Diabetes Core Update – Special Edition: Hypoglycemia Working Group Statement

Podcast: Diabetes Core Update
Date: October 29, 2013
Host: Dr. Neil Skolnik
Guest: Dr. Elizabeth Seaquist, Professor of Medicine, University of Minnesota

Episode Overview

This special edition of the Diabetes Core Update podcast centers on the landmark statement by the American Diabetes Association (ADA) and the Endocrine Society regarding hypoglycemia in diabetes, published in the May 2013 issue of Diabetes Care. Dr. Neil Skolnik interviews Dr. Elizabeth Seaquist, the report's first author, to discuss the group’s recommendations, focusing on hypoglycemia’s definition, long-term risks, implications for clinical targets, and strategies for clinician and patient management.

Key Discussion Points & Insights

1. Defining and Reporting Hypoglycemia

Timestamp: 02:25–03:18

• The working group deliberated extensively on the appropriate blood glucose threshold for hypoglycemia.
• The agreed “alert value”:
  • Blood glucose <70 mg/dL (3.9 mmol/L)
  • Chosen as the actionable threshold to prompt intervention before severe symptoms arise.
  • Distinction between definitions for clinical care versus research; <70 is most crucial for clinicians and patients.
• Quote:

  “People do get symptoms of hypoglycemia at this level, but it’s not so low that a person is so hypoglycemic they’re unable to take action.”
  — Dr. Elizabeth Seaquist [02:42]

2. Short and Long-Term Implications of Hypoglycemia

Timestamp: 03:18–04:31

• Acute consequences: confusion, unconsciousness, seizures, and death.
• Newer data—especially from the ACCORD study—links hypoglycemia with higher mortality risk, especially in older adults with comorbidities.
• These findings challenge aggressive glycemic targets in vulnerable patients.
• Quote:

  “The ACCORD study demonstrated that hypoglycemia increased the risk—people with hypoglycemia had a higher mortality risk than those who did not have hypoglycemia...”
  — Dr. Seaquist [03:57]

3. Hypoglycemic Unawareness (Hypoglycemia-Associated Autonomic Failure)

Timestamp: 04:59–06:48

• “Hypoglycemia unawareness” occurs after repeated low blood glucose episodes.
• Each hypoglycemic episode reduces the body’s counterregulatory response, making recognition of subsequent lows harder; the first symptom could become unconsciousness.
• Importance for primary care providers: ask patients about their lowest glucose levels and whether they ever fail to notice hypoglycemia.
• Quote:

  “If your patients are having values in the 50s and they say, ‘I didn’t know I was low, I felt fine,’ that’s a warning sign...that really puts them at risk for unconsciousness as the first symptom.”
  — Dr. Seaquist [06:26]

4. Implications for Treatment Targets

Timestamp: 06:48–08:55

• Historical approach: aggressive A1C goals (<7%) for all.
• Updated thinking: personalized targets, especially for older adults/multiple comorbidities, are safer.
• Intensive targets in high-risk patients (per ACCORD) increased mortality by 20%.
• Balance intensity of glycemic control with individual risk for hypoglycemia.
• Medication class and risk:
  • Metformin: very low risk for hypoglycemia.
  • Sulfonylureas & insulin: higher risk—calls for caution.
• Quote:

  “Many organizations are now saying...you need to take a look at all the comorbid[ities], the life expectancy of the person, the social support system, before you really come up with the right A1C target.”
  — Dr. Seaquist [08:36]

5. Strategies to Help Patients Avoid Hypoglycemia

Timestamp: 09:53–10:45

• Patient education:
  • Symptoms and levels of hypoglycemia.
  • Treatment protocols (e.g., “15-15 rule”: 15 grams carbs, recheck in 15 minutes).
  • Importance of reporting all hypoglycemia episodes to clinicians.
• Clinical response:
  • Frequent hypoglycemia or hypoglycemic unawareness = consider less aggressive targets and reevaluate medication regimens.
• Quote:

  “If people are having frequent hypoglycemia and no longer have symptoms...it’s time to step back a bit.”
  — Dr. Seaquist [10:32]

6. Core Takeaway and Clinical Call-to-Action

Timestamp: 10:45–11:49

• Consistent and proactive inquiry about hypoglycemia at every diabetes visit is crucial.
• Selection of glucose targets and medication regimens must take risk of hypoglycemia into account.
• “The single most important takeaway” is the heightened awareness of hypoglycemia’s clinical significance and impact on patient management.
• Quote:

  “...The increasing recognition, based upon an abundance of evidence, of the importance of hypoglycemia and the fact that this awareness should influence our choice of treatment targets for patients and also lead us to ask about hypoglycemia at each and every diabetes related visit.”
  — Dr. Neal Skolnik [11:17]

Memorable Quotes

• On the alert threshold:

  “The value is less than 70 in the statement...I think the 70 value is the really important number to remember.”
  — Dr. Seaquist [02:56]

• On clinical vigilance:

  “That’s not a good thing. That’s a warning sign that they’re having recurrent hypoglycemia sufficiently often to cause them to have this blunted response that really puts them at risk for unconsciousness as the first symptom.”
  — Dr. Seaquist [06:22]

Segment Timestamps

| Time | Topic | |------------|------------------------------------------------------| | 00:01–00:32| Introduction and episode purpose | | 02:25–03:18| Hypoglycemia: Definition and reporting | | 03:18–04:31| Short/long-term risks; ACCORD trial discussion | | 04:59–06:48| Hypoglycemic unawareness explained | | 06:48–08:55| Adjusting A1C targets based on hypoglycemia risk | | 09:53–10:45| Patient education and response strategies | | 10:45–11:49| Key takeaways and clinical action |

Final Thoughts

This episode highlights a critical shift toward person-centered care for diabetes, emphasizing that hypoglycemia is not just a complication, but a factor that often dictates optimal clinical strategy. Through clear case examples and guidance, Dr. Seaquist and Dr. Skolnik advocate for tailored glycemic goals and vigilant ongoing assessment, particularly in higher-risk populations.

For more in-depth content and the full statement, listeners are encouraged to visit diabetesjournals.org.