Table 1

Identification and initial assessment of people with problematic hypoglycemia

Identification of patients with T1D and  problematic hypoglycemiaAssessment of hypoglycemia risk should be performed annually for all patients with T1D. Frequently, episodes of hypoglycemia are not reported to physicians. Health care planners should consider whether appropriate referral pathways exist for patients experiencing SH (patients attended by emergency medical services or emergency department physicians or dispensed glucagon injections by their pharmacist). Number of calls for an ambulance or glucagon injections during the past month and past year should be considered as well as whether injuries may have been due to unidentified hypoglycemia.
 History of hypoglycemiaFrequency of episodes
Nocturnal hypoglycemia
Episodes of SH
Ability to detect episodes
Presence of adrenergic and neuroglycopenic symptoms of hypoglycemia
Precipitating factors (e.g., insulin dosing errors, exercise, alcohol)
 Review diabetes self-careAdequate frequency of SBGM?
Appropriate diet?
 Review for presence of risk factors for SHOlder age
Long duration of diabetes
Renal impairment
Low BMI
IAH (Clarke or Gold scores ≥4)
Erratic, unpredictable blood glucose levels
Very low HbA1c
Initial assessment of people identified with problematic hypoglycemia
 Insulin therapy
  Insulin preparationsUse of regular and NPH insulins have greater risk for hypoglycemia than insulin analogs
Premixed insulins are not recommended
  Insulin dosingInappropriate balance between basal and bolus doses
Excessive correction doses
Inappropriate timing of insulin
Lack of adjustment for (prior) exercise and/or heat
Overestimation of meal size or carbohydrate content
  Insulin administrationLipohypertrophy
Intramuscular injection
Needle length
Injection technique
 Physiologic/other causes
  Diabetes complicationsHAAF
Gastroparesis
  MalabsorptionCeliac disease
Pancreatic exocrine insufficiency
  EndocrinopathiesAdrenal insufficiency
Hypopituitarism
  FactitiousMisuse of insulin
Alcohol excess
  AutoimmuneInsulin autoimmune syndrome
  MetabolicRenal failure
Hepatic failure
Inborn errors of metabolism
  Psychological/psychosocialFear of hyperglycemia/diabetes complications
Fear of hypoglycemia
Denial, not willing to attend educational programs or to use technology
Depression or other psychiatric problems
Cognitive impairment
  • This approach may identify some reversible causes for hypoglycemia, which can be addressed relatively easily. It may also identify some individuals for whom some of the interventions described in this article are contraindicated or who require specific nonendocrine interventions.