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Intensive Insulin Treatment in Patients with Recurrent Hypoglycemia
- Robert D. Hoeldtke, MD, PhD; and
- Guenther Boden, MD
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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.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
