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Cited by 233Diabetes Management and ResearchDiabetes Management and EducationDiabetes Treatment and Management

Evidence-Informed Clinical Practice Recommendations for Treatment of Type 1 Diabetes Complicated by Problematic Hypoglycemia

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Choudhary, Pratik, Rickels, Michael R., Senior, Peter A., Vantyghem, Marie-Christine, Maffi, Paola, Kay, Thomas W., Keymeulen, Bart, Inagaki, Nobuya +3 more·2015·Diabetes Care
DOI 10.2337/dc15-0090PMC PMC4439532
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Abstract

Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3–6 months. If targets are not met, one diabetes technology—continuous subcutaneous insulin infusion or continuous glucose monitoring—should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.

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Authors
Choudhary, P., Rickels, M. R., Senior, P. A., Vantyghem, M.-C., Maffi, P., Kay, T. W., Keymeulen, B., Inagaki, N., Saudek, F., Lehmann, R., & Hering, B. J.
Affiliations
  • King's College London (GB)
  • University of Pennsylvania (US)
  • University of Alberta (CA)
  • Inserm (FR)
  • IRCCS Ospedale San Raffaele (IT)
  • The University of Melbourne (AU)
  • Vrije Universiteit Brussel (BE)
  • Kyoto University (JP)
  • Institute of Clinical and Experimental Medicine (CZ)
  • University of Zurich (CH)
  • University of Minnesota (US)
Corresponding author
Hering, Bernhard J.
ORCID
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2015-05-12
Volume
38
Issue
6
Pages
1016-1029
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/dc15-0090
PMC
PMC4439532
OpenAlex
W1811184783
Cited by
233
References
112
Citations by year
2026: 7 · 2025: 9 · 2024: 14 · 2023: 23 · 2022: 27 · 2021: 24 · 2020: 20 · 2019: 29 · 2018: 28 · 2017: 23 · 2016: 20 · 2015: 9
FWCI
4.03
Type
journal article
Language
en
Open access
Locations
  • Diabetes Care (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion)
  • VUBIR (Vrije Universiteit Brussel) (submittedVersion)
Funders
  • Sanofi
  • Diabetes UK (13/0005643, 14/0004865)
  • National Institutes of Health (5r01dk091331-10)
  • National Institute of Allergy and Infectious Diseases (U01AI102463, U01AI065193)
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01-DK-091331, U01DK070430)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
type 1 diabetes, severe hypoglycemia, impaired awareness of hypoglycemia, hypoglycemia education, insulin pump therapy, continuous glucose monitoring, sensor-augmented pump, islet transplantation, pancreas transplantation, individualized glycemic targets
MeSH terms
Algorithms, Awareness, Blood Glucose, Diabetes Mellitus, Type 1, Humans, Hypoglycemia, Hypoglycemic Agents, Insulin, Insulin Infusion Systems, Patient Education as Topic, Blood Glucose Self-Monitoring, Pancreas Transplantation, Evidence-Based Medicine

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