2016 Q3 Diabetes Tech Talk: Managing hypoglycemia with Dr. George Grunberger

Diabetes Tech Talk:
Managing hypoglycemia with Dr. George Grunberger


Dr. George Grunberger, AACE President

In a recent issue of In the Know, Dr. George Grunberger shared his valuable insights on the future of diabetes technology. In this issue Dr. Grunberger discusses how technology can help patients with diabetes prevent and manage hypoglycemia? There's no better person to ask than Dr. George Grunberger, MD, FACP, FACE!

Q: How does hypoglycemia affect the lives of your patients?

Hypoglycemia is the most feared complication of diabetes. For patients on hypoglycemic drugs like insulin and sulfonylureas, it can have a huge impact. Once people experience hypoglycemia, they're scared and will do anything possible to avoid it. Defensive eating is a classic example, such as the bedtime or midnight snack patients eat to avoid getting hypoglycemia at night. People gain weight and blame it on their insulin, but it's really the extra food they're eating.

Also, hypoglycemia affects people's productivity at work because of the things they do to avoid, minimize, or treat their hypoglycemia. People have to miss days from work or school and severe hypoglycemia might take 24 hours before blood sugar is normal. Besides absenteeism, there's presentism. This term refers to people showing up for work but not performing to their full potential. When people with diabetes are going into hypoglycemia, they have no choice but to treat it. Yet this involves so many tasks: There's glucose monitoring to confirm the symptoms are hypoglycemia. Then the patient has to treat it by consuming an appropriate glucose source. Then there's the finger stick again to confirm it's resolved. So there are costs in terms of both the materials and the time it takes, to detect, to treat, and to confirm the result.

Q: What strategies can people use to help avoid hypoglycemia at the office or at school?

There are easy answers and more complicated answers. The easy answer is to be on a continuous glucose monitor (CGM). In the 21st century, there's no excuse for people with type 1 diabetes or on insulin therapy not to be on CGM. Considering the cost of hypoglycemia, the cost of CGM, while not small, is worth it, because if you're on CGM, you know when you're heading toward hypoglycemia so you can act to avoid it. People who don't use CGM have to wait until they have symptoms, then do a finger stick to document whether or not they have hypoglycemia. If you have CGM, the CGM can help predict that your blood sugar might drop too low and take measures to avoid it.

There's also a lot of education involved. When patients are getting hypoglycemia, they need to identify when it occurs. Is it in the middle of the night or in the early morning before they eat? Then they have to deal with the basal insulin. If it happens during the day, especially between meals, typically it's because people misjudged insulin requirements for the particular meal. People on pumps or multiple daily insulin injections (MDI) have to decide at that moment how much insulin to give to cover their meal. They have to know the carbohydrate content and glycemic effects of the meal and their blood glucose value before they eat because they will have to calculate the correction factors.

It takes education, education, education. Remember, it's the patient who is making the decision in the moment. However, the diabetes educator's role in patient education is critical to ensuring the patient understands how to do insulin dosing.

Q: What advice should educators give to patients about dealing with nocturnal hypoglycemia?

With CGM, the patient sets the low and high levels. If the CGM detects glucose below the low glucose alarm level set by the patient, it will make noise and hopefully wake up the patient.

A lot of systems are on the market that integrate CGM and the pump, but only one currently has a low glucose threshold suspend system. In most systems with an integrated pump and CGM, the alarm sounds but the pump doesn't stop infusing insulin. If the patient ignores the alarm or sleeps through the alarm, the pump keeps going. In the system with the threshold suspend, the CGM not only sounds the alarm, but it also stops insulin delivery for up to 2 hours if the patient doesn't respond. It's the only one that's integrated and actually stops insulin so the patient doesn't get into worse trouble.

Q: What advice would you give educators to pass onto patients for dealing with nocturnal hypoglycemia if they don't have threshold suspend or even CGM?

For people who don't have CGM, like it or not, any time the patient adjusts insulin, whether they're on the pump or just injections, they must set the alarm clock and check their blood sugars at 2:00 or 3:00 a.m.—when blood sugar is usually the lowest—to make sure they're not getting nocturnal hypoglycemia. A lot of times they're asymptomatic and don't wake up. For those who do have CGM, the only advice is to review the records and see whether they show nocturnal hypoglycemia. The next step would be to reduce the basal insulin. If the basal insulin is an injection, then reduce the basal insulin dose. If it's a pump, then decrease the basal rate.


George Grunberger, MD, FACP, FACE, established Grunberger Diabetes Institute in Bloomfield Hills, Michigan, in 2002. He is also Clinical Professor of Internal Medicine and Molecular Medicine & Genetics at Wayne State University School of Medicine and Professor of Medicine at Oakland University William Beaumont School of Medicine. As tenured Full Professor at Wayne in 1986, he established and directed the Diabetes Program at the Detroit Medical Center and the University's Comprehensive Diabetes Center until 2002. He served as Director of Center for Molecular Medicine & Genetics (1997-2001) and Interim Chairman of Internal Medicine at Wayne and Physician-in-Chief of the Detroit Medical Center (1995-1996). He completed endocrinology & metabolism fellowship at the Diabetes Branch of NIDDK/NIH where he stayed on as Senior Investigator until 1986. Dr. Grunberger did his internal medicine residency at University Hospitals of Cleveland and received his M.D. ('77) at New York University School of Medicine and B.A. at Columbia College ('73) in New York City. In 2015, Dr. Grunberger was appointed as Visiting Professor in the First Faculty of Medicine at Charles University in Prague.

His AACE activities include six years as national Board member, an officer of the organization since 2014, and membership on multiple committees and councils (e.g., Coding, Nominating, Intensive Insulin Management, Continuous Glucose Monitoring, Diabetes Scientific, Public and Media Relations, Clinical and Practice Management Initiatives, Educational Initiatives, CAP Steering, and Clinical Research).

Dr. Grunberger served as chair of the Finance, Chapters, 2012 Annual Meeting Program, Task Force on Insulin Pump Management, PCP Diabetes Initiative, and FDA Issues committees.

He currently chairs the FDA Subcommittee, Primary Care Physician Education Committee and the Task Force for the Reimbursement of International Education Programs. He chaired the Consensus Conference on Glucose Monitoring in September 2014 and serves as co-chair for the Corporate AACE Partnership Steering Committee and Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan. He served locally as the Michigan AACE Chapter President for six years and has been active in other professional organizations.