What follow-up care should be provided for patients with recurrent hypoglycaemic episodes?

For patients experiencing recurrent hypoglycaemic episodes, follow-up care should include a comprehensive review of possible contributory causes such as inappropriate insulin regimens, lifestyle factors including meal and activity patterns and alcohol intake, injection technique and site problems, impaired awareness of hypoglycaemia, changes in insulin sensitivity, previous physical activity, drug interactions, lack of self-management knowledge, and possible organic causes like comorbidities (e.g., hyperthyroidism, coeliac disease, Addison's disease, chronic kidney disease) ¹,²,³,⁵.

Patients should be assessed for impaired hypoglycaemia awareness using validated tools like the Gold or Clarke score at least annually, and education should be provided or reinforced on hypoglycaemia awareness and management, including structured education in flexible insulin therapy and additional training if impaired awareness persists ⁵.

Consider referral to specialist services for adults with recurrent severe hypoglycaemia not responding to standard interventions, including centres assessing for islet or pancreas transplantation ¹,⁵.

For nocturnal hypoglycaemia, review insulin regimens, evening eating habits, physical activity, and self-management skills, and advise occasional blood glucose monitoring between 2 am and 3 am when hypoglycaemia is most likely ¹,³.

Psychological factors such as anxiety, depression, eating disorders, and poor psychosocial support should be evaluated and addressed, with referral to mental health professionals as needed ¹,²,³.

Blood Glucose Awareness Training (BGAT), an online educational programme, may be considered to improve hypoglycaemia and blood glucose awareness in adults with recurrent episodes ¹,²,³.