Hypoglycemia Unawareness and Recurrent Severe Hypoglycemia in an Individual With Type 1 Diabetes Mellitus on Insulin

Background/ObjectiveHypoglycemia unawareness is a complication of recurrent hypoglycemia that can complicate diabetes management and impact quality of life. We present the case of an individual with type 1 diabetes with hypoglycemia unawareness and recurrent severe hypoglycemia requiring emergency intervention.Case ReportA 55 year-old man with type 1 diabetes was referred for hypoglycemia unawareness and recurrent hypoglycemia with seizures. Over the prior 4 years he had >400 paramedic responses with 56 hospitalizations. Blood glucose levels ranged between 0.7-2.4 mmol/L during these episodes and presenting HbA1c was 4.6% (28 mmol/mol). He was taking insulin glargine daily and aspart with meals via insulin pens and no alternative etiology for his hypoglycemia was identified. The patient expressed difficulty with self-management, social instability and limited appointment attendance. He was provided a continuous glucose monitor, educational support, and glycemic targets were broadened. After 6 months, HbA1c was 4.6% (28 mmol/mol) and he had 65 paramedic responses. A multi-disciplinary team was organized for biweekly follow-up, community outreach, remote technological support, and psychological counselling. After 2 years, the patient had 2 emergency responses and HbA1c was 7.2% (55.2 mmol/mol).DiscussionPermissive hyperglycemia, educational interventions, and continuous glucose monitoring are validated strategies for prevention of hypoglycemia. Limiting hypoglycemia is crucial to restore hypoglycemia awareness, and in severe cases may require high intensity follow-up, community outreach, and psychosocial support.ConclusionHypoglycemia unawareness can complicate hypoglycemia prevention. Severe refractory cases are often multi-faceted and may warrant a multi-disciplinary approach to identify and target patient-specific needs.