Morbidity Of Hypoglycaemia And Need For Emergency Treatment

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Many people with type 1 diabetes regard severe hypoglycaemia with the same degree of trepidation as that reserved for the advanced complications of diabetes such as loss of sight or renal failure (Pramming et al., 1991). Hypoglycaemia is not simply extremely unpleasant for the individual concerned; it has the potential risk of severe morbidity and may precipitate major vascular events such as stroke, myocardial infarction, acute cardiac failure and ventricular arrhythmias (Landstedt-Hallin et al., 1999; McAulay and Frier, 2001; Desouza et al., 2003) (see Chapter 12). Healthcare professionals may not always recognise the causative role of hypoglycaemia when treating these secondary events, especially if they are unfamiliar with some of the age-related neurological manifestations of hypoglycaemia. The elderly are particularly at risk of hypoglycaemia-related physical injury and bone fractures as a result of their general frailty and the presence of co-morbidities, such as osteoporosis (McAulay and Frier 2001). In a seven-year review of 102 cases of hypoglycaemic coma secondary to either insulin or glibenclamide, 92 patients had type 2 diabetes; seven sustained physical injury, five died, two suffered myocardial ischaemia and one patient had a stroke (Ben-Ami et al., 1999).

In type 1 diabetes, relatives often treat severe hypoglycaemia at home, but while people with insulin-treated type 2 diabetes experience severe hypoglycaemia less frequently, they appear to require the assistance of the emergency services with equal frequency. This might suggest that people with insulin-treated diabetes are at greater risk of morbidity and disability during hypoglycaemia, and they and their relatives may be less able to cope than younger people with type 1 diabetes. In addition, many people with insulin-treated type 2 diabetes live alone. A population survey in the region of Tayside in Scotland indicated that the annual rate of severe hypoglycaemia requiring emergency medical intervention was similar in these groups (Leese et al., 2003). All episodes of severe hypoglycaemia requiring input from the emergency medical services in one year were identified. A total of 160 people with diabetes required treatment for 244 episodes of severe hypoglycaemia. Emergency treatment was required for 7.1% of those with type 1 diabetes, 7.3% of those with insulin-treated type 2 diabetes and 0.8% of people taking oral antidiabetic agents.

In a different prospective survey in the same region of Tayside, the occurrence of hypo-glycaemia was monitored over a period of one month in a cohort of 267 people with insulin-treated diabetes (both type 1 and type 2) (Donnelly et al., 2005). The prevalence of all forms of hypoglycaemia in the group with insulin-treated type 2 diabetes was 45% with an incidence of 16.4 episodes per patient per year, compared to an incidence of 42.9 episodes per patient per year in type 1 diabetes. The incidence of severe hypoglycaemia was 0.35 episodes per patient per year in the group with type 2 diabetes and 1.15 episodes per patient per year in those with type 1 diabetes. The figures for the incidences were extrapolated from prospective data collected over one month but these calculated rates for people with type 1 diabetes are consistent with those recorded in other European studies (Pramming et al., 1991; MacLeod et al., 1993; ter Braak et al., 2000; Pedersen-Bjergaard et al., 2004), suggesting that the data collected were representative of the annual event rate. In this study, only 10% of the group with type 1 diabetes experiencing severe hypoglycaemia required emergency service treatment compared to one in three of the group with type 2 diabetes. Thus the frequency of severe hypoglycaemia recorded in people with type 2 diabetes was higher than anticipated and their need to enlist the help of the emergency services was greater than in those with type 1 diabetes.

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