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Prevention of hypoglycaemia, the ASAP (Anticipate, Suspect, Act, Prevent) strategy.

Byline: Sanjay Kalra and Yashdeep Gupta


This article describes a simple framework to prevent hypoglycaemia. Four strategies of prevention are detailed, which correspond to four levels of prevention (primordial, primary, secondary and tertiary). This framework, given the mnemonic ASAP (As Soon As Possible) includes action to Anticipate and Avoid, and Suspect and Screen hypoglycaemia. It also enjoins us to Act and Assist persons with hypoglycaemia in a timely manner, while working to Prevent and Protect them by using safer glucose lowering drugs and insulins.

Keywords: Diabetes, Hypoglycaemia, Insulin analogues, Levels of prevention, Modern glucose lowering drugs.

Diabetes is a dynamic disease, which presents multiple, ever changing challenges for both patient and physician. One such challenge is hypoglycaemia. 1 Ideally, hypoglycaemia should not occur at all, and modern diabetes management should have succeeded in 'eradicating' this acute complication of diabetes. Newer glucose-lowering drugs have succeeded in reducing the risk of hypoglycaemia markedly. Traditional sulfonylureas such as chlorpropamide and glibenclamide, are either obsolete or rarely used now. 2 Insulins with marked variability, such as Lente, semi Lente and ultra-Lente are no longer manufactured, as are bovine and porcine insulins. Human insulins are gradually being replaced by modern analogue insulins, which carry a lower risk of hypoglycaemia, especially nocturnal hypoglycaemia. 3,4

However, a complicated interplay of diet, physical activity pharmacological treatment strategies, and comorbid complications, ensure that hypoglycaemia is still a major concern in diabetes care. We suggest an ASAP strategy, which should be implemented by all diabetes care providers, including primary care physicians, ASAP (As Soon As Possible) (Table).

Table: Prevention of hypoglycemia, ASAP (As Soon As Possible).

ASAP###Level of prevention###Clinical situation###Action

Anticipate and Avoid###Primary###Hypoglycaemia is anticipated###Clinical conversation to elicit possible changes in diet, physical activity, concomitant

###medication intake

###Appropriate lifestyle and dose modification

Suspect and Screen###Secondary###Hypoglycaemia is suspected###Careful history taking to elicit typical and atypical, including culture- bound

###symptoms of hypoglycaemia

###Frequent and/or focused glucose monitoring

Act and Assist###Tertiary###Hypoglycaemia is documented/confirmed###Timely management of hypoglycaemia, by oneself or with assistance

Prevent and protect###Primordial###Avoidance of risk factors of hypoglycaemia###Prescribe safe glucose-lowering medication with low risk of hypoglycaemia

1. Anticipate and Avoid: Hypoglycaemia should be anticipated and prevented proactively rather than just being managed in a reactive manner. A history-taking or clinical conversation may reveal planned, or expected, situations where hypoglycaemia may occur. These include fasting (religious or otherwise), excessive physical activity, other changes in life style, and travel. Doses of secretagogues and insulin should be adjusted to avoid hypoglycaemia. 2 Patient education and empowerment facilitates this process of primary prevention.

2. Suspect and Screen: A high index of suspicion should be kept for typical as well as atypical symptoms of hypoglycaemia. Traditionally, symptoms of hypoglycaemia have been classified as neuroglycopenic and adrenergic. 5 There may also be symptoms related to glucagon secretion. Nocturnal hypoglycaemia presents with unique symptoms. Linguistic issues also crop up while interpreting symptoms suggestive of hypoglycaemia; culture-bound complaints may be reported. 6,7 The astute physician should suspect hypoglycaemia in relevant clinical situations, and should take measures to screen for it through laboratory-based or self-monitoring of blood glucose. This 'early diagnosis' strategy is akin to secondary prevention.

3. Act and Assist: In case hypoglycaemia occurs, it should be managed immediately. People living with diabetes, and their care givers, should be trained to manage hypoglycaemia with oral carbohydrates. In selected cases, glucagon may be kept handy for use if required. 8 Health care professionals and facilities should be able to manage severe hypoglycaemia effectively. This is a tertiary prevention strategy.

4. Prevent and Protect: The burden of hypoglycaemia can be reduced even further by using safer, better tolerated drugs which are associated with a lower risk of hypoglycaemia. Novel insulin analogues such as degludec and degludec aspart have demonstrated lesser risk of hypoglycaemia and nocturnal hypoglycaemia. 3,4 Glucagon like peptide-1 receptor agonists (GLP1RA), dipeptidyl peptidase 4 inhibitors (DPP4i) and sodium glucose cotransporter 2 inhibitors (SGLT2i) are modern classes of glucose lowering drugs with lower risk of hypoglycaemia. A similar advantage is shared by insulin sensitizers, alpha glucosidase inhibitors, and modern sulfonylureas. Such practice can be compared with primordial prevention, in which proactive measures are taken prior to onset of risk factors.


The ASAP strategy presents an easily understandable framework which views hypoglycaemia from a proactive, preventive framework, rather than a reactive, curative viewpoint. It highlights basic measures that can be taken when hypoglycaemia is anticipated, suspected, or documented/ experienced, in order to mitigate its impact.


1. Kalra S, Mukherjee JJ, Venkataraman S, Bantwal G, Shaikh S, Saboo B, et al. Hypoglycemia: The neglected complication. Indian J Endocr Metab 2013; 17:819-34.

2. Kalra S, Aamir AH, Raza A, Das AK, Khan AKA, Shrestha D et al. Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement. Indian J Endocr Metab. 2015; 19: 577-596.

3. Kalra S. Insulin degludec aspart: the first co-formulation of insulin analogues. Diabetes Therapy. 2014; 5: 65-72.

4. Yoo HJ, Park KY, Park KS, Ahn KJ, Min KW, Park JH, et al. Safety and efficacy of modern insulin analogues. Diabetes and metabolism journal. 2013; 37: 181-9.

5. Maffioli P, Derosa G. Hypoglycemia, its implications in clinical practice, and possible ways to prevent it. Current medical research and opinion. 2014; 30: 771-3.

6. Bhutani J, Kalra S, Bhutani S, Kalra B. Hypoglycemia perception: Cross-cultural differences in Punjabi and Hindi speaking postmenopausal women. Indian J Endocrin Metab 2013; 17: 286.

7. Kalra S, Balhara YP, Mithal A. Cross-cultural variation in symptom perception of hypoglycemia. Journal of mid-life health. 2013; 4: 176.

8. Boido A, Ceriani V, Pontiroli AE. Glucagon for hypoglycemic episodes in insulin-treated diabetic patients: a systematic review and meta-analysis with a comparison of glucagon with dextrose and of different glucagon formulations. Acta diabetologica. 2015; 52: 405-12.
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Publication:Journal of Pakistan Medical Association
Date:Apr 30, 2017
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