nsuch as fasting as part of religious obser-\nvance. Fasting may increase the risk for hy-poglycemia among in... | [
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with insulin or insulin secretagogues if not\nproperly planned for, so clinicians need toengage these individuals to codevelop a di-abetes treatment plan that is safe and re-\nspectful of their traditions (114).\nYoung children with type 1 diabetes and\nthe elderly, including those with type 1 and | [
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the elderly, including those with type 1 and\ntype 2 diabetes (115,116), are noted as be-ing particularly vulnerable to hypoglycemia\nbecause of their reduced ability to recognize\nhypoglycemic symptoms and effectivelycommunicate their needs. Individualizedglycemic goals, patient education, nutritionintervention (e.g.,... | [
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overnight hypoglycemia when speci fically\nneeded to treat low blood glucose), physicalactivity management, medication adjust-\nment, glucose monitoring, and routine clinical | [
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ment, glucose monitoring, and routine clinical\nsurveillance may improve outcomes (105).CGM with automated low-glucose suspendand automated insulin delivery systems havebeen shown to be effective in reducing hypo-glycemia in type 1 diabetes (117). For peoplewith type 1 diabetes with level 3 hypoglyce-\nmia and hypoglyc... | [
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mia and hypoglycemia unawareness that per-\nsists despite medical treatment, human islettransplantation may be an option, but the ap-proach remains experimental (118,119).\nHypoglycemia Treatment | [
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Hypoglycemia Treatment\nHealth care professionals should counselindividuals with diabetes to treat hypogly-cemia with fast-acting carbohydrates atthe hypoglycemia alert value of 70 mg/dL(3.9 mmol/L) or less (120 –122). Individu- | [
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als should be counseled to recheck theirglucose 15 min after ingesting carbohy-drates and to repeat carbohydrate ingestionand seek care for ongoing hypoglycemia.These instructions should be reviewed ateach clinical visit.\nFor most individuals, 15 g carbohydrates\nshould be ingested. Individuals using auto-mated insuli... | [
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mended to ingest 5 –10 g carbohydrates\n(except for hypoglycemia with exercise or\nwith signi ficant overestimation of carbohy-\ndrate/meal bolus) (123). The acute glyce-mic response to food correlates betterwith the glucose content than with the to-tal carbohydrate content. Pure glucose is\nthe preferred treatment, but... | [
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the preferred treatment, but any form of\ncarbohydrate that contains glucose willraise blood glucose. Added fat may slowa n dt h e np r o l o n gt h ea c u t eg l y c e m i cr e -sponse. Carbohydrate sources high in pro-tein may increase insulin secretion andshould not be used to treat hypoglycemia(124). Ongoing insuli... | [
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secretagogues may lead to recurrent hypo-\nglycemia unless more food is ingested afterrecovery.\nGlucagon\nThe use of glucagon is indicated for thetreatment of hypoglycemia in people un-able or unwilling to consume carbohy-drates by mouth. All individuals treatedwith insulin or who are at high risk of hypo-glycemia as ... | [
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scribed glucagon. For these individuals,\nclinicians should routinely review their ac-cess to glucagon, as appropriate glucagonprescribing is very low in current practice(125,126). An individual does not need tobe a health care professional to safely ad-\nminister glucagon. Those in close contact | [
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... |
minister glucagon. Those in close contact\nwith, or having custodial care of, these in-dividuals (family members, roommates,school personnel, childcare professionals,\ncorrectional institution staff, or coworkers)\nshould be instructed on the use of gluca-gon, including where the glucagon productis kept and when and ho... | [
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0.06... |
It is essential that they be explicitly edu-\ncated to never administer insulin to individ-uals experiencing hypoglycemia. Glucagonwas traditionally dispensed as a powder that\nrequires reconstitution prior to injection. | [
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0.07569941878318787,
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0.004... |
requires reconstitution prior to injection.\nHowever, intranasal and ready-to-inject glu-cagon preparations are now widely availableand are preferred due to their ease of admin-\nistration resulting in more rapid correction of\nhypoglycemia (127 –130). Although physical | [
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0.10651233792304993,
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0.04296129569411278,
0.033039018511772156,
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... |
hypoglycemia (127 –130). Although physical\nand chemical stability of glucagon is im-proved with newer formulations, care should\nbe taken to replace glucagon products when\nthey reach their expiration date and storeglucagon based on speci fic product instruc-\nt i o n st oe n s u r es a f ea n de f f e c t i v eu s e .... | [
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0.11179383099079132,
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0.015783734619617462,
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-0... |
t i o n st oe n s u r es a f ea n de f f e c t i v eu s e .F o r\ncurrently available glucagon products and\nassociated costs, see Table 6.6 . Health insur-\nance providers may prefer only select gluca-gon products, so it is important to check\nindividuals’ insurance coverage and prescribe\nformulary products whenever ... | [
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0.01205014530569315,
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0.0014736347366124392,
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0.02657570317387581,
0.09823276102542877,
0.11607687920331955,
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0.02849932387471199,
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formulary products whenever possible.\nHypoglycemia Prevention\nA multicomponent hypoglycemia preven-\ntion plan ( Table 6.7 )i sc r i t i c a lt oc a r i n g\nfor individuals at risk for hypoglycemia.\nHypoglycemia prevention begins by es-\ntablishing an individual ’s hypoglycemia\nhistory and risk factors, as discuss... | [
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0.01243531517... |
history and risk factors, as discussed in\nHYPOGLYCEMIA RISK ASSESSMENT above. Structured\npatient education for hypoglycemia pre-vention and treatment is critical and hasbeen shown to improve hypoglycemiaoutcomes (131,132). Education should\nideally be provided through a diabetes | [
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0.005064... |
ideally be provided through a diabetes\nself-management education and supportprogram or by a trained diabetes educa-tor, although these services are not avail-\nable in many areas (133,134). If structured\neducation is not available, clinicians shouldeducate individuals at risk for hypoglyce-mia on hypoglycemia de finit... | [
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-... |
tions that may precipitate hypoglycemia(fasting, delayed meals, physical activity,and illness), blood glucose self-monitoring,avoidance of driving with hypoglycemia, step-\nby-step instructions on hypoglycemia treat- | [
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by-step instructions on hypoglycemia treat-\nment as discussed above, and glucagon useas appropriate (131).S120 Glycemic Goals and Hypoglycemia Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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... |
CGM can be a valuable tool for detect-\ning and preventing hypoglycemia in many\nindividuals with diabetes, and it is recom-mended for insulin-treated individuals, es-pecially those using multiple daily insulininjections or continuous subcutaneous in-sulin infusion. There is clinical trial evidencethat CGM reduces rate... | [
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0.0545... |
these populations. CGM can reveal asymp- | [
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tomatic hypoglycemia and help identifypatterns and precipitants of hypoglycemicevents (135,136). Real-time CGM can pro-vide alarms that can warn individuals offalling glucose so that they can intervene(135,136). For more information on usingBGM and CGM for hypoglycemia preven-tion, see Section 7, “Diabetes Technology. ... | [
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An essential component of hypoglycemia\nprevention is appropriate modi fication\nto diabetes treatment in the setting ofintercurrent illness (discussed in detailbelow) or to prevent recurrent hypogly-\ncemic events. Level 2 or 3 hypoglycemic\nevents especially should trigger a reeval-uation of the individual ’s diabetes... | [
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plan, with consideration of deintensi fication\nof therapy within individualized glycemicgoals.Individuals with impaired awareness of\nhypoglycemia bene fit from, and should\nbe referred to, training programs that can\nreestablish awareness of hypoglycemia.\nFear of hypoglycemia and hypoglycemia\nunawareness often cooccu... | [
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unawareness often cooccur, so interven-\nt i o n sa i m e da tt r e a t i n go n eo f t e nb e n e fit\nboth (137). Formal, evidence-based train-\ning programs that have been developed\ninclude the Blood Glucose Awareness Train-\ning Program, Dose Adjusted for Normal Eat-\ning (DAFNE), and DAFNEplus (138– 140). | [
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ing (DAFNE), and DAFNEplus (138– 140).\nWhere these programs are not available,training can be provided through quali fied\nbehavioral health professionals, diabetes\neducators, or other professionals with expe-\nrience in this area, although this approach\nhas not been evaluated in clinical trials. In\naddition, severa... | [
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addition, several weeks of avoidance of hy-\npoglycemia can improve counterregulation\nand hypoglycemia awareness in many peo-ple with diabetes (141). Hence, individuals\nwith one or more episodes of clinically sig-\nnificant hypoglycemia may bene fitf r o ma t\nleast short-term relaxation of glycemic goals(142).\nINTERC... | [
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INTERCURRENT ILLNESS\nStressful events (e.g., illness, trauma, and\nsurgery) increase the risk for both hypergly-\ncemia and hypoglycemia among individuals\nwith diabetes. In severe cases, they may\nprecipitate diabetic ketoacidosis or a non-ketotic hyperglycemic hyperosmolar state,\nlife-threatening conditions that re... | [
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0.04676463082432747,
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0.00696168... |
life-threatening conditions that require im-\nmediate medical care. Any individuals with\ndiabetes experiencing illness or other stress-\nful events should be assessed for the need\nfor more frequent monitoring of glucose; ke-\ntosis-prone individuals also require urine orblood ketone monitoring. Clinicians should | [
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0.0... |
reevaluate diabetes treatment during these\nevents and make adjustments as appropri-\nate. Clinicians should be aware of medi-\ncation interactions that may precipitate\nhypoglycemia. Notably, sulfonylureas in-\nteract with a number of commonly usedantimicrobials ( fluoroquinolones, clarithro- | [
0.0016235887305811048,
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0.017462560907006264,
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0.05... |
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