It is strongly advised that people with diabetes, especially patients like this case, wear some sort of identification, such as a bracelet, or carry a card that state their condition [ 15 ].

Normalization of autonomic response takes 7—14 days on average, but it can take up to 3 months to normalize the threshold of symptoms, neuroendocrine response, and glucagon response although glucagon response is never fully recovered [ 37 , 38 ].

Another suggestion was to switch human insulin to the analog type of insulin. Hypoglycemia is a fairly common complication in diabetic patients receiving oral or insulin therapy.

However, in a subset of patients who are unaware of hypoglycemia for a variety of reasons, these warning signs do not exist, resulting in severe and life-threatening hypoglycemic episodes.

As a result, patients who have multiple episodes of HU are advised to raise their blood sugar control threshold for at least 2 weeks and to wear at all times a bracelet or label indicating their medical condition.

In addition, in these patients, the use of CGM equipped with alarms in the occurrence of severely low blood sugar can be a perfect option. Patient data and information can be accessed for review after obtaining permission from the patient without any disclosure of her name.

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Dagogo-Jack S, Rattarasarn C, Cryer PE. Reversal of hypoglycemia unawareness, but not defective glucose counterregulation, in IDDM. Download references. In appreciation, we express our gratitude to Dr. Rafiee for sharing the patient history and encouraging us to share this case as a valuable subject for other physicians.

Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, First Floor, No 10, Jalal-Al-Ahmad Street, North Kargar Avenue, Tehran, , Iran. Radiology Department, Iran University of Medical Sciences, Tehran, Iran.

Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. Tehran University of Medical Sciences, Tehran, Iran. You can also search for this author in PubMed Google Scholar.

YSH: Study conception and design, data collection, and draft manuscript preparation. ME, SST: Draft of manuscript. All authors reviewed the results and read and approved the final manuscript.

Correspondence to Yasaman Sharifi. Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the Journal of Medical Case Reports.

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Reprints and permissions. Sharifi, Y. Hypoglycemic unawareness: challenges, triggers, and recommendations in patients with hypoglycemic unawareness: a case report. J Med Case Reports 16 , Download citation.

Received : 14 January Accepted : 14 June Published : 21 July Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. The following sections discuss considerations for hypoglycemia prevention, including medication, diet and physical activity, use of glucose monitoring, and screening and management of hypoglycemia unawareness.

TABLE 1 summarizes the associated hypoglycemia risk of common glucose-lowering medications. If a patient is struggling with severe or recurrent hypoglycemia, it is important for the clinician to critically evaluate the appropriateness of the continued use of high-risk medications.

Although physical activity has many health benefits and should be encouraged in patients with diabetes, it can contribute to hypoglycemia in at-risk individuals; therefore, caution is warranted and individualized strategies for hypoglycemia prevention should be developed.

The effect of exercise on glucose levels will vary depending on the timing of physical activity relative to meals and medication administration as well as the duration and intensity of physical activity.

Monitoring via finger-stick glucose readings and a glucose meter or a continuous glucose monitor CGM is essential for the detection and avoidance of hypoglycemia. Patients at risk for hypoglycemia should be counseled to check their blood glucose before engaging in potentially dangerous activities e.

As noted previously, the threshold for experiencing hypoglycemia is often lower in patients who have frequent hypoglycemic events. The ADA also recommends that insulin-treated patients with hypoglycemia unawareness be advised to raise their glycemic target to strictly avoid hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce the risk of future episodes.

While implementation of strategies to prevent hypoglycemia is critical, diabetes patients at risk for hypoglycemia e. Hypoglycemia treatment involves two main strategies: 1 administration of oral carbohydrates and 2 administration of glucagon in the setting of severe hypoglycemia.

The preferred treatment for hypoglycemia in conscious patients is glucose, but any readily available form of carbohydrate that contains glucose may be used. The Rule of 15 both facilitates the appropriate resolution of hypoglycemia and prevents overtreatment of the hypoglycemic event in order to minimize rebound hyperglycemia.

Carbohydrate sources high in protein should be avoided, as protein will delay carbohydrate absorption and resolution of hypoglycemia. It may be helpful to provide patients with examples of carbohydrate sources that contain approximately 15 grams of carbohydrate, such as glucose tablets or gel carbohydrate content may vary , five or six Life Savers candies, 4 oz of juice or soda regular, not diet , and 8 oz of skim milk.

In situations where the patient is unconscious or otherwise unable to ingest oral carbohydrates, the administration of exogenous glucagon is indicated. Lyophilized glucagon has been available commercially for several decades. Newer Glucagon Formulations: The limitations of traditional lyophilized glucagon kits have led to the development of two new glucagon formulations that address barriers to use and appropriate administration.

The following paragraphs give a brief overview of the Baqsimi and Gvoke glucagon products see also TABLE 3. Baqsimi glucagon nasal powder — This product is a dry glucagon powder administered intranasally via a prefilled device.

Intranasal glucagon has been shown to be comparable to traditional glucagon emergency kits in terms of hypoglycemia resolution. While all glucagon formulations can lead to adverse effects such as nausea, vomiting, and headache, intranasal glucagon can also cause rhinorrhea, nasal congestion or discomfort, and epistaxis.

The Baqsimi nasal device comes in a yellow tube enclosed in shrink wrap. The device is gently inserted into one nostril, and the plunger is then firmly depressed all the way in to administer the full dose.

Because this formulation is a nasal powder, it may be stored at temperatures up to 86°F; however, it should not be stored in moist or humid conditions, as moisture may render the drug ineffective.

Gvoke glucagon injection — This new glucagon solution, which is administered via injection, does not require reconstitution.

Hypoglycemia remains a significant barrier in the optimal management of diabetes. Pharmacists can play a critical role in educating diabetes patients about the prevention, recognition, and appropriate treatment of hypoglycemia in the ambulatory care setting.

The widespread availability of CGM systems and newer, easier-to-use glucagon formulations provides opportunities for pharmacists to educate patients about these treatment options if they are struggling with recurrent hypoglycemic events.

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