Practice 10-Minute Consultation


BMJ 2011; 342 doi: (Published 16 February 2011) Cite this as: BMJ 2011;342:d567

Hypoglycaemia unawareness unawareness

The otherwise excellent article on hypoglycaemia (1) identifies the
major dangers of severe hypoglycaemia but gives inadequate guidance on the
diagnosis and management of hypoglycaemia unawareness. Avoidance of
blood glucose dips below 4 for a period of approximately 6 weeks usually
re-establishes a higher and safer threshold for hypoglycaemic symptoms
(2). This principle was highlighted by the British Diabetic Association in
"Make Four the Floor"(3)

Increasing numbers of insulin treated patients are followed up solely
in primary care, raising the question of whether staff have sufficient
knowledge to identify and manage patients with hypoglycaemic unawareness
many of whom are having severe hypoglycaemic episodes.

General practitioners(67) and practice nurses(16) at two recent local
diabetes meetings were presented a scenario of a consultation with an
insulin treated man with hypoglycaemic unawareness who was having severe
hypoglycaemic episodes. They were asked to write down the top 3 aims
during consultation and the answers were assessed in relation to
identifying the cause(s) of hypoglycaemia, the immediate management and
advice to re-establish hypoglycaemic awareness.

Of the 83 responses: in 32 there was no clear indication that the
precipitating cause(s) of hypoglycaemia would be identified or that
insulin doses would be reduced

in 71 driving or safety issues were not mentioned

in 74 hypoglycaemic unawareness/ reduced threshold was not identified

in 77 there was no advice to avoid blood glucose dips below 4

These results suggest that although primary care receives inducements
to achieve tight diabetic control the appropriate skills are lacking to
identify and manage the counterbalancing complication, namely severe
hypoglycaemia. This unawareness of hypoglycaemic unawareness poses a
significant hazard to patients and requires support and education of
primary care staff who manage diabetic patients. In addition to focused
education, clear care pathways need to be agreed and population
monitoring of HBA1c should be balanced by the incidence of severe
hypoglycaemia.Using the term "the syndrome of hypoglycaemic unawareness"
may aid its recognition as a discrete, important and potentially dangerous

1 Gupta PS,Green AN,Chowdery TA BMJ2011;342:d567

2 Frier B, Fisher M Hypoglycaemia in Clinical Diabetes 2nd edit.2007
publ.J Wiley

3 O'Neill S, Balance Jan.1997 p21-23

Competing interests: No competing interests

26 February 2011
David H Cove
consultant physician
Dorset County Hospital