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Nearly two-thirds of all Type 2 diabetic patients taking sulfonylureas report they frequently experience symptoms associated with hypoglycemia. But the vast majority of them (84%) don’t associate it with their medication.
They should, say diabetes experts connected with Novo Nordisk Pharmaceuticals in Princeton, NJ, manufacturer of Prandin (repaglinide), a short-acting drug designed to keep blood sugars level, especially when a patient must skip a meal.
But the jury is out on that one. Some experts say hypoglycemia is rare among Type 2 diabetics and the symptoms associated with it could apply to many conditions, including the pressures of daily life.
Novo conducted a telephone survey of 500 patients, 72% of whom said they used sulfonylureas, some of them in combination with other oral diabetic agents.
Two-thirds of the patients on sulfonylureas reported they experience one of more symptoms associated with hypoglycemia once a week or more, including: weakness and fatigue, anxiety and nervousness, unusual hunger, sweating, irritability, impaired vision, shaking, dizziness, head-ache, and fast heartbeat. (See box, below left.)
Yet, the company reported only 16% of the patients connected the symptoms to their long-acting oral agents, which sustain slow, steady insulin release and could result in hypoglycemic incidents if meals are missed or delayed.
While the United Kingdom Prospective Diabetes Study concluded that tight glycemic control delays or prevents complications for Type 2 diabetics, hypoglycemia increases with intensive drug treatment, particularly for those using sulfonylureas and/or insulin.
"The symptoms of hypoglycemia are so subtle that many patients don’t even associate it with a problem," says Alan Garber, MD, a professor medicine at Baylor College of Medicine in Houston, who has conducted research for Novo. Garber says he has developed the habit of asking patient if they sometimes "sort of zone out" or have "spells or episodes."
Doctors may be missing an opportunity to help patients with erratic schedules smooth out their blood sugars and vastly improve their quality of life with repaglinide (a short-acting drug in the meglitinide class) because of a "knee-jerk reaction to what they know," Garber says. "Until 1995, sulfonylureas were the only oral drugs available for diabetes, but now we have newer and improved medications."
But primary care physicians are "not as involved in the subtleties of managing diabetes," he adds, and "unless a patient has grossly symptomatic hypoglycemia, the possibility isn’t even considered." Some of Garber’s colleagues are not so sure that hypoglycemia is as common at the survey results indicate.
"People with Type 2 diabetes can get symptoms of low blood sugar whether or not their sugar is actually low," says Mark Burge, MD, assistant professor of medicine and endocrinology at the University of New Mexico in Albuquerque. Burge is also author of a study that showed sulfonylureas were well-tolerated among elderly patients who fasted without experiencing hypoglycemia. The study was published in the Journal of the American Medical Association in January 1998.
The only way to tell if patents are experiencing true hypoglycemia, says Burge, is to measure their blood glucose. He disagrees with Garber about the use of repaglinide, because he says hypoglycemia should be thoroughly documented through a battery of tests before additional oral agents are prescribed and admits that such extensive testing is rarely done.
"It makes sense that a person taking long-acting sulfonylureas who missed a meal might be a little more likely to become hypoglycemic," says Philip Cryer, MD, a professor of endocrinology and metabolism at Washington University School of Medicine in St. Louis. "But I would test it before I prescribed a medication based on these kinds of symptoms. We all experience these symptoms at one time or another, whether or not we have diabetes. Hypoglycemia can be a problem for patients with diabetes, but it is most common in Type 1s and in Type 2s, for whom the disease has progressed to the point where they are using insulin," he says.
[For more information, contact Alan Garber at (713) 790-4769, Mark Burge at (505) 277-2626, and Philip Cryer at (314) 362-7617.]