Unrecognized Hypo- and Hyperglycemia in Well-Controlled Patients with Type 2 Diabetes Mellitus: The Results of Continuous Glucose Monitoring

Abstract

The aim of this study was to determine the prevalence and extent of glycemic excursions (hypo- and hyperglycemic) in elderly patients with well-controlled type 2 diabetes using a Continuous Glucose Monitor System (CGMS) (Medtronic MiniMed^®). Elderly patients (>65 years old) with type 2 diabetes were recruited if their glycosylated hemoglobin (HbA1c) was <7.5% and if their oral hypoglycemic therapy included a sulfonylurea. Patients were asked to undergo two consecutive 72-h periods of continuous glucose monitoring at baseline and then again at 1 month (total 288 h). Patients were asked to record four self-monitored capillary blood glucose levels each day for calibration of the monitor and also to record meal times, exercise, and symptoms of hypoglycemia. The number of hyperglycemic (>144 mg/dL), hypoglycemic (<50 mg/dL), and borderline-hypoglycemic (50-65 mg/dL) events were determined (an event was defined as a glucose value that persisted for at least 15 min with or without symptoms). Twenty-five patients (21 men, four women) 73.9 ± 4.4 years old with an HbA1c of 6.2 ± 0.8% were each monitored for an average of 187.57 h. The mean glucose values were: fasting, 139 ± 40 mg/dL; 2 h post-breakfast, 167 ± 58 mg/dL; 2 h post-lunch, 157 ± 53 mg/dL; and 2 h post-dinner, 149 ± 49 mg/dL. Twenty patients (80%) experienced a total of 103 hypoglycemic events, and 14 of these patients experienced 54 events where the glucose levels were ≤40 mg/dL. Twenty-four patients (96%) experienced borderline-hypoglycemia (n = 229 events). Patients experienced a mean of 0.62 ± 0.72 episodes of hypoglycemia (interstitial glucose <50 mg/dL) per day (four to five episodes overall), 0.35 ± 0.6 episodes per day where the interstitial glucose was ≤40 mg/dL (two to three episodes overall), and 1.37 ± 1.22 episodes of borderline-hypoglycemia (nine to 10 episodes overall). Each episode of hypoglycemia persisted for 78 ± 73 min, and borderline-hypoglycemia for 45 ± 11 min. Patients were hypoglycemic 3.3% of the time and borderline-hypoglycemic 3.7% of the time. No episode of hypoglycemia was recorded by any patient in his or her daily diary. High postprandial glucose values (>144 mg/dL 2 h postprandial) were recorded after 57% of all meals (breakfast 60%, lunch 57.5%, dinner 55.2%). The CGMS was generally well tolerated, but 52% of patients could not be studied for the full 12 days of monitoring. Thus hypoglycemia and excessive postprandial glycemic excursions are common in well-controlled patients with type 2 diabetes treated with a sulfonylurea with or without metformin. The CGMS is a useful research and clinical tool to assess glycemia in patients with type 2 diabetes but is not tolerated by all subjects.