(CSEMP051) HYPOGLYCEMIA UNAWARENESS AND RECURRENT SEVERE HYPOGLYCEMIA IN A PATIENT WITH TYPE 1 DIABETES MELLITUS ON INSULIN THERAPY: A SPECIALIZED MULTI-DISCIPLINARY APPROACH.

Abstract: Background
Hypoglycemia is a common complication of insulin therapy in individuals with type 1 diabetes mellitus (T1DM). The combination of beta-cell loss and impaired glucagon response complicates patients’ ability to achieve their target HbA1c while avoiding hypoglycemia. In addition, hypoglycemias attenuate the sympathoadrenal response and hepatic glucose release, termed hypoglycemia-associated autonomic failure, which can persist for more than 24 hours and increases the risk of hypoglycemia recurrence. Achieving tight glycemic control while preventing onset of hypoglycemia thus presents a therapeutic challenge to clinicians.

Case Description:
A 55 year old man with T1DM was evaluated in a specialist Endocrinology clinic for hypoglycaemia unawareness and recurrent episodes of severe hypoglycaemia requiring almost daily EMS responses and 56 hospitalizations over 4 years. His presenting HbA1c was 4.6%. A multi-disciplinary team (MDT) was formed, comprising an endocrinologist, diabetes nurse educator, registered dietician, family practitioner, emergency department physician and a community paramedic team, with ultimate successful resolution of hypoglycemic crises. In the 1.5 year period post-MDT implementation, the patient required only 5 EMS responses, 1 hospitalization, and repeat HbA1c was 7.2%

Discussion
This case presents a multidisciplinary approach to reduce the incidence of severe hypoglycemia, reduce hospitalization rate and ameliorate cost-effectiveness of care for a complex patient with hypoglycemia unawareness and severe hypoglycaemia recurrence. Initial strategies to combat hypoglycemia, including insulin regimen titration with permissive hyperglycemia and provision of a continuous glucose monitor (CGM), alone showed limited effect. We therefore employed a multi-disciplinary, patient-centred approach to care that incorporated the following strategies: 1) identification and targeting of patient-specific needs and therapeutic barriers across multiple dimensions of patient well-being, including social, psychological and financial well-being; 2) implementation of a dynamic goal-directed approach characterized by frequent inter-provider communication; 3) regular, frequent patient follow-up with a Diabetes clinic team and a community outreach program; 4) patient empowerment, including promotion of diabetes self-efficacy and reduction in patient stigmatization.

Conclusion
Severe recurrent hypoglycemia in individuals with T1DM managed with insulin therapy can present a complex therapeutic challenge to care providers. We describe the implementation of a multi-disciplinary team that employed a goal-directed, collaborative, and patient-centred approach to hypoglycemia prevention. We highlight four key themes that were central to the successful resolution of hypoglycemic events requiring hospitalization.