Hypoglycemia begets hypoglycemia in IDDM - PDF document

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Perspectives in Hypoglycemia Begets Hypoglycemia IDDM atrogenic hypoglycemia causes recurrent psychological morbidity IDDM iatrogenic hypoglycemia highly structured Trial the more than IDDM therapy makes a difference (it reduced ne- phropathy, and neuropathy in Diabetes Control and Complications Trial [2]), will lead widespread attempts glucose concentrations nondiabetic range possible, iatrogenic hypoglycemia will almost assur- edly become even greater patients with current insulin replacement relative insulin for exam- insulin doses during an or after physical activity. it has become increasingly clear hypoglycemia is excess alone and compro- -- - - -- From the Division of Endocrinology, Diabetes, ment of Medicme; Clinical Research and Training Center, requests to Cryer, Diabetes, and 8127), September 1993 and accepted in revised September 1993. insulin-dependent diabetes mellitus. compromised glucose IDDM defective glucose (3,4), therapy per associated with a cemia, segregate clinically, and sociated autonomic that a single caused reduced the following morn- (9), coupled with conceptually similar data from other laboratories (10,11), recent antecedent hypoglycemia might overall hypothesis in patients IDDM, recent antecedent iatrogenic hypoglycemia is a major cause latter, by reducing both physiological defense against recurrent iatrogenic a vicious (8). Two key elements confirmed. In with IDDM, a single c2- h episode elevated glycemic moderate hyperinsulinemia and symptomatic neurogenic and neuroglycopenic) function at a (i.e., in patients with insulinomas, provides indirect support lead to iatro- DIABETES, VOL. 42, DECEMBER 1993 1691 Perspectives in Hypoglycemia Begets Hypoglycemia IDDM atrogenic hypoglycemia causes recurrent psychological morbidity IDDM iatrogenic hypoglycemia highly structured Trial the more than IDDM therapy makes a difference (it reduced ne- phropathy, and neuropathy in Diabetes Control and Complications Trial [2]), will lead widespread attempts glucose concentrations nondiabetic range possible, iatrogenic hypoglycemia will almost assur- edly become even greater patients with current insulin replacement relative insulin for exam- insulin doses during an or after physical activity. it has become increasingly clear hypoglycemia is excess alone and compro- -- - - -- From the Division of Endocrinology, Diabetes, ment of Medicme; Clinical Research and Training Center, requests to Cryer, Diabetes, and 8127), September 1993 and accepted in revised September 1993. insulin-dependent diabetes mellitus. compromised glucose IDDM defective glucose (3,4), therapy per associated with a cemia, segregate clinically, and sociated autonomic that a single caused reduced the following morn- (9), coupled with conceptually similar data from other laboratories (10,11), recent antecedent hypoglycemia might overall hypothesis in patients IDDM, recent antecedent iatrogenic hypoglycemia is a major cause latter, by reducing both physiological defense against recurrent iatrogenic a vicious (8). Two key elements confirmed. In with IDDM, a single c2- h episode elevated glycemic moderate hyperinsulinemia and symptomatic neurogenic and neuroglycopenic) function at a (i.e., in patients with insulinomas, provides indirect support lead to iatro- DIABETES, VOL. 42, DECEMBER 1993 1691 genic hypoglycemia IDDM Furthermore, the experimental asymptomatic nocturnal hypoglycemia produces a worrisome from because iatrogenic hypoglycemia occurs during long-recognized clinical IDDM (5), previously allowed developing hypoglycemia (e.g., neuroglycopenia. Recently presented prospec- is associated with a fivefold increased iatrogenic hypoglycemia (6). recent antecedent iatrogenic glycemia involved in the pathogenesis suggested by hypoglycemia-asso- failure hypothesis, in the intensive therapy November issue al. approach to 8 intensively treated patients relatively short IDDM (17 attempts to avoid iatrogenic in a detected hypoglycemia and HbA,, 6.9%). Compared nondia- betic cognitive dysfunction a given level in the 2 wk, and attempts to neuroglycopenic), cognitive, and growth hor- from those epinephrine, and increased albeit tors have recently presented generally al. changes might greater deterioration gly- cemic control might occur over time. appear to might point a control without attempts avoid iatrogenic hypoglycemia in original study (16), it is unlikely that the abnormal responses baseline would to normal such a group (17). genic hypoglycemia Similarly, it is conceivable, but again unlikely, that the iatrogenic hypoglycemia goals alone rather increased symptomatic and counterregulatory (particularly epinephrine) responses glycemic goals. Thus, it appears that the glycemia can pulous avoidance iatrogenic hypoglycemia (8). largely reversible. the syndrome counter- observed enhanced epinephrine re- expected to (1,3,4). observed increased glucagon coun- terregulation might reversible, but the increases were small were still observation needs it is that the symptoms that occur during are the result recent antecedent hypoglycemia (18). Similarly, IDDM recent antecedent important questions level, what mechanism(s) elevated glycemic thresholds induced by clinical level, strategies will permit IDDM the physiology counterreg- ulation its pathophysiology the relation- iatrogenic hypoglycemia, However, the from the patients with IDDM compromising glycemic control remains part by Health Service RR- and DK-07120 and the American Diabetes Association. substantial contributions and postdoctoral skilled technical support and University General Clinical Donna Brooks gratefully acknowl- 1. Iatrogenic hypoglycemia in IDDM: consequences, risk Vol. 7. Home PD, Marshall S, Alberti Diabetes Control Complications Trial intensive treatment development and long-term complications insulin-dependent diabe- mellitus: N Engl J Med 329:978-86, DA, Cryer Levandoski L, Santiago type I 308:485-91, 1983 4. Bolli GB, De Cosmo Ventura MM, Massi-Benedetti M, F, Gerich Brunetti A reliable genic hypoglycemia IDDM Furthermore, the experimental asymptomatic nocturnal hypoglycemia produces a worrisome from because iatrogenic hypoglycemia occurs during long-recognized clinical IDDM (5), previously allowed developing hypoglycemia (e.g., neuroglycopenia. Recently presented prospec- is associated with a fivefold increased iatrogenic hypoglycemia (6). recent antecedent iatrogenic glycemia involved in the pathogenesis suggested by hypoglycemia-asso- failure hypothesis, in the intensive therapy November issue al. approach to 8 intensively treated patients relatively short IDDM (17 attempts to avoid iatrogenic in a detected hypoglycemia and HbA,, 6.9%). Compared nondia- betic cognitive dysfunction a given level in the 2 wk, and attempts to neuroglycopenic), cognitive, and growth hor- from those epinephrine, and increased albeit tors have recently presented generally al. changes might greater deterioration gly- cemic control might occur over time. appear to might point a control without attempts avoid iatrogenic hypoglycemia in original study (16), it is unlikely that the abnormal responses baseline would to normal such a group (17). genic hypoglycemia Similarly, it is conceivable, but again unlikely, that the iatrogenic hypoglycemia goals alone rather increased symptomatic and counterregulatory (particularly epinephrine) responses glycemic goals. Thus, it appears that the glycemia can pulous avoidance iatrogenic hypoglycemia (8). largely reversible. the syndrome counter- observed enhanced epinephrine re- expected to (1,3,4). observed increased glucagon coun- terregulation might reversible, but the increases were small were still observation needs it is that the symptoms that occur during are the result recent antecedent hypoglycemia (18). Similarly, IDDM recent antecedent important questions level, what mechanism(s) elevated glycemic thresholds induced by clinical level, strategies will permit IDDM the physiology counterreg- ulation its pathophysiology the relation- iatrogenic hypoglycemia, However, the from the patients with IDDM compromising glycemic control remains part by Health Service RR- and DK-07120 and the American Diabetes Association. substantial contributions and postdoctoral skilled technical support and University General Clinical Donna Brooks gratefully acknowl- 1. Iatrogenic hypoglycemia in IDDM: consequences, risk Vol. 7. Home PD, Marshall S, Alberti Diabetes Control Complications Trial intensive treatment development and long-term complications insulin-dependent diabe- mellitus: N Engl J Med 329:978-86, DA, Cryer Levandoski L, Santiago type I 308:485-91, 1983 4. Bolli GB, De Cosmo Ventura MM, Massi-Benedetti M, F, Gerich Brunetti A reliable