This article is sponsored by the Academy for Continued Healthcare Learning, an independently owned and operated full-service medical education company that has been developing certified health care education for nearly twenty years.

Visit the tools and a CME quality improvement activity at preventhypotoolkit.org. This activity is supported by an educational grant from Lilly. This activity was sponsored by Purdue University College of Pharmacy in partnership with ACHL.

Despite advances in diabetes care, hypoglycemia remains a common complication. Yes, new therapies are associated with less hypoglycemia risk, and patients are increasingly using continuous glucose monitoring, but episodes of hypoglycemia still occur. Some of these episodes are severe, and patients require assistance for recovery.

Hypoglycemia and fear of an episode can be extremely detrimental to patients’ quality of life. Hypoglycemia is also linked to higher healthcare utilization, poorer glycemic control, and medication nonadherence. Evidence from landmark clinical trials also shows that episodes of severe hypoglycemia increase the risk of all-cause mortality and cardiovascular morbidity and mortality. Severe hypoglycemia is a serious complication and a medical emergency.

How can you help your patients prevent hypoglycemia and be prepared for an episode? First, in accordance with the ADA Standards of Care, you should assess patients’ occurrence and risk of hypoglycemia at every encounter. Ask if they have experienced any potential signs or episodes since you last saw them or if they have required assistance from another person. Review their self-monitoring blood glucose or continuous glucose monitoring data. Next, make sure they understand how to recognize the signs and treat an episode.

As outlined in the ADA Standards of Care, patients with an increased risk of level 2 or 3 hypoglycemia should have an active prescription for glucagon. Unfortunately, glucagon remains underutilized and underprescribed even with these recommendations. And, few patients fill their prescriptions for emergency glucagon.

Second-generation glucagon formulations can help patients and their caregivers choose the best approach. Once a patient obtains their emergency glucagon, the patient and their family, friends, and coworkers should know where it is and how to use it. Patients should also periodically verify the expiration date of their glucagon.

To better support health care providers, Davida Kruger, APN-BC and Anne Peters, MD, in collaboration with the Academy for Continued Healthcare Learning (ACHL), developed a simple, systematic approach to quality improvement to ensure that patients are prepared to prevent, recognize, and manage hypoglycemia. The framework and tools are intended for easy access and application in any practice setting.

You can obtain MOC credit for participation, or if you’re not able to participate in the quality improvement initiative, there is also a way to participate in our accredited CME/CPE/CE activity.

The quality improvement activity includes interventions and tools to assist you in practice:

• a presentation by Ms. Kruger and Dr. Peters that includes the latest evidence and guidance supported by embedded commentary
• Ms. Kruger and Dr. Peters discussing a series of case studies featuring patients at high risk of severe hypoglycemia
• a digital clinical tool to help you assess a patient’s risk and ensure they are prepared
• a handout on developing alerts
• a patient education infographic on hypoglycemia and glucagon

Faculty biographies

Davida Kruger, APN-BC, has been a certified nurse practitioner in diabetes at Henry Ford Health in Detroit, MI, for 40 years. Her role includes clinical practice and research, and she is board-certified in both primary care and advanced diabetes management. She has been a co-investigator on numerous diabetes interventions and care studies, including the NIH-funded multicenter EDIC and ACCORD trials. She lectures extensively throughout the United States on maximizing outcomes in diabetes and diabetes management. She has published more than 60 abstracts, articles, and chapters on diabetes management. She has also served as editor-in-chief of two American Diabetes Association journals: Diabetes Spectrum and Clinical Diabetes.

Anne L. Peters, MD, is a professor of clinical medicine at the Keck School of Medicine of the University of Southern California. She runs diabetes centers in Beverly Hills and in underserved East Los Angeles. In addition to her clinical work, she has been a principal investigator on multiple grants, has written over 200 articles and four books, and has given over 500 lectures locally, nationally, and internationally. She has been on multiple guideline writing committees for the treatment of both type 1 and type 2 diabetes. Her major interests involve translating research findings, from lifestyle interventions to technology, to people with diabetes throughout the socioeconomic spectrum.  She was the recipient of the ADA Outstanding Physician Clinician Award, the Bernardo Houssay Award from the National Minority Quality Forum, and received a 2021 Endocrine Society Laureate Award for Public Service.

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we have a special sponsored episode on hypoglycemia, in partnership with Purdue University College of Pharmacy and the Academy for Continued Healthcare Learning. Despite advances in therapies and the increased use of continuous glucose monitoring, episodes of severe hypoglycemia still occur in patients with diabetes. The good news is that we can make sure that patients are prepared to manage any severe episodes of hypoglycemia. Please visit the tools and a CME quality improvement activity at preventhypotoolkit.org. That’s preventhypotoolkit.org. That link is in the show notes. This activity is supported by an educational grant from Lilly.

So today I’m joined by Davida Kruger, a certified nurse practitioner in diabetes at Henry Ford Health in Detroit, Michigan, and Dr. Anne Peters, a professor of clinical medicine at the Keck School of Medicine of the University of Southern California. So both of you, Davida and Anne, welcome to the show.

Davida Kruger: Good to be here.

Kevin Pho: So today let’s get started on our discussion about assessing patients’ risk of hypoglycemia and preparing patients for severe episodes of hypoglycemia. But I’m going to ask both of you first just to briefly share your story and journey to where you are today. Davida, why don’t you go first?

Davida Kruger: I’m a certified nurse practitioner, for the past 40 years working in the division of endocrinology with people who have diabetes. That’s what I do 100 percent of the time: I work with people who have diabetes.

Kevin Pho: And Anne, briefly share your story and journey to where you are today.

Anne Peters: Well, I’m very similar to Davida, in that I’ve just basically done this for my entire career, both type 1 and type 2, although shifting somewhat more to people with type 1 diabetes, and in particular using technology. But I’ve also always spent half my time working in a well-served community and the other half of my time in an underserved community. So I’m very interested in how we apply tools and technology to people who are less fortunate but who need health care even more, perhaps, than anybody else.

Kevin Pho: And we’re going to talk certainly more about those issues and hear some stories from both of your perspectives. So let’s get right into the questions here. So Anne, can you please describe the burden of hypoglycemia in patients with diabetes?

Anne Peters: Well, from a patient perspective, I think the burden is huge, because people who are at risk for hypoglycemia, which means pretty much everybody who takes insulin and some sulfonylurea agents or other drugs that can make them go low, are always wandering around the planet worried about going low. When you give insulin, you have to get the dose right, and if you get the dose wrong, that is often because people’s dose will change based on what they eat, how high their sugar is, whether they’re exercising, or whether they’re stressed. Whatever they’re doing can change that dose, and therefore it’s always a little bit of a guessing game, and they’re always at risk for going low.

I think it makes people afraid. I think it makes people worried about bringing their blood sugar down into the normal range. I think it has a whole host of psychological consequences as well as physiologic consequences for our patients.

Kevin Pho: And just a follow-up. Patients who go low in their blood sugars, how do they typically present to you in the office?

Anne Peters: Well, I ask every patient who is on insulin if they’re having episodes of going low, and I also in general use a lot of continuous glucose monitoring, so I can look to see if they are going low. But I don’t think I have a single patient on insulin who doesn’t have hypoglycemia. What I’m really worried about is severe hypoglycemia, when somebody loses consciousness and has to be helped by another to recover. So it’s the severe episodes of hypoglycemia that I’m most worried about, but all of my patients have some hypoglycemia. It’s just part of the process.

Kevin Pho: And Davida, what typically causes severe hypoglycemia?

Davida Kruger: Things that cause severe hypoglycemia. So first of all, I got a phone call from a family that their 76-year-old father took his 43 units of his long-acting insulin and only 4 units of his short-acting insulin and mixed those two up. So now we have all of this rapid-acting insulin on board, and I’m trying to come up with a plan so that we don’t have an assisted hypoglycemic event, which will include monitoring that person’s blood sugar probably hourly for the next six hours, and feeding them. So there are mistakes in switching your insulin. People reach into the refrigerator and unknowingly make mistakes; it’s human nature.

Schedule changes: Patients wake up and they decide they’re going to go for a walk, and they end up walking twice as long as they think they were going to walk, and they have hypoglycemia because their body’s not used to it. A missed meal, a missed snack, a meeting that runs over. I mean, I could give you a thousand reasons of things that cause hypoglycemia. But as Anne said, patients are living with hypoglycemia every day. Our job is to teach them how to prevent it so that it doesn’t become a severe episode.

And you asked Anne a question about what hypoglycemia looks like. That’s so individual. We can give you, like, a half a dozen symptoms of hypoglycemia, but it’s sort of like an aura of anything, and patients have their own symptoms, and they have to get used to that. And family members get used to what that person’s symptoms are, so they can help them when their blood sugars are just low, rather than severe, when it needs assistance.

Kevin Pho: And Anne, is the incidence of hypoglycemia related, of course, to a patient’s glycemic control, and when should a patient’s glycemic target be reconsidered to address these episodes of hypoglycemia?

Anne Peters: Well, I think that’s a slightly complicated question. In the past, we knew that the tighter the control, meaning the more normal the blood glucose levels, the higher the risk for hypoglycemia. But that was before we had the newer insulins, the pumps, and the sensors. We have a lot more tools, but people still have episodes of hypoglycemia in spite of all of the tools we have. And things that put people at more risk are being older, because as you get older, sadly, it actually gets harder to manage type 1 diabetes. But there are also people who have what’s called hypoglycemia unawareness. They lose those warning signals that Davida was discussing, and they’re at really high risk. And then if people have recurrent episodes of severe hypoglycemia, you want to change the targets.

But the good news, for me at least, is that if somebody’s having a lot of issues with lows and I raise their targets, so that I make their lower number 100 so they don’t ever go below 100, and then make it so that they don’t have to be as tightly controlled, what happens is it will restore their sensing of lows. So there are ways and programs to work on with a patient to get them more aware of their hypoglycemia, and that’s where, frankly, having a really good diabetes educator helps, because you really need to be on the patient.

A lot of these patients have a fear of hyperglycemia, because they’re so afraid of complications that they keep themselves lower than they ought to be, and to some degree, that takes a lot of hand-holding and convincing to raise their sugars so that they can start sensing their lows again. But I think that this is a lot of education, a lot of hard work, and a certain amount of psychology. I think that for people, avoiding lows is a big issue, and yet doable, if we adjust the targets and then do all of the things that I know Davida can teach us about that help people prepare for lows and then treat them when they have them.

Kevin Pho: Davida, how can clinicians assess their patients’ risk of hypoglycemia, particularly severe episodes?

Davida Kruger: Well, I think it’s a conversation you have at every visit, and I know both Anne and I do that. We have dot phrases that remind us to do it. But it’s a conversation during the visit, or during a phone call, video, whatever it is, that says, “Are you having episodes of hypoglycemia?” And then you have to ask more, because a lot of times patients will say, “Oh, no, I’m good until my blood sugar gets down to 40.” And actually, you don’t think very well if your blood sugar is probably less than 70, maybe for some patients less than 80. So you really have to tease it out and understand what the questions are.

The other thing is, while Anne and I both spend about 70 or 80 percent of our time probably with type 1 diabetes, I don’t want people to think that people who have type 2 diabetes who are on insulin do not experience hypoglycemia, because they do. And by the time our patients who have type 2 diabetes are on insulin, they’re also in a situation like our type 1 patients, where they don’t have a lot of beta-cell function and they don’t have a lot of counterregulatory function, so they’re at great risk for hypoglycemia. So we can change targets, and we can look at A1C, but the fact is, even if A1C is high, the patient has a risk of hypoglycemia, and you’ve got to ask the question.

So every visit, talk to your patients: What are your symptoms? When do you get them? Is there a particular time of day? Maybe it’s the patient who exercises every morning, and then all day long they’re having hypoglycemia. Well, there are things we can change in their care that allow them to still exercise but lower their insulin on the days that they’re exercising. They need to carry things with them to treat low blood sugar. If you prescribe insulin, you need to prescribe glucagon, and your patients and family members need to know how to use that, and always carry something with you. But it starts at the visit. It starts with the health care provider. It starts with the educator. And you always have to ask those questions about hypoglycemia: Are you having it? What does it look like to you? What numbers do you have? And how do you treat it?

Kevin Pho: And Anne, once a patient has been deemed to be at risk for severe hypoglycemia, how do you prepare that patient for potential episodes?

Anne Peters: Well, first of all, as Davida just said, everybody who’s on insulin is at risk for severe hypoglycemia, whether they have type 1 or type 2, and patients who are on sulfonylurea agents and some other oral agents are also at risk. And so the first thing that I do, again, I am lucky enough to have diabetes educators with whom I work who can do a lot of this, because it takes time and it takes education. In clinic, when I’m busy, I actually often don’t have time, because I’m dealing with other things with the patient, although every single time I forget to discuss hypoglycemia, I think of Davida, because I know that she remembers. In the old days, I used to have people fill out a form in the waiting room about hypoglycemia, so that I’d look at it when I saw the patient, so I’d know. But now, when I do telemedicine, I don’t have that form, because it’s just been a more abstract way. I’m not with the patient.

So I think the first thing is that people need to be aware of it. They need to be aware of the circumstances under which it can happen, but they also need to always carry something with them to treat it. I want people to carry with them some simple carbohydrate as well as glucagon, and I also want to make sure they have glucagon that their partner, or whoever they’re with, would know how to give them, because the patient isn’t giving glucagon to themselves. It’s somebody else. And so if it’s in the bedside table in case it happens at night, that’s great, but again, the person who would give it needs to know where it is, and the person who would give it needs to also be trained. The newer kinds of glucagon are much, much easier to administer than the old forms, but I still think a little bit of teaching is really good for that person, so when they panic, they don’t miss it.

I just had a patient who came in and said that they’d had to call the paramedics, and I said, “Well, did you have glucagon at home?” And of course they had glucagon at home, because I did what Davida says, and I had them all prepared. And I said, “Well, why did you have to call the paramedics?” And he said that his girlfriend got so panicked that she shot the glucagon into the air and didn’t give it to him, and then couldn’t find the second glucagon. And you know, these things happen. It’s scary to see your loved one unconscious and maybe having a seizure. I mean, it’s difficult for everybody.

And as all of us know, we’ve had people have severe hypoglycemic episodes in all sorts of settings. I’ve had moms have severe hypoglycemia in front of their kids, and they hate that. They feel humiliated, they feel out of control, and they feel like they can’t take care of their child. It’s just horrible for people to have that sense that they’re not strong enough, that they’re not healthy enough. I want people with type 1 and type 2 diabetes on insulin to feel just like anybody. I want them to feel in control. I want them to feel good. And yet this thing, this hypoglycemia, lurks, and that’s why we have to be so careful about discussing it and educating patients around it.

Kevin Pho: Today we’re talking with Davida Kruger, a certified nurse practitioner in diabetes at Henry Ford Health in Detroit, Michigan, and Anne Peters, a professor of clinical medicine at the Keck School of Medicine of the University of Southern California. This is a special sponsored episode on hypoglycemia, in partnership with Purdue University College of Pharmacy and the Academy for Continued Healthcare Learning. Please visit the tools and a CME quality improvement activity at preventhypotoolkit.org. That’s preventhypotoolkit.org, and that link is in the show notes. Davida, we now have second-generation glucagon formulations for patients. Can you discuss these and how you select one for an individual patient?

Davida Kruger: Absolutely. So we believe in shared decision-making, which means that I can suggest things, but the patient ultimately decides. I would say to my patients, “I don’t go home with you at night. That’s a good thing for you and a good thing for me.” But I try to offer them something that might fit better into their lifestyle. So we have the emergency glucagon kits. We call those the little red boxes. They’ve been around on the market for quite a while. The problem is they have a lot of steps that have to occur, and the person who is going to administer them is already stressed out about watching what’s going on with their loved one. They don’t remember, even though the directions are in the lid. They don’t remember how to use it. You have to draw it up, you have to mix it, and there’s a needle that you can see.

And so the second generation, which is what we hope all of the commercial plans as well as Medicare and Medicaid will approve, if they have not already, is either nasal, which is a little device that is put into the nose and squeezed, or the prefilled syringe or the pens. You take off the lid, and you never see the needle. You literally press it onto the skin, you hear some clicks, and the glucagon has been administered. So there are three second-generation options, and we really hope that everyone has an opportunity not only to get it but never to have to use it. But they do need to know where it is.

And I think, really quickly, about a story. I had a friend staying at my house who had type 1 diabetes and had a seizure, and I never asked her where the glucagon was, and I couldn’t find the glucagon while she was seizing. And I’m a trained health professional. I had to call EMS because I didn’t ask the question, and she didn’t tell me where it was. So that is absolutely the thing we have to make sure of: Not only do the people that might be using the glucagon know how to administer it, but where is it? Because if you know how to administer it but you can’t find it, that’s of no use to anybody. But the new generations are so simple and easy to use, and we really do try to move everybody to a new second generation.

Kevin Pho: And despite the availability of these different glucagon formulations, evidence suggests that many at-risk patients aren’t prescribed glucagon or don’t get their prescription filled. What are the barriers that prevent patients from receiving glucagon?

Anne Peters: I think that there are many barriers, unfortunately. One is that people just don’t have the time to think to prescribe it. It’s not a medication you’re going to take every day. In fact, it’s a medication we hope you never have to take, but it needs to be there. And most patients, or at least many patients, with diabetes, particularly with type 2 diabetes, are treated in primary care, and when a primary care clinician is seeing a patient, there are many competing needs. And frankly, all I do is diabetes, and yet I forget to say, “Do you have an unexpired glucagon kit at home?” And so I really feel that it’s hard, and I wish there were ways that it was easier to remind me to make sure somebody has an active way to give glucagon at home.

And another barrier, frankly, is coverage, because what I do is what Davida does: I ask patients, but also their partners, what kind of glucagon, of the second-generation glucagons, they’d prefer, whether the intranasal or the pen form, and then prescribe it. But not all insurers pay for both. And so if someone goes to the pharmacy to get it and there’s a pushback, they may not pick it up, because they’re like, “Well, I don’t really need this to live. I need my insulin to live, but I don’t need the glucagon.” So I find that there are insurance barriers, which have gotten less, but nonetheless you still have to deal with them.

But also, I’m telling you, it’s harder to remember than you’d think. Having this conversation always makes me aware of my deficiencies, so I’m the first to admit I’m not the greatest at this. I just wish I had a way that I knew when somebody needed a glucagon prescription. Some of my patients remember, but if someone hasn’t had an episode of severe hypoglycemia, they may not remember to ask for it. But then when they have one, then of course I get all motivated again and remember, but then I forget again. And it’s not forgetting so much as it’s just, I’m not being prompted, and it should be part of my checklist.

And again, as Davida says, when there are hard things going on, you’re talking with a patient about, you know, the patient she was just talking about, who’s given an unintentional overdose of the wrong kind of insulin, those are the kinds of things that take our attention away. And I’m sure, in that patient, Davida is sure that they have glucagon at home. But I’m telling you, I understand everybody’s issue in terms of doing this, and yet we all have to do better. I just wish we all had a Davida to help us, but I don’t, at least not that way. And so I just have to keep reminding myself: Ask the patient if they have unexpired glucagon at home, and if they don’t, make sure they have it.

Kevin Pho: So Davida, can you tell us about the quality improvement CME activity and accompanying tools that you developed with Anne for providers? And this can be found at preventhypotoolkit.org.

Davida Kruger: Well, thank you. Yes, absolutely. So we’ve been working on this with Purdue, and people can still view a case-based program where people participated. We actually had cases, and we talked about different ways we could handle them better. And I would add that one of the things we also talked about is what Anne just said, about how we trigger ordering the glucagon. And the biggest holdup is, I order it and it isn’t picked up because of cost. That’s not what I find to be the biggest issue.

And then we also have some different assessment tools and guides and alerts at the website that you mentioned, that providers can go and look at and add to their practice, that can help them understand how to prescribe, utilize, and educate their patients to use glucagon as needed. But it’s a very important factor. We’re all in the same situation, where we want to make sure the patient has what they need, and they don’t always have what they need. And also, if they have to call EMS, with the cost even to get EMS there and get to the ER, it is much better for everyone involved to be able to have glucagon at home. But it’s a great assessment tool, so that you can talk to your patients about the risk of hypoglycemia, prevention of hypoglycemia, treatment of hypoglycemia, and utilization of other tools.

Kevin Pho: So we have a special sponsored episode today on hypoglycemia, in partnership with Purdue University College of Pharmacy and the Academy for Continued Healthcare Learning. Please visit the tools that Davida talked about and a CME quality improvement activity at preventhypotoolkit.org, and that link will be in the show notes. And I’m going to ask each of you one final question, and really just your take-home messages to the KevinMD audience. So Davida, why don’t you go first?

Davida Kruger: I think my take-home message is that hypoglycemia is actually more prevalent than we think, and it’s one of the rate-limiting things to get people to treatment goal, and probably the things that keep both the provider and the patient awake at night. And so preparing the patient with the tools they need and asking the right questions really goes a long way in helping manage diabetes and safety for our patients.

Kevin Pho: And Anne, your take-home messages?

Anne Peters: My take-home message is that, first of all, mild hypoglycemia is more common than people think, and we haven’t really touched on it. But it’s very important to have people not only prepared for treating mild hypoglycemia so it doesn’t become severe hypoglycemia, but also knowing how to take the right amount of carbohydrates so they don’t rebound high, and then dose again when they’re high, and then go down low again. So I think treating mild hypoglycemia effectively and educating around that is step one, in addition to step two, which is just remembering to make sure your patients have glucagon, that it’s in a place where somebody else would know how to find it, and that someone is comfortable administering it.

The bottom line is, as Davida noted, if all the wheels fall off the cart and there’s nothing else to do, you have to call the paramedics, because this is a life-threatening emergency. But for many, many reasons, hopefully people have the glucagon, it can be administered, and that doesn’t have to happen.

But my other caveat is that in seniors, some of them may end up with more than just hypoglycemia. They may end up with a cardiovascular issue. There may be other things going on, because they have known cardiovascular disease, and in an episode of severe hypoglycemia, your evaluation after that might need to include other issues. So just make sure that for some of these elderly patients, you look at all of it besides just the episode of severe hypoglycemia.

Kevin Pho: Davida and Anne, thank you so much for joining me today. Please visit the CME quality improvement activity at preventhypotoolkit.org. Thank you so much for your time and insight.

Anne Peters: Thank you.