Minimizing Hypoglycemia While Maintaining Glycemic Control in Diabetes

In an accompanying Perspectives article, Cryer (1) identifies a number of different areas where therapeutic interventions have the potential to reduce hypoglycemia without compromising glycemic control. Some approaches provide well-defined clinical benefits, a few offer dramatic reductions in hypoglycemia but remain out of reach for most people, and others, although promising, have yet to be properly evaluated (Table 1). In this Perspectives article, I examine the evidence that underpins these interventions. It is beyond the scope of this article to review the data for each potential intervention in detail, but the reader is directed to the source where appropriate. The focus of this article is treatment of type 1 diabetes, as most of the specific potential therapies have been evaluated in this group, although included are comments in relation to recent trials of intensive therapy in type 2 diabetes. ### Education and skills training in self-management. Long before the benefits of tight glucose control had been established (2), the belief that insulin therapy should be designed to replace insulin “physiologically” had been advocated by a small number of enthusiastic clinicians. The advent of blood glucose monitoring in the late 1970s had a major impact, since background and meal-related insulin could be given separately and adjusted according to self-monitored blood glucose measurements. Participants were encouraged to eat freely, calculating their insulin dose according to their chosen amount of carbohydrate. Integrating these components was a complex task, probably beyond that of many physicians, let alone patients. If this was to be undertaken every day, then patients needed to acquire the skill of flexible insulin self-management and apply it successfully. The therapeutic education approach was pioneered by Assal et al. (3), and Berger and Muhlhauser (4) went on to develop a residential training course (Insulin Treatment and Training program [ITTP]) evaluating the intervention in a series of studies, including …