REPLY
Intensive Insulin Treatment in Patients with Recurrent Hypoglycemia
Robert D. Hoeldtke, MD, PhD, and
Guenther Boden, MD
15 August 1994 | Volume 121 Issue 4 | Pages 307-308
IN RESPONSE:
We thank Dr. Rosman for his helpful comments and acknowledge that our perspective on the management of patients with hypoglycemia unawareness may differ from the views expressed by the Diabetes Control and Complications Trial Research Group [4]. Our more conservative approach is based on the following considerations.
First, the safety of intensive insulin therapy has not been established in patients with a history of recurrent hypoglycemia. Patients who had experienced recurrent hypoglycemia-related cerebral dysfunction (coma, confusion, or seizures) were excluded from the Diabetes Control and Complications Trial [5]. Moreover, study patients with a history of one severe hypoglycemic episode had more frequent severe hypoglycemia (relative risk, 2.54) during the trial [6]. The risk will undoubtedly be enhanced when less experienced health care providers, or those without support staff, initiate intensive insulin therapy. Although blood glucose awareness training may be beneficial [7], this is not generally available and (to our knowledge) has not been validated in patients receiving intensive insulin therapy.
For these reasons, we believe that a history of severe hypoglycemia represents a relative contraindication to intensive insulin therapy.
1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329:977-86.
2. The Diabetes Control and Complications Trial Research Group. Epidemiology of severe hypoglycemia in the Diabetes Control and Complications Trial. Am J Med. 1991; 90:450-9.
3. The Diabetes Control and Complications Trial Research Group. The diabetes control and complications trial (DCCT): design and methodologic considerations for the feasibility phase. Diabetes. 1986; 35:530-45.
4. Cox DJ, Gonder-Frederick L, Julian DM, Clarke W. Long-term follow-up evaluation of blood glucose awareness training. Diabetes Care. 1994; 17:1-5.
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