LETTER
Intensive Insulin Treatment in Patients with Recurrent Hypoglycemia
Paul M. Rosman, DO
15 August 1994 | Volume 121 Issue 4 | Pages 307-308
TO THE EDITOR:
The thoughtful perspective on hypoglycemia unawareness by Hoeldtke and Boden [1] ended with the stunning conclusion that intensive insulin therapy should probably be withheld from patients with recurrent hypoglycemia. To support this conclusion, they cite the Diabetes Control and Complications Trial, which they say "has confirmed that the prevalence of severe hypoglycemia remains a major obstacle to attempts to prevent diabetic complications with intensive insulin therapy" [1]. My reading of the report leads me to a different conclusion. The report states that "because of the risk, intensive insulin therapy should be implemented with caution, especially in patients with repeated severe hypoglycemia or awareness of hypoglycemia" [2].
The decision to initiate intensive insulin therapy in a patient with recurrent hypoglycemia deserves to be made clinically and should be based on the ability to establish "patient-driven" intensive management of diabetes control in individual patients. During the Diabetes Control and Complications Trial, this approach was used with frequent success (Kruger D. Personal communication) to minimize recurrent or severe hypoglycemia in the intensively treated patients. Further, Cox and colleagues [3] have shown that behavior modification techniques emphasizing blood glucose awareness training "result in reductions of severe hypoglycemic episodes and automobile crashes in the long-term"
1. Hoeldtke RD, Boden G. Epinephrine secretion, hypoglycemia unawareness, and diabetic autonomic neuropathy. Ann Intern Med. 1994; 120:512-7.
2. 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.
3. 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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