Insulin therapy and hypoglycemia

Hypoglycemia is the most important and common side effect of insulin therapy. It is also the rate limiting factor in safely achieving excellent glycemic control. A three-fold increased risk of severe hypoglycemia occurs in both type 1 and type 2 diabetes with tight glucose control. This dictates a need to individualize therapy and glycemia goals to minimize this risk. Several ways to reduce hypoglycemia risk are recognized and discussed. They include frequent monitoring of blood sugars with home blood glucose tests and sometimes continuous glucose monitoring (CGM) in order to identify hypoglycemia particularly in hypoglycemia unawareness. Considerations include prompt measured hypoglycemia treatment, attempts to reduce glycemic variability, balancing basal and meal insulin therapy, a pattern therapy approach and use of a physiological mimicry with insulin analogues in a flexible manner. Methods to achieve adequate control while focusing on minimizing the risk of hypoglycemia are delineated in this article.