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Hypoglycemia: Out of Sight, Out of Mind

  • Authors: Jennifer D. Goldman, BC-ADM, FCCP, PharmD, CDCES
  • CME / ABIM MOC / CE Released: 9/14/2023
  • Valid for credit through: 9/14/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care clinicians, pharmacists, nurses/nurse practitioners, and other members of the healthcare team who manage and treat patients with diabetes.

The goal of this activity is for clinicians to be better able to prevent hypoglycemic events in patients with diabetes.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Overall management of hypoglycemia
  • Have greater competence related to
    • Recognizing individuals who may be at risk for hypoglycemia
  • Demonstrate greater confidence in their ability to
    • Collaborate with other clinicians to improve care for patients with or who may be at risk for hypoglycemia


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  • Jennifer D. Goldman, BC-ADM, FCCP, PharmD, CDCES

    Professor of Pharmacy Practice
    Massachusetts College of Pharmacy and Health Sciences
    Boston, Massachusetts
    Clinical Pharmacist, Well Life Medical
    Peabody, Massachusetts


    Jennifer D. Goldman, BC-ADM, FCCP, PharmD, CDCES, has the following relevant financial relationships:
    Consultant or advisor for: Sanofi
    Speaker or member of speakers bureau for: Abbott Diabetes; Bayer; CeQur Corporation; Lilly; Novo Nordisk; Xeris Pharmaceuticals, Inc.
    Owns stock (publicly traded) in: Abbott Diabetes; Lilly; Novo Nordisk


  • Asha P. Gupta, PharmD, RPh

    Medical Education Director, Medscape, LLC


    Asha P. Gupta, PharmD, RPh, has no relevant financial relationships.

Compliance Reviewer/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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Hypoglycemia: Out of Sight, Out of Mind

Authors: Jennifer D. Goldman, BC-ADM, FCCP, PharmD, CDCESFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/14/2023

Valid for credit through: 9/14/2024, 11:59 PM EST


Activity Transcript

Jennifer D. Goldman, BC-ADM, FCCP, PharmD, CDCES: Hi, my name is Jennifer Goldman. I'm a clinical pharmacist and professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences in Boston, Massachusetts. I teach in the pharmacy and physician assistant programs there. And I've been practicing 33 years, 15 years in family medicine and 12 years in internal medicine.

Today, I'm here to talk to you about hypoglycemia, out of sight and out of mind. And I am particularly passionate about this topic, because I had a dear friend of mine who died from a severe hypoglycemic reaction when he did not have glucagon available. For 60 years, only glucagon kits were available -- until 2019, and this is when easy-to-use preparations have been released. And I'd like to challenge you to start utilizing these. And I truly believe that my friend would be alive today had this been available.

Hypoglycemia affects type 1 diabetes (T1D) and type 2 diabetes (T2D), not just T1D. 8.3 million people are using insulin -- 1.6 million people have T1D and 6.7 million have T2D. Of that cohort of 8.3 million people, only 8% have a prescription for glucagon. So, this is significant. (Editor’s note: Estimated rates differ across publications.)

Hypoglycemia's associated with lots of complications and as well as cost due to hospitalizations and death.

One severe event can be catastrophic for a patient, just like it was for my friend. The risk of death is 3 times higher in patients with both T1D and T2D due to hypoglycemia. And the cost is exorbitant, $1.6 billion a year. 

Severe hypoglycemia, particularly repetitive hypoglycemia, can lead to cognitive decline, attention problems, executive function issues, and it can persist. With that, let's talk about the definitions of hypoglycemia. It's defined as 3 levels by the American Diabetes Association (ADA), and American Association of Clinical Endocrinology (AACE), and Endocrine Society (ENDO). 

Level 1 is a blood sugar of less than 70 mg/dL (but greater than or equal to 54 mg/dL), and someone might have neurogenic symptoms, so shaking or tachycardia, so having palpitations, sweating, hunger. A level 2 is less than 54 mg/dL, and you might start seeing cognitive impairments. So these are neuroglycopenic symptoms, behavioral problems. They might be combative, they might be dizziness, blurred vision. 

And then, there's level 3, and level three has no defined threshold. Level 3 is when someone might have altered mental status or physical status. They're requiring help or requiring assistance. They're requiring emergency treatment, really. And this might not be recognized. This might lead to loss of consciousness, seizure, coma, death. So, this is the one where we want to make sure anyone who's at risk of a level 2 or a level 3 reaction has access to glucagon.

Now, who's at risk of hypoglycemia? You need to think about that too, because when your patients are in front of you, whether you're a prescriber or you're a pharmacist in the community, and you could be the last touchpoint for that patient when they're filling that prescription. People at risk ... they might have had diabetes for a long time, they have a history of hypoglycemia, they're using insulin, or they're using a secretagogues -- so sulfonylurea, that increases the risk. Maybe they're older, maybe they have comorbidities, cognitive decline. Maybe their medication adherence is off. 

Or these might be people that have certain situations, like they skipped meals, or it was delayed by accident, or alcohol use -- and sometimes that's delayed hypoglycemia -- could be 24 to 48 hours later. So, knowing these things helps us educate patients on what to look for.

We talked about educating them on the symptoms and let's review that again just to make sure that they understand, but also for us. And we need to make sure that we're asking about this when we are seeing these patients. "Do you experience shakiness, irritability, or hunger?" These are the things we want to tell patients. "If you have hypoglycemia, this is what you might feel. You need to check your blood sugar." But if they don't have access to check their blood sugar at that time, it's safer to treat that hypoglycemia. So, if you have these feelings, even if you can't check your blood sugar, you need to treat that. 

We need to educate patients to be prepared. What we need to do about being prepared is prevention. So, make sure they understand how to prevent -- and that would be the rule of 15. So, 15 grams of glucose, do it again in 15 minutes. If you check your blood sugar and it's still less than 70 mg/dL, or if they have feelings, or they might not have access to check, so 15 grams of glucose is the preferred treatment in someone who's conscious. If their blood sugar's a level 1, they have skipped a meal, make sure they have something to eat.

One thing you have to understand, with the rule of 15, is it doesn't fix everything. So yes, we're going to do that glucose. Yes, we're going to repeat it. But some people with a blood sugar of less than 70 mg/dL will not respond. And some people with a blood sugar of less than 40 mg/dL won't respond, will not come up enough to get them out of that situation, and they'll continue into a level 3 reaction. So, we have to make sure they have glucagon.

And so, I had told you that about only 8% are getting prescriptions -- we need to change that. 

Glucagon is indicated that the treatment of hypoglycemia in people who are unwilling or unable to consume carbohydrates. But remember, this person does not need to be unconscious to use glucagon. Their blood sugars aren't responding. The other thing we need to make sure we do is prepare patients to take care of themselves if they're alone. So, it's fine to say your family member can give you glucagon, especially now that we have newer products, and I'll tell you about in a second. But we need to make sure patients can self-treat themselves and they know when to self-treat themselves.

Let me tell you a little bit about the newer products that have been on the market since 2019. We've got liquid stable glucagon and nasal glucagon. Traditionally, there was that glucagon kit, that had a vial of glucagon powder that had to be reconstituted with diluent, shaken up, mixed, pulled back in with another needle and injected. So imagine if you are alone, and you're having cognitive decline, and you're frightened, and you have symptoms, (the product was) not used. So, not helpful. 

We've got this liquid stable glucagon. It's available now in an autoinjector, it's available in a prefilled syringe, and it's available in a vial of liquid stable glucagon. That one is used for people over 2 years old. Dasiglucagon is available in a prefilled syringe. It's also stable liquid glucagon and also in an autoinjector, and that's for people 6 years old and above. And then, we have nasal powdered glucagon, and that is available for people 4 years old and above.

We want to make sure that people are prepared. Make sure you ask them, "Where is your glucagon? Where do you keep it?" Because if it's not with them or they're going to work and they don't have it, then they're not going to be able to use it. Tell them what to expect. All of these products are going to bring their blood sugars up in 10 minutes or so, 10 to 15 minutes. And have them call 9-1-1. This is serious. And speaking of 9-1-1, I was surprised to learn a few years ago that emergency medical services (EMS) does not carry glucagon. 

If you are a pharmacist in the community ... if you ever called (a prescriber) and said, "Hey, I'm filling this insulin prescription for your patient, and I noticed they don't have glucagon prescription. Do you want me to give them one for you and teach them?" As a provider, make sure that we're giving them glucagon. As a pharmacist, if you're a pharmacist in the community, make sure when you look at that patient's medication list, they have glucagon.

The other thing is in terms of side effects, the most common thing you see would be nausea. But it's interesting, if a patient asks me, "What side effects might I expect," the side effects are clearly going to be better than not using it. So, in one hand you have death, and in the other hand you might have some nausea. 

Make sure they call 9-1-1. Make sure they have glucagon. Make sure they know how to use it.

In terms of the ENDO guidelines, the ADA Standards of Care, AACE, all 2023, all recommend that patients have access to glucagon for severe hypoglycemic reaction.

So remember, level 1 (hypoglycemia), you want to have some glucose, have some food, make sure patients know this. Level 2 (hypoglycemia), also have carbohydrates. But if you’re having patients that ... it's not coming up and they're afraid, and they're fearful that something bad (can happen), they're alone ... make sure they have access to glucagon.

I'd like to share a patient case with you. I had mentioned earlier that T2D, we cannot forget about this ... I have a patient that I have been seeing for probably 15 years. And at this time, and it was before 2019, he was on 22 units of basal insulin, metformin, and an SGLT2 inhibitor, and that's it. Doing well, never (had a case of) hypoglycemia. 

He was at a family event at his home. He skipped a meal that day and he had hypoglycemic symptoms, and they used carbohydrates, glucose. They could not get his blood sugars up. Everyone was afraid. Everyone was panicking. They called 9-1-1. There was no glucagon in that ambulance. He ended up in the emergency room. He wasn't hospitalized at that time. But truly that was a wake-up call. So to me, especially for T2D, to make sure that, even with T2D, we are prepared, and that patient is prepared with glucagon.

I think that in terms of some important takeaways for you -- is education, education, education. Make sure you ask that patient who's sitting in front of you, do they know the signs and symptoms? Do you know how to treat it? Do you have glucose with you? Where is it? Do you have glucagon? Make sure their family members know where the glucagon is located and how to use it, and make sure they know how to treat in an emergency situation. Please take that with you and see if we can make a difference.

Thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

This transcript has not been copyedited.

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