Intended for healthcare professionals


Hypoglycemia as an indicator of good diabetes care

BMJ 2016; 352 doi: (Published 07 March 2016) Cite this as: BMJ 2016;352:i1084
  1. Rene Rodriguez-Gutierrez, postdoctoral researcher12,
  2. Kasia J Lipska, assistant professor of medicine3,
  3. Rozalina G McCoy, assistant professor of medicine4 5,
  4. Naykky Singh Ospina, endocrinology fellow1,
  5. Henry H Ting, senior vice president6,
  6. Victor M Montori,, professor of medicine1,
  7. Hypoglycemia as a Quality Measure in Diabetes Study Group
  1. 1Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
  2. 2Division of Endocrinology, University Hospital Dr Jose E Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
  3. 3Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
  4. 4Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
  5. 5Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
  6. 6New York-Presbyterian Hospital, New York, USA
  1. Correspondence to: V M Montori montori.victor{at}
  • Accepted 5 February 2016

Rene Rodriguez-Gutierrez and colleagues argue that more attention should be paid to hypoglycemia when assessing management of diabetes

The goals of diabetes care are to reduce the risk of short and long term complications, increase longevity, and improve health related quality of life. Tight glycemic control—aiming for a hemoglobin A1c (HbA1c) concentration below 6.5-7.0%—has been the cornerstone of diabetes care based on the results of early randomized clinical trials that suggested a reduction in microvascular and macrovascular complications.1 2 These trials also found a twofold to threefold increase in the risk of severe hypoglycemia among patients randomized to intensive glycemic control.3 4 However, given the long term benefits of intensive glycemic control, this risk seemed justified and some have suggested a target for HbA1c “as close to normal as possible (<6%).”5 6 For many patients, hypoglycemia is the limiting factor to achieving stringent glycemic goals.5 7 It is also often perceived an unavoidable burden that needs to be accepted in order to accrue the potential long term benefits of glycemic control.

But this model of care is now changing, particularly in type 2 diabetes. The effect of tight glycemic control on microvascular and macrovascular outcomes that are important to patients (end stage renal disease, dialysis, blindness, clinical neuropathy, stroke, and death) remains uncertain,8 9 10 11 making it increasingly difficult for many patients and clinicians to accept the risk of severe hypoglycemia. Furthermore, even mild episodes of hypoglycemia (those that are self treated) impose a burden, cause distress, and disrupt the ability of patients to perform everyday activities.12 In addition, severe hypoglycemia is associated with adverse outcomes such as death, cardiovascular events, cognitive impairment, dementia, impaired autonomic function, fall related fractures, poor quality of life, and increased cost (table).12 13 …

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