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Guideline Summary
Guideline Title
Evaluation and management of adult hypoglycemic disorders: an Endocrine Society clinical practice guideline.
Bibliographic Source(s)
Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ, Endocrine Society. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009 Mar;94(3):709-28. [189 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Hypoglycemic disorders, including treatment-induced hypoglycemic episodes in diabetes mellitus
  • Whipple's triad
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Endocrinology
Family Practice
Internal Medicine
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus

Target Population

Adult patients with hypoglycemic disorders, including those with diabetes mellitus

Interventions and Practices Considered

Diagnosis/Evaluation

  1. Workup for hypoglycemic disorder
    • Documentation of Whipple's triad
  2. In persons without diabetes mellitus
    • Review of history, physical findings, and laboratory data
    • Measurement of plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate concentrations, and insulin antibodies during an episode of spontaneous hypoglycemia
    • Recreation of symptomatic hypoglycemia if spontaneous hypoglycemia cannot be observed
    • Computed tomography or magnetic resonance imaging (MRI), transabdominal and endoscopic ultrasonography, and, if necessary, selective pancreatic arterial calcium injections with measurements of hepatic venous insulin levels to localize an insulinoma
  3. In persons with diabetes mellitus
    • Evaluation of conventional risk factors and compromised defenses in those with treatment-induced hypoglycemia

Treatment/Management

  1. Tailoring treatment as needed in persons without diabetes mellitus
  2. Maintaining therapeutic glycemic goal at lowest mean glycemia that can be accomplished safely
  3. Adjusting regimen if hypoglycemia is a problem
  4. Two to three week period of hypoglycemia avoidance, if history of hypoglycemia unawareness
  5. Review of treatment regimen and glycemia goals if episode of severe hypoglycemia
  6. Urgent treatment of hypoglycemia to include ingestion of carbohydrates, parenteral glucagon or glucose
  7. Educating patients regarding risk of hypoglycemia with rapid decrease in blood glucose or concentration less than 70 mg/dL
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests and procedures
  • Glycemic control
  • Hypoglycemic episodes
  • Morbidity and mortality related to hypoglycemia
  • Patient well-being

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Endocrine Society's Hypoglycemia Task Force commissioned two systematic reviews (see the "Availability of Companion Documents" field) to support their guidelines on the evaluation and management of adult hypoglycemic disorders.

Drug-Induced Hypoglycemia

Eligibility Criteria

Eligible studies reported hypoglycemia as a side effect of a medication not used to treat hyperglycemia, regardless of their study design, language, size, or duration of patient follow-up.

Ineligible studies were review articles, commentaries and letters that did not contain original data, and studies that reported hypoglycemia caused by antihyperglycemic agents (i.e., medications licensed for the treatment of hyperglycemia in diabetes), industrial and nonpharmacological chemical exposures, alcohol, herbs and nutritional supplements, and in vitro and animal studies.

When patients with potential drug-induced hypoglycemia were on insulin or sulfonylureas and there was an indication in the published report that they had no episodes of hypoglycemia before the introduction of the suspected drug, the article was included, realizing that this association is going to be very weak and supported by very low quality evidence.

Study Identification

An expert reference librarian designed and conducted the electronic search strategy with input from study investigators with expertise in conducting systematic reviews. To identify eligible studies, electronic databases (MEDLINE, EMBASE, Web of Science, and SCOPUS) through November 2007 were searched. In addition, the drug information system Micromedex was searched for hypoglycemic reactions in nondiabetic medications. The search strategy, which was tailored to each database, included controlled vocabulary and text words describing the concept of hypoglycemia and the subheadings: chemically-induced, epidemiology, and etiology, which were exploded in MEDLINE. In EMBASE, the term hypoglycemia with the subheadings side effect, epidemiology, and etiology, as well as the term "drug-induced disease" were used. Both searches also included the terms blood glucose/drug effects. Specific drug families/adverse effects (excluding hypoglycemic agents) were AND-ed to the concept of hypoglycemia. Text words were used in SCOPUS and Web of Science: "drug-induced" SAME (hypoglycaem* or glycem* or glycaem* or hypoglycemi*) or (hypoglycaem* or glycem* or glycaem* or hypoglycemi*) SAME (effect or effects or induced or caused) AND drug.*

Hypoglycemia with Intensive Insulin Therapy

Eligibility Criteria

Randomized controlled trials (RCTs) of intensive insulin therapy delivered either as continuous subcutaneous insulin infusion (CSII) (insulin pump) or as multiple daily injections (MDIs) in adults or children with diabetes of any kind, published in any language, were eligible for this review. Studies in critical illness or pregnancy were excluded. To minimize reporting bias, trials that did not fully report on glycemic control or hypoglycemia were not excluded. Because the latest systematic reviews summarized data before 2002 and because, in this field, there is an ongoing evolution in the nature of the technology surrounding insulin administration (both in terms of insulin preparations and of insulin pumps), it was arbitrarily decided to focus the review on randomized controlled trials published since 2002.

Search Strategy

Electronic databases were searched for eligible randomized controlled trials in MEDLINE (PubMed), EMBASE, and Cochrane's CENTRAL, from 2002 until August 2007 using terms (both text words and database-specific controlled vocabulary) that referred to both insulin and randomized trials. The reference lists of included trials were also reviewed. The clinical trials registry Clinicaltrials.gov was searched for unpublished and ongoing trials. Two multicenter ongoing trials (Medtronic STAR 3 and Juvenile Diabetes Research Foundation Artificial Pancreas Project) were identified, and pump manufacturers including Deltec, Animas, and OmniPod were contacted. The search was updated on March 17, 2008. Two meta-analyses published since the completion of this review were also included in the review.

Study Selection

Two reviewers working independently reviewed titles and abstracts resulting from the search and then the full text versions of those that seemed potentially eligible. Inter-reviewer agreement on trial eligibility was 100%.

Number of Source Documents

Drug-Induced Hypoglycemia

A literature search yielded 3,055 references, of which, 448 proved eligible for inclusion in this review. Figure 1 in the original guideline document depicts the search and selection procedures.

Hypoglycemia with Intensive Insulin Therapy

Initial search of the literature yielded 101 publications, of which 55 were relevant to this review based on titles and abstracts. After review, 12 eligible reports of 11 randomized controlled trials (RCTs) were found. The updated search in March 2008 led to the identification of four additional RCTs for a total of 15 included RCTs.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of the Evidence

+OOO Denotes very low quality evidence

++OO Denotes low quality evidence

+++O Denotes moderate quality evidence

++++ Denotes high quality evidence

Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The Endocrine Society's Hypoglycemia Task Force commissioned two systematic reviews (see the "Availability of Companion Documents" field) to support their guidelines on the evaluation and management of adult hypoglycemic disorders.

Drug-Induced Hypoglycemia

Data Collection

Teams of reviewers working independently and in duplicate used standardized forms and screened all abstracts and titles and, upon retrieval of candidate studies, reviewed the full text publications and determined study eligibility. Disagreements were resolved by consensus. Reviewers extracted descriptive, methodological, and outcome data from all eligible studies. Data extraction was done in duplicate until an adequate reproducibility (chance-adjusted interrater reliability or κ statistic ≥ 0.90) was achieved, and thereafter the individual data extraction was continued.

Data collected from studies included a description of the population (e.g., patients with diabetes, elderly), description of the exposure (overdose or commonly used dosing), the severity of hypoglycemia (whether it was symptomatic; whether it required another person's assistance), how hypoglycemia was documented (patient-reported or measured by another party), and whether patients had any comorbidities or other exposures that can predispose them to hypoglycemia.

Quality Assessment

Reviewers employed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rate the quality of research evidence, taking into account the elements that can strengthen the quality of observational studies such as strong associations and dose-response relationships. In addition, the categorization of the studies followed a hierarchy of evidence that considered the strongest association between a particular drug and hypoglycemia to be derived from: 1) n-of-1 trials or challenge/rechallenge studies (i.e. studies in which patients developed hypoglycemia after using a drug, then hypoglycemia resolved with cessation of the drug but reoccurred with reusage of drug); 2) consistent randomized controlled trials (RCTs) of drug vs. placebo; 3) heterogeneous randomized controlled trials and controlled cohort studies; 4) case series with no significant confounders; and finally, 5) case series with significant confounders. To assess for confounding, reviewers determined whether patients suspected to have drug-induced hypoglycemia had one or more of the 35 clinical situations that Service compiled and reported to be associated with clinically important hypoglycemia. The concomitant use of insulin or sulfonylureas also reduced the confidence that the offending medication could have caused hypoglycemia, resulting in a downgrading of the quality of the evidence.

Because a large number of published cases about a drug may only reflect the common usage of this drug, the number of cases of hypoglycemia reported per drug was not considered a factor that increased the quality of evidence or one that strengthened the association with hypoglycemia.

Statistical Analysis

A random effect meta-analysis was planned to pool association measures (odds ratios) from controlled studies (case-controlled studies, controlled cohort studies, and randomized controlled trials) comparing risk against placebo or a baseline incidence of hypoglycemia. In uncontrolled studies (single cohort studies), the proportion of patients who were exposed to the drug and suffered hypoglycemia was reported.

Hypoglycemia with Intensive Insulin Therapy

Quality Assessment

Four reviewers working independently and in duplicate analyzed the eligible articles to assess the reported quality of the methods. The reviewers used determinants of bias with empirical validation including allocation concealment, blinding of outcome assessors, and loss to follow-up. They also noted funding and presence of authors affiliated to the funding source. Chance-adjusted inter-reviewer agreement (κ statistic) ranged from 0.6 to 0.8 for these characteristics. Differences were resolved by arbitration.

Data Extraction

Three reviewers working independently and in duplicate extracted data from each of the eligible trials using an electronic structured extraction form including study characteristics (population, interventions, and outcomes). Patient characteristics including type and duration of diabetes, awareness of hypoglycemia, and experience with intensive insulin therapy were noted. The characteristics of the interventions including pump model, type of insulin used, glycemic goals, and the extent of training and support provided to participants before and during the trial were also noted. The extent of glycemic control achieved using glycosylated hemoglobin (HbA1c) was determined.

Extraction of Hypoglycemia Outcomes

Given that this work relies on published reports, the definitions the authors put forward for hypoglycemia were used. When more than one definition could apply, mild hypoglycemia was defined as blood glucose less than 3.3 mmol/liter (60 mg/dL) or hypoglycemia that did not require assistance by another person for its resolution. It was not possible to distinguish which episodes of mild hypoglycemia were symptomatic. Severe hypoglycemia was defined as hypoglycemia that required assistance by another person for its resolution.

Because of the paucity of severe hypoglycemic events and their skewed distribution, reviewers were particularly interested in the number of patients experiencing at least one episode in each group. Given that mild hypoglycemia is more common, reviewers were interested in both the number of patients experiencing hypoglycemia and the mean number of episodes they experienced. Recognizing that "number of episodes" would have a skewed distribution, i.e., few patients having most of the events, reviewers sought to identify categorical information about this distribution (e.g., number of patients with one episode, with one to five episodes, with more than five episodes per week). However, this type of information was not available, and therefore the mean number of episodes per patient per week was estimated.

Author Contact

Letters were sent by electronic mail detailing the findings to the corresponding authors (and any other author with contact address listed on the main manuscript) of each of the eligible studies. They were asked to verify these data and to complete the areas for which a satisfactory answer from the published record had not been identified. In case of no response, the request was repeated 1 week later.

Statistical Analysis

A DerSimonian-Laird random effects model was used to estimate pooled odds ratio (OR) and 95% confidence intervals (CI) for hypoglycemic events between groups and to estimate pooled weighted mean differences in HbA1c between groups and their 95% confidence interval.

Because some of the included studies used a crossover design, the Becker-Balagtas marginal estimated odds ratio was used to summarize the hypoglycemia outcomes from these studies, and the inverse variance method was used to pool these trials and to pool them with parallel-design trials. In these cases, sensitivity analyses were conducted imputing correlations between phases between 0 and 0.7; because important differences in the confidence intervals of the study estimates across this broad range of correlations were not found, a correlation of 0.3 for the base analyses was chosen. Similarly, the mean standard deviation (SD) value was used from those imputed across a range of correlations to estimate a common standard deviation value for the crossover trials to pool HbA1c and mean number of mild hypoglycemic events per patient per week across the crossover studies.

The degree of inconsistency in the results between studies was assessed using the I2 statistic. This statistic reflects the proportion of inconsistency between studies that cannot be explained by chance alone.

To explain inconsistency, a subgroup analysis was planned on the following characteristics: participant age group (pediatric, adolescent, and adult studies), type of diabetes, type of basal insulin used in multiple daily injection (MDI) groups, inequality in prandial insulin used between groups (analog insulin in continuous subcutaneous insulin infusion [CSII] vs. regular insulin in MDI), imbalance in training and support offered to each group, and length of study. A treatment-subgroup interaction with significance at the 0.05 level was tested for.

Reviewers also tried to estimate the relationship between HbA1c achieved at the end of the study and differences in the risk of hypoglycemia between groups using univariate analyses of HbA1c against the log odds ratio (OR). StatsDirect statistical software (2007; StatsDirect Ltd., Cheshire, UK) was used to perform all of the statistical analyses.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Participants

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, five additional experts, one methodologist, and a medical writer.

Evidence

Using the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, the quality of evidence is graded very low (+OOO), low (++OO), moderate (+++O), or high (++++).

Consensus Process

Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

  • 1 - Indicates a strong recommendation and is associated with the phrase "The Task Force recommends."
  • 2 - Denotes a weak recommendation and is associated with the phrase "The Task Force suggests."
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The drafts prepared by the task force with the help of a medical writer were reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee (CGS), Clinical Affairs Core Committee (CACC), American Diabetes Association, European Association for the Study of Diabetes, the European Society of Endocrinology, and the Society's Council. The version approved by the CGS and CACC was placed on The Endocrine Society's Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes.

Recommendations

Major Recommendations

Definitions for the quality of the evidence (+OOO, ++OO, +++O, and ++++); the strength of the recommendation (1 or 2), and the difference between a "recommendation" and a "suggestion" are provided at the end of the "Major Recommendations" field.

Workup for a Hypoglycemic Disorder

The Task Force recommends evaluation and management of hypoglycemia only in patients in whom Whipple's triad—symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised—is documented (1| ++++).

Evaluation and Management of Hypoglycemia in Persons without Diabetes Mellitus

Compared with a much less thorough workup, the Task Force recommends the following strategy in patients with hypoglycemia without diabetes mellitus (1| +++O):

  • Review the history, physical findings, and all available laboratory data seeking clues to specific disorders—drugs, critical illnesses, hormone deficiencies, nonislet cell tumors.
  • When the cause of the hypoglycemic disorder is not evident, i.e., in a seemingly well individual, measure plasma glucose, insulin, C-peptide, proinsulin, and beta-hydroxybutyrate concentrations and screen for oral hypoglycemic agents, during an episode of spontaneous hypoglycemia, and observe the plasma glucose response to IV injection of 1.0 mg glucagon. These steps will distinguish hypoglycemia caused by endogenous (or exogenous) insulin from that caused by other mechanisms. Also, measure insulin antibodies.
  • When a spontaneous hypoglycemic episode cannot be observed, formally recreate the circumstances in which symptomatic hypoglycemia is likely to occur, i.e., during a fast of up to 72 h or after a mixed meal. The findings of symptoms, signs, or both with plasma concentrations of glucose less than 55 mg/dL (3.0 mmol/liter), insulin of at least 3.0 μU/mL (18 pmol/liter), C-peptide of at least 0.6 ng/ml (0.2 nmol/liter), and proinsulin of at least 5.0 pmol/liter document endogenous hyperinsulinism; beta-hydroxybutyrate levels of 2.7 mmol/liter or less and an increase in plasma glucose of at least 25 mg/dL (1.4 mmol/liter) after IV glucagon indicate mediation of the hypoglycemia by insulin (or by an insulin-like growth factor [IGF]).
  • In a patient with documented fasting or postprandial endogenous hyperinsulinemic hypoglycemia, negative screening for oral hypoglycemic agents, and no circulating insulin antibodies, conduct procedures for localizing an insulinoma. These may include computed tomography or magnetic resonance imaging (MRI), transabdominal and endoscopic ultrasonography, and, if necessary, selective pancreatic arterial calcium injections with measurements of hepatic venous insulin levels.
  • Tailor treatment to the specific hypoglycemic disorder, taking into account the burden of hypoglycemia on patient well-being and patient preferences.

Evaluation and Management of Hypoglycemia in Persons with Diabetes Mellitus

The Task Force suggests that persons with diabetes become concerned about the possibility of developing hypoglycemia when the self-monitored blood glucose concentration is falling rapidly or is no greater than 70 mg/dl (3.9 mmol/liter) (2| +OOO).

Given the established long-term microvascular benefits of glycemic control, the Task Force recommends that the therapeutic glycemic goal be the lowest mean glycemia (e.g., hemoglobin A1c [HbA1C]) that can be accomplished safely in a given patient at a given point in the progression of that individual patient's diabetes (1| ++++).

The Task Force recommends that the prevention of hypoglycemia in diabetes involve addressing the issue in each patient contact and, if hypoglycemia is a problem, making adjustments in the regimen based on review and application of the principles of intensive glycemic therapy—diabetes self-management (supported by education and empowerment), frequent self-monitoring of blood glucose, flexible and appropriate insulin or insulin secretagogue regimens, individualized glycemic goals, and ongoing professional guidance and support—and consideration of each of the known risk factors for hypoglycemia (1| +++O).

The Task Force recommends that both the conventional risk factors and those indicative of compromised defenses against hypoglycemia be considered in a patient with recurrent treatment-induced hypoglycemia (1| ++++). The conventional risk factors are excessive or ill-timed dosing of, or wrong type of, insulin or insulin secretagogue and conditions under which exogenous glucose delivery or endogenous glucose production is decreased, glucose utilization is increased, sensitivity to insulin is increased, or insulin clearance is decreased. Compromised defenses against hypoglycemia are indicated by the degree of endogenous insulin deficiency, a history of severe hypoglycemia, hypoglycemia unawareness, or both as well as recent antecedent hypoglycemia, prior exercise or sleep, and lower glycemic goals per se.

With a history of hypoglycemia unawareness (i.e., recurrent hypoglycemia without symptoms), the Task Force recommends a 2- to 3-wk period of scrupulous avoidance of hypoglycemia, with the anticipation that awareness of hypoglycemia will return in many patients (1| ++OO).

Unless the cause is easily remediable, the Task Force recommends that an episode of severe hypoglycemia should lead to a fundamental review of the treatment regimen and the glycemic goals (1| ++++).

The Task Force recommends that urgent treatment of hypoglycemia should be accomplished by ingestion of carbohydrates if that is feasible, or by parenteral glucagon or glucose if it is not feasible (1| ++++).

Definitions:

Quality of Evidence

+OOO Denotes very low quality evidence

++OO Denotes low quality evidence

+++O Denotes moderate quality evidence

++++ Denotes high quality evidence

Strength of Recommendation

1 - Indicates a strong recommendation and is associated with the phrase "The Task Force recommends."

2 - Denotes a weak recommendation and is associated with the phrase "The Task Force suggests."

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Accurate diagnosis of causes of hypoglycemia in people without diabetes mellitus
  • Prevention and management of treatment-induced hypoglycemia in patients with diabetes mellitus, which may lead to improved glycemic control, decreased hypoglycemic episodes, and decreased morbidity and mortality
Potential Harms

Glucagon often causes substantial, albeit transient, hyperglycemia, and it can cause nausea and even vomiting.

Qualifying Statements

Qualifying Statements
  • Clinical Practice Guidelines are developed to be of assistance to endocrinologists by providing guidance and recommendations for particular areas of practice. The Guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The Guidelines cannot guarantee any specific outcome, nor do they establish a standard of care. The Guidelines are not intended to dictate the treatment of a particular patient. Treatment decisions must be made based on the independent judgment of health care providers and each patient's individual circumstances.
  • The Endocrine Society makes no warranty, express or implied, regarding the Guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. The Society shall not be liable for direct, indirect, special, incidental, or consequential damages related to the use of the information contained herein.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ, Endocrine Society. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009 Mar;94(3):709-28. [189 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar
Guideline Developer(s)
The Endocrine Society - Professional Association
Source(s) of Funding

The Endocrine Society

Guideline Committee

The Adult Hypoglycemic Disorders Guideline Task Force

Composition of Group That Authored the Guideline

Task Force Members: Philip E. Cryer (Chair); Lloyd Axelrod; Ashley B. Grossman; Simon R. Heller; Victor M. Montori; Elizabeth R. Seaquist; F. John Service

Financial Disclosures/Conflicts of Interest

Philip E. Cryer, M.D. (Chair) — Financial or Business/Organizational Interests: consultant for the following: Amgen Inc., Johnson & Johnson, MannKind, Marcadia Biotech, Merck, Medtronic MiniMed, Novo Nordisk, Takeda, TolerRx Inc., National Institutes of Health; Significant Financial Interest or Leadership Position: past president of American Diabetes Association (1996–1997), past editor of Diabetes (1992–1996)

Lloyd Axelrod, M.D. — Financial or Business/Organizational Interests: advisor or consultant for the following: American College of Physicians, American Medical Association, Best Doctors, Inc., UpToDate, Eli Lilly and Co., Smart Cells Inc., Cell Genesys Inc.; Significant Financial Interest or Leadership Position: none declared

Ashley B. Grossman, M.D. — Financial or Business/Organizational Interests: consultant for the following: Novartis, Ipsen; Significant Financial Interest or Leadership Position: none declared

Simon R. Heller, D.M., FRCP — Financial or Business/Organizational Interests: consultant for the following: Novo Nordisk, Aventis, Eli Lilly, MannKind, Menarini; Significant Financial Interest or Leadership Position: none declared

*Victor M. Montori, M.D. — Financial or Business/Organization Interests: none declared; Consultation/Advisement: KER Unit (Mayo Clinic)

Elizabeth R. Seaquist, M.D. — Financial or Business/Organizational Interests: Pfizer, Merck, Co., Caring for Diabetes Educational Forum; Significant Financial Interest or Leadership Position: none declared

F. John Service, M.D., Ph.D. — Financial or Business/Organizational Interests: American Association of Clinical Endocrinologists; Significant Financial Interest or Leadership Position: none declared

*Evidence based reviews for this guideline were prepared under contract with The Endocrine Society.

Guideline Endorser(s)
American Diabetes Association - Professional Association
European Association for the Study of Diabetes - Disease Specific Society
European Society of Endocrinology - Medical Specialty Society
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from The Endocrine Society External Web Site Policy.

Print copies: Available from The Endocrine Society, Phone: (301) 941.0210; Email: Societyservices@endo-society.org

Availability of Companion Documents

The following are available:

  • Murad MH, Coto Yglesias F, Wang AT, Mullan RJ, Elamin M, Sheidaee N, Erwin PJ, Montori VM, Drug-induced hypoglycemia: a systematic review. J Clin Endocrinol Metab. 2009 Mar. 94:741-5.
  • Fatourechi M, Kudva Y, Murad M, Elamin M, Tabini C, Montori V. Hypoglycemia with intensive insulin therapy: a systematic review and meta-analysis of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. J Clin Endocrinol Metab. 2008 Dec. 94:729–40.

Print copies: Available from The Endocrine Society, Phone: (301) 941.0210; Email: Societyservices@endo-society.org

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 5, 2010. The information was verified by the guideline developer on September 16, 2010.

Copyright Statement

This is an author manuscript copyrighted by The Endocrine Society. This may not be duplicated or reproduced, other than for personal use or within the rule of "Fair Use of Copyrighted Materials" (section 107, Title 17, U.S. Code) without permission of the copyright owner, The Endocrine Society. From the time of acceptance following peer review, the full text of this manuscript is made freely available by The Endocrine Society at http://www.endo-society.org/guidelines/Current-Clinical-Practice-Guidelines.cfm External Web Site Policy.

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