How should I adjust insulin therapy for a patient with Type 1 Diabetes who is experiencing recurrent hypoglycemia?

For a patient with Type 1 Diabetes experiencing recurrent hypoglycemia, the approach involves a comprehensive review and potential adjustment of their insulin therapy, alongside addressing contributing factors and considering specialist referral.

• Review Insulin Regimen and Doses:
  • If hypoglycemia becomes unusually problematic or increases in frequency, the insulin regimen should be reviewed, including dose distributions and insulin types ⁴.
  • A dose reduction of insulin may be needed, particularly if the patient has a low HbA1c level and/or recurrent hypoglycemia ³.
  • For nocturnal hypoglycemia, the current insulin regimen, evening eating habits, and previous physical activity should be reviewed, and an insulin type and regimen less likely to cause low glucose levels at night should be chosen ⁴.
• Address Contributing Factors:
  • Possible causes to review include inappropriate insulin regimens, meal and activity patterns (including alcohol), injection technique and skills, injection site problems, potential organic causes (e.g., gastroparesis), changes in insulin sensitivity (e.g., due to certain drugs or renal failure), mental health problems, previous physical activity, and lack of appropriate self-management knowledge and skills ⁴.
• Education and Technology:
  • Ensure the patient has received structured education in flexible insulin therapy using basal–bolus regimens and is correctly following its principles ⁴.
  • Offer additional education focused on avoiding and treating hypoglycemia if impaired awareness persists after structured education ⁴.
  • Consider offering an an insulin pump or real-time continuous glucose monitoring ⁴.
  • Individualized blood glucose targets should not be relaxed to address impaired hypoglycemia awareness ⁴.
• Specialist Referral:
  • If recurrent severe hypoglycemia has not responded to other treatments, or if impaired hypoglycemia awareness is associated with recurrent severe hypoglycemia despite interventions, consider referring the patient to a specialist diabetes team or centre ³,⁴.