A 36-year-old woman comes to the office due to type 1 diabetes mellitus. She was initially diagnosed 20 years ago and is treated with a combination of long- and short-acting insulin analogues. A month ago, the patient had an episode of severe hypoglycemia with near loss of consciousness that required the administration of a home glucagon kit by her husband. Since then, she has felt normal. Review of the patient's continuous glucose-monitoring system shows multiple glucose excursions

Question

A 36-year-old woman comes to the office due to type 1 diabetes mellitus.  She was initially diagnosed 20 years ago and is treated with a combination of long- and short-acting insulin analogues.  A month ago, the patient had an episode of severe hypoglycemia with near loss of consciousness that required the administration of a home glucagon kit by her husband.  Since then, she has felt normal.  Review of the patient's continuous glucose-monitoring system shows multiple glucose excursions <50 mg/dL in the past week; however, none of these episodes was associated with tremor, sweating, or altered mental status.  Hemoglobin A1c is 7.8%.  Which of the following interventions is most likely to restore hypoglycemic awareness in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_becc_67f5_8f63_f3ef2536b16a_MD0005_00 Patients with long-standing type 1 diabetes mellitus are at increased risk for insulin-induced hypoglycemia. These patients often have alpha cell failure, leading to reduced glucagon secretion in response to hypoglycemia. In addition, they commonly have a blunted autonomic response to hypoglycemia with less prominent neurogenic symptoms (eg, arousal, tremor, sweating) and therefore reduced hypoglycemic awareness. Hypoglycemic awareness is further reduced following severe hypoglycemic events. Recurrent or severe hypoglycemia reduces epinephrine-induced hepatic glucose release and suppresses the symptoms related to the catecholamine surge, increasing the risk for progressively worse hypoglycemia (ie, hypoglycemia-associated autonomic failure). Management requires strict avoidance of hypoglycemia, which can often restore awareness within 2-3 weeks. Careful timing of insulin administration, close monitoring of blood glucose, and modified carbohydrate ingestion (eg, in relation to physical activity) are necessary. hypoglycemia-associated autonomic failure (Choice A) Beta blockers can blunt hypoglycemia-induced sympathetic symptoms and further reduce hypoglycemic awareness. They increase the risk for severe hypoglycemia and therefore would not be ideal for this patient. (Choice C) Maintaining hemoglobin A1c <7% is recommended for most patients with diabetes mellitus to reduce the progression of microvascular complications (eg, neuropathy, nephropathy). However, this is associated with an increased risk for severe hypoglycemia; this patient's glycemic targets may need to be loosened until she can consistently avoid hypoglycemia. (Choice D) Exercise can induce hypoglycemia in patients on insulin therapy and may necessitate reduced dosing. In addition, high-intensity exercise may reduce hypoglycemic awareness. Although exercise is an important part of diabetes care, this patient's hypoglycemic awareness should be restored through strict avoidance of hypoglycemia before a new exercise regimen is initiated. (Choice E) Weight loss can increase insulin sensitivity and reduce dosing requirements. However, it can also increase the risk of hypoglycemia unless the insulin dose is carefully monitored. Educational objective: Recurrent or severe hypoglycemia in patients with long-standing type 1 diabetes mellitus reduces the autonomic symptoms of hypoglycemia (eg, tremor, arousal), increasing the risk for further severe hypoglycemic episodes. Strict avoidance of hypoglycemia for 2-3 weeks can restore hypoglycemic awareness.

A 36-Year-Old Woman Comes to the Office Due to Type