It’s time to back off from the fear-mongering around severe hypoglycaemia, according to researchers who point to increasing evidence that improved glycaemic control in children with type 1 diabetes is not associated with increasing rates of hypoglycaemia.

A longitudinal analysis of trends in HbA1c and hypoglycaemia rates in Australian and European cohorts shows that the relationship between the two outcomes has changed.

In the Western Australian Children’s Diabetes Database, comprising 2,595 children less than 15 years of age, the mean HbA1c dropped from 9.2% in 1995 to 8.3% in 2016.

Over the same time period, the rate of severe hypoglycaemic events decreased by 6% per year.

And in almost 60,000 children from the German/Austrian Diabetes Patient History Documentation database, HbA1c dropped from 8.3% to 7.8% at the same time as rates of severe hypoglycaemia dropped by 2% per year.

One of the study leads Professor Liz Davis told the limbic the findings suggested there had been a paradigm shift in the association between glycaemic control and hypoglycaemia.

“We took two completely different data sets with different models of care, longitudinal data over 22 years of time, over 300,000 patient years – so a lot of data – and found very similar patterns.”

“In contrast to the approach that as you improve glycaemic control you are increasing the risk of hypos and you need to warn families to look out for that … we’ve shown that there is no longer a link.”

Professor Davis, co-director of the Children’s Diabetes Centre at Telethon Kids Institute and head of Perth Children’s Hospital’s Endocrinology and Diabetes Department, said the fear of hypoglycaemia was very real for parents.

“And certainly you can understand that if they are nervous about the risk of severe hypoglycaemia, and you are teaching that glycaemic control increases that, there is a natural hesitation from families about how far they want to go to improve that glycaemic control.”

“For me this a really important study. Now the challenge is for all of us in our clinical services to start reducing the emphasis that we put on severe hypoglycaemia and to start presenting that to families framed in a different way so we are not driving fear of hypoglycaemia.”

“One of the challenges is doing the research and showing the data; the bigger challenge is translating that information and implementing it into clinical practice.”

Improved management

She said the change was probably driven by access to new technology such as CGM, better blood glucose testing, better insulins, multiple daily injections rather than twice daily for children still on needles, and the newer pumps.

“The flip side is that it is actually now the kids that have the worst glycaemic control who have the biggest risk of hypos and that’s a bit of a paradigm shift as well.”

“There is a message in there that when you have poor glycaemic control, extra insulin may be given at times but unless you are right on top of the diabetes you might not know exactly what dose to give so you give too much and go low.”

“Or sometimes poor control just represents that families haven’t had as much education or haven’t understood the education and so they might combine exercise with a meal that doesn’t have enough carbs and then use normal insulin, which is a perfect storm for hypoglycaemia but they not appreciate that risk.”

Professor Davis said there was a balance to be found between warning people about every possible risk and needlessly raising anxiety that might prevent optimal glucose control.

“We certainly have to train families on what to do if there is a hypoglycemic event and how to manage it but it’s really important to not have that front and centre.”

“It used to be one of the first things we taught but now, once they’ve got a bit more information, we add it into the program.”

She said it was also important to emphasise to families that blood glucose needs to be low for quite a period of time before a severe hypoglycaemic event would occur.

“And particularly in Australia now with CGM… parents can see the trend when blood glucose levels are starting to drop and they can have a nice, relaxed simple approach to intervening and preventing that blood sugar from going any lower and preventing any severe hypos.”