Clinical paediatric endocrinologist Professor Tim Jones from Western Australia tells ISPADAPEG delegates why hypoglycaemia matters, and how technology can help.
In the beginning
When Professor Jones first began practicing in Western Australia in the early 1990s the average HbA1c was 10.8%, a figure that he says now seems unbelievable.
“Back then we didn’t really worry about hypoglycaemia because it didn’t happen that much” he told delegates during a lunchtime symposium sponsored by Medtronic.
But the publication of the DCCT trial in the 1990s changed this by highlighting a need to improve diabetes control.
HBA1c levels subsequently dropped but as a result hypoglycemia ‘sky-rocketed’, becoming the important focus of research and treatment that it is today, explained Professor Jones.
How common is hypoglycaemia?
“Despite improvements in glycaemic control over the past decades many children and young adults with diabetes still don’t achieve optimal glycaemic control”, said Professor Jones.
“They are still at risk of hypoglycaemia and they still have a burden of care that can result in psychological problems and distress,” he said.
Surveys showed that most people with type 1 diabetes experience one or two hypoglycaemia events a year that require access to healthcare. Non-severe hypoglycaemia was more pervasive, occurring once or twice a week for most patients.
However it was important to note that while doctors call these events ‘non-severe’, they can be severe from the patients’ point of view, Professor Jones remarked. He gave an example of one of his patients, where this mismatch occurred.
“If you’re a 15 year old teenager who has to eat in front of his friends and look like a pig, as one patient once told me, that’s a severe adverse event to that patient,” he said.
The impact and the fear
“Hypoglycemia doesn’t just affect the child, it affects families and their clinicians”, said Professor Jones.
Referring to a study that asked children to write down their worries about having a hypoglycaemic event Professor Jones said some of the comments were quite poignant.
For example a poem written by a 9 year old that had had diabetes since the age of 9 months talked about her mum not having slept through the night for 9 years.
And one child said they were worried about “passing out and dieing [sic]”.
“If you have children who are worried about dying when they are 9 years of age it’s not surprising we need to have social workers and psychologists,” he said.
Fear of hypoglycaemia often comes hand in hand with poorer diabetes control, Professor Jones explained.
It [fear] can be a barrier to optimal treatment and can sometimes lead to inappropriate parental management, like making a child eat a snack before bedtime or avoiding leaving children alone.
Hypoglycaemia was also a concern in adults, with a survey published by Larkin et al. in the journal Diabetes Education revealing that hypoglycaemia was the number one concern adults with type 2 diabetes had around starting insulin .
Another survey of adults with type 1 and type 2 diabetes showed that severe hypoglycaemia was up there with the fear of renal impairment and blindness [2,3].
“It’s an equivalent complication in the minds of many of my patients,” he said.
Other studies showed that hypoglycaemia was considered by patients to be an equivalent impairment of quality of life as diabetic neuropathy [3,4,5].
The possibilities of technology
Professor Jones is currently running a trial on the use of the Medtronic predictive system that suspends before a pre-set threshold.
While the results are yet to be published, a case-study of a 17-year-old avid cyclist illustrates the impact technology can have on diabetes control.
The young man used a pump but his blood glucose fluctuated widely and he had frequent episodes of hypoglycaemia.
An event put on by the hospital and the local Diabetes Australia group sparked his engagement in the management of his diabetes and inspired him to take up cycling professionally.
He started with Real-Time Continuous Glucose Monitoring (RT-CGM) and was initiated with Suspend before low function on the MiniMed® 640G with the SmartGuardTM system.
Six months later he put on weight (suspected to be muscle), his HBA1c went from 11.5 to 8.2% and he had less episodes of hypoglycaemia. He was also able to cycle more frequently.
“We’re hopeful that with increasing use of these technologies we will see further reduction in hypoglycaemia and further reduction of burden of diabetes and an improvement in diabetes control,” Professor Jones said.
- Larkin M et al., Diabetes Educ. 2008;34:511-7
2, 3, Banke Petersen Eur Diabetes Nursing 2007; 4: 113–118 Bohme et al., Diabetes Metab. 2013;39:63-70
3, 4, 5, Kim et al, Diab Res Clin Pract, 2014:103:522-529 Okubu, Clin Exp Neph, 2013 and Koltowski, AJC; 2014