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T1DCRN researcher Professor Thomas Kay from St Vincent’s Institute in Melbourne and an international team of specialists have developed a new four-stage treatment plan to tackle problematic hypoglycaemia.

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Severe hypoglycaemia is experienced by a third of people with type 1 diabetes at least once per year, when they will require another person to assist them in recovery. Severe hypoglycaemia can usually be explained by exercise, alcohol or errors in insulin dose, but in some people it is unpredictable and can occur seemingly without explanation.  This problematic hypoglycaemia has significant impacts on health and quality of life, but can be difficult to treat.

Professor Kay and his team reviewed a large body of evidence on existing treatment options for severe problematic hypoglycaemia and devised a four-stage algorithm to help clinicians develop an individualised treatment plan. The aim of the guidelines, published in Diabetes Care, is to balance the avoidance of severe hypoglycaemia with the achievement of optimal glucose control.

The guidelines recommend that all patients should first be assessed for underlying causes, hypoglycaemia unawareness and HbA1C. Individualised treatment can then be designed using the four-stage plan:

Stage 1: If the patient is not at target HbA1c, they should undergo structured or hypoglycaemia-specific education programs, followed by individualised glycaemic and hypoglycaemic target treatments.

Stage 2: If the patient is still not meeting targets, then the use of an insulin pump and/or a continuous glucose monitor is recommended, in addition to education programs.

Stage 3: The next treatment option is the use of a sensor-augmented pump, preferably with a low-glucose suspend feature to switch off insulin delivery when blood glucose levels are dropping too low. In addition, frequent contact with an expert hypoglycaemia team can help to restore awareness of hypoglycaemia and address any behavioural contributors to recurrent severe hypoglycaemia.

Stage 4: If all the previous options have failed, it is recommended that islet or pancreas transplant is considered. This is a last-resort option due to the necessity of life-long immunosuppressive drugs and possible complications.

Hypoglycaemia is responsible for up to 10% of deaths in people with type 1 diabetes, yet blood glucose levels that are too high contribute to the development of long-term complications. These guidelines will help endocrinologists develop individualised therapy that balances the avoidance of severe hypoglycaemia with maintaining acceptable blood glucose control.

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