title: Hypoglycemia unawareness is associated with reduced adherence to therapeutic decisions in patients with type 1 diabetes: evidence from a clinical audit.
abstract: OBJECTIVE
  Hypoglycemia unawareness increases severe hypoglycemia risk. Hypoglycemia avoidance restores awareness, but it is difficult to sustain. We compared adherence to treatment changes by awareness status.
  
  
  METHODS
  Case notes of 90 type 1 diabetic patients were analyzed retrospectively, identifying awareness status and insulin regimens over four visits. The proportion of patients adhering to advice and percent advice taken were calculated.
  
  
  RESULTS
  A total of 31 patients with hypoglycemia awareness and 19 patients with hypoglycemia unawareness were identified, with insulin regimens available in 23 and 13, respectively. Patients with hypoglycemia unawareness were older (P = 0.001) and had longer diabetes duration (P = 0.002) and lower A1C (P = 0.007). More patients with hypoglycemia unawareness reported severe hypoglycemia (P = 0.002) and fewer were adherent (53.8 vs. 87.0%, P = 0.046), with lower adherence scores (42.5 +/- 24.7 vs. 75.3 +/- 27.5%, P = 0.001).
  
  
  CONCLUSIONS
  Reduced adherence to changes in insulin regimen in hypoglycemia unawareness is compatible with habituation to hypoglycemic stress. Therapies aimed at reversing repetitive harmful behaviors may be useful to restore hypoglycemia awareness and protection from severe hypoglycemia.
authors.affiliation: Diabetes Research Group, King's College London School of Medicine, King's College, London, UK. charlotte.b.smith@doctors.org.uk
authors.forename: Charlotte B
authors.initials: CB
authors.lastname: Smith
authors.forename: Pratik
authors.initials: P
authors.lastname: Choudhary
authors.forename: Andrew
authors.initials: A
authors.lastname: Pernet
authors.forename: David
authors.initials: D
authors.lastname: Hopkins
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Amiel
mesh_terms: D000328:Adult; D001364:Awareness; D015992:Body Mass Index; D054869:Clinical Audit / Q000379:methods*; D003071:Cognition; D003657:Decision Making; D003922:Diabetes Mellitus, Type 1 / Q000097:blood* / Q000188:drug therapy / Q000523:psychology; D003928:Diabetic Nephropathies / Q000453:epidemiology; D003929:Diabetic Neuropathies / Q000453:epidemiology; D003930:Diabetic Retinopathy / Q000453:epidemiology; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000503:physiopathology* / Q000517:prevention & control* / Q000523:psychology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin