OBSTACLE hypoglycemia: Targeting a major hurdle in diabetes management!
RD Patell, RV Dosi
Department of Medicine, Medical College Baroda and Sir Sayajirao General Hospital, Vadodara, Gujarat, India
Dr. R D Patell
Department of Medicine, Medical College Baroda and Sir Sayajirao General Hospital, Vadodara, Gujarat
|How to cite this article:|
Patell R D, Dosi R V. OBSTACLE hypoglycemia: Targeting a major hurdle in diabetes management!.J Postgrad Med 2014;60:161-162
|How to cite this URL:|
Patell R D, Dosi R V. OBSTACLE hypoglycemia: Targeting a major hurdle in diabetes management!. J Postgrad Med [serial online] 2014 [cited 2023 Feb 4 ];60:161-162
Available from: https://www.jpgmonline.com/text.asp?2014/60/2/161/132328
India holds the uncoveted position as the 'diabetic capital of the world' today with an estimated 40 million individuals suffering and the numbers rising.  In tow with this is a large burden of microvascular complications of the retina, renal glomeruli, and peripheral nerves as well as accelerated atherosclerosis leading to ischemic heart disease, cerebrovascular disease, and peripheral vascular insuffiency. The American Diabetes Association ADA's currently recommended goal of achieving a HBA1c <7% is well established to prevent and control the rate of complications. The real world poses a significant problem though. and the numbers are far from satisfactory.  Hypoglycemia, and the fear and potentially disastrous consequences that follow, is well recognized in patients with Type 1 diabetes; its importance in Type 2 diabetes mellitus (DM) is often underestimated. And less well appreciated ,
Despite the several additions in therapeutic options sulphonylureas (SU) remain an extremely affordable and drug class and are well established as a cornerstone of diabetic therapy for a large percentage of patients. Hypoglycemia is a familiar complication of SU (especially but by no means exclusively the older and longer acting agents).  Achieving a balance between optimum glycemic control by preventing hyperglycemia as well as avoiding hypoglycemia holds the key. In this issue of the journal, Kalra S and colleagues report an interesting study to correlate severity and frequency of hypoglycemia in SU treated patients of Type 2 DM. 
This multicenter study's greatest strength lies in its prospective design. Subjects were followed and assessed for symptoms of hypoglycemia by administering the Stanford Hypoglycemia Questionnaire, thus minimizing recall bias. This is important for the milder episodes that might have been otherwise forgotten. Although unblinded and uncontrolled, the study design reflects real life practice well and would make extrapolation of their findings easier and more relevant. Although a lack of access to glucometers is a reality for a majority of Indian patients, it also prevented an objective assessment of the episode and thus they can only be classified as 'probable symptomatic hypoglycemia', an obvious pitfall. Continuous glucose monitoring or frequent finger stick glucose sensors would be ideal but may be impractical in the setting studied.
The high prevalence of reported hypoglycemia is quite strikingly divergent from a metanalysis of clinical trials studying hypoglycemia and the use of SU,  perhaps illustrating the oft-mentioned caveat cautioning that randomized controlled trials may not reflect general practice accurately, even if concessions are made for the Hawthorne effect in the OBSTACLE hypoglycemia study. Hypoglycemia unawareness is now known not to be unique to patient with Type 1 DM; several factors have been identified especially in older patients of Type 2 DM that could potentially impair detection including autonomic neuropathy, frailty, decreased awareness, and concomitant use of beta-blockers.  This too needs to be considered when interpreting a study design that relies heavily on self-reported hypoglycemia.
Hypoglycemia in type 2 DM may be an under recognized and underestimated problem in scientific literature and a drive to address this is paramount. At the same time, it seems to be a major deterrent to physicians and patients in the setting and achieving recommended glycemic targets. Moreover, the impact of hypoglycemia on the quality of life of patients of type 2 DM on oral therapy is significant.  Studies like OBSTACLE hypoglycemia with its inherent limitations would still be step in the right direction to help understand and hopefully aid researchers and practitioners to design strategies to overcome the hurdle of hypoglycemia in the care of diabetes.
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