K. Weinger et al., BLOOD-GLUCOSE ESTIMATION AND SYMPTOMS DURING HYPERGLYCEMIA AND HYPOGLYCEMIA IN PATIENTS WITH INSULIN-DEPENDENT DIABETES-MELLITUS, The American journal of medicine, 98(1), 1995, pp. 22-31
PURPOSE: To investigate hypoglycemic and hyperglycemic symptoms, accur
acy of estimating blood glucose, and their relation to glycemic contro
l and counterregulatory hormone levels in insulin-dependent diabetes m
ellitus. PATIENTS AND METHODS: During randomly ordered stepped hypogly
cemic and hyperglycemic insulin clamps on two separate days, 42 patien
ts with insulin-dependent diabetes mellitus rated the intensity of 40
moods and symptoms when glucose was 8.9, 5.6 and 2.2 mmol/L, and 8.9,
14.4 and 21.1 mmol/l. The subjects were blinded to their actual glucos
e levels and asked to estimate them at each step. Epinephrine, norepin
ephrine, cortisol, growth hormone, and glucagon were measured at each
glucose plateau. RESULTS: Cluster analysis yielded five symptom groups
during hypoglycemia: autonomic symptoms, negative moods, positive moo
ds, feeling weak/dizzy, and feeling relaxed. At 2.2 mmol/L, mean score
s for all five symptom groups and 11 of 17 unclustered symptoms differ
ed from those reported at the baseline glucose of 8.9 mmol/L (P <0.05)
, but 34% of patients reported no awareness of autonomic symptoms. The
intensity of autonomic symptoms correlated positively with HbA(1) (r
=.43, P <0.01), epinephrine (r = .59, P <0.001), norepinephrine (r =.4
5, P <0.01) and cortisol (r =.62, P < 0.001), and negatively with gluc
ose estimation error (r = -.45, P = 0.01). Six patients (15%) were una
ware of both autonomic and neuroglycopenic symptoms during hypoglycemi
a. At 21.1 mmol/L, only 5 of 40 symptoms differed (P <0.05) from basel
ine. Seventeen percent of subjects made potentially serious errors whe
n estimating glucose at 2.2 mmol/L, and 66% at 21.1 mmol/L. Many patie
nts experienced symptoms different from those they reported as their u
sual manifestations of changing glucose levels. CONCLUSIONS: Since the
majority of patients made clinically serious errors in glucose estima
tion, and many used symptoms that did not discriminate hyperglycemia a
nd hypoglycemia, individualized training to increase awareness of gluc
ose-related symptoms and glucose levels may help patients reduce the f
requency or severity of hyperglycemic and hypoglycemic events.