The HSF interviews Mary-Elizabeth Patti, MD, nationally recognized expert on hypoglycemia, who answers questions about hypoglycemia (outside of diabetes), and issues a national call to action.

Mary-Elizabeth Patti, MD is a board-certified endocrinologist, Director of the Joslin Diabetes Center Hypoglycemia Clinic, and a Harvard Medical School Associate Professor of Medicine practicing at Joslin Diabetes Center (a Harvard Medical School affiliate). Dr. Patti’s clinical practice and research efforts encompass both diabetes and hypoglycemia (low blood glucose levels). Dr. Patti is internationally recognized as an expert in the diagnosis and treatment of hypoglycemia, treats patients referred to her from around the country who are facing this challenging condition, and has published many scientific papers about hypoglycemia. Dr. Patti is frequently asked to speak at national academic meetings (American Diabetes Association, Endocrine Society, etc.) about the diagnosis and management of this disease.

HSF: What is hypoglycemia?

Dr. Patti: While much less common than diabetes (high blood sugar), hypoglycemia (low blood sugar) is also an established medical disease. Severe hypoglycemia can be caused by uncontrollable and excessive insulin production from within the body, due to genetic disorders, tumors of the pancreas (insulinoma), prediabetes, or prior stomach or intestinal surgery, all of which can cause uncontrollable surges in insulin levels; these high insulin levels cause the glucose levels to drop quickly to dangerous levels.

Since glucose is a critical fuel for brain cells, low glucose can cause abrupt change in brain function, as the brain requires glucose as a fuel in order to function properly. This can be dangerous, causing loss of thinking skills, reduced reaction time, loss of consciousness, seizures, motor vehicle accidents, coma, and even death. Some patients with severe hypoglycemia (glucose concentrations less than 3.0 mmol/L or 54 mg/dL) become disabled by this condition, and are no longer able to work due to inability to drive or maintain employment. 

If hypoglycemia is mild, it can be treated with food or glucose. Medications and strict dietary measures are used to try to reduce the frequency and severity of low glucose, but these are sometimes not fully effective. Insulin secretion remains uncontrollable, causing glucose levels to drop to dangerous levels at unpredictable times.

If hypoglycemia is severe, patients require the assistance of others in order to treat, and may require injections of a hormone called glucagon which elevates glucose levels back to the normal range. If hypoglycemia happens repeatedly, patients are often unaware of hypoglycemia until it is so severe that they are no longer able to treat it themselves. With loss of warning signs, patients may experience sudden loss of brain function and loss of personal safety without warning.

HSF: In what conditions can hypoglycemia occur?

Dr. Patti: Hypoglycemia occurs most often in diabetes, when the doses of insulin or medications which stimulate insulin release are too high relative to food or activity. However, hypoglycemia can occur also when the body is making too much insulin on its own. This can occur due to an insulin-producing tumor (insulinoma), or when the pancreas makes too much insulin after meals due to abnormal function of the insulin-producing cells, some cases of prediabetes, or due to abnormally high levels of hormones which direct the pancreas to make too much insulin. This can occur after a variety of types of gastrointestinal surgery. These conditions are not as common as diabetes, so are less recognized by the general public. However, for those patients affected by hypoglycemia, it is just as dangerous whether associated with diabetes or whether it occurs outside of diabetes. 

HSF: Are glucose monitors helpful in controlling hypoglycemia?

Dr. Patti: Continuous glucose monitors have been exceptionally powerful tools to assist patients in managing diabetes and to maintain their health and safety. These monitors analyze glucose levels in the fluid under the skin every 5 minutes. Data from the monitor is transmitted to a receiver or phone, which then displays the result. If glucose levels fall below a certain threshold, an alarm is generated which alerts the patient about a dangerous level of glucose, allowing the patient to treat and correct the glucose before it becomes severe and life-threatening. This is especially critical for those patients who do not have awareness of hypoglycemia, as the meter provides the information to them even though they have no symptoms.

HSF: Current Medicare statutes do NOT permit coverage for patients with severe hypoglycemia occurring in the absence of diabetes. 

Dr. Patti: Currently the Medicare statute, Social Security Act Title XVIII, section 1861(n) defines durable medical equipment (DME) coverage of glucose monitoring devices for patients with diabetes. As a physician at Joslin, I can attest that coverage of glucose monitoring is absolutely critical for patients with diabetes, allowing individuals to monitor glucose levels to guide decision-making regarding insulin and other medications, improve health, and improve safety and avoidance of severe hypoglycemia (glucose concentrations less than 3.0 mmol/L or 54 mg/dL) which can occur with diabetes medications.

This (coverage restriction) makes no sense, as hypoglycemia is dangerous and life-threatening, whether due to insulin or other medications for diabetes, or whether the body itself makes too much insulin. As a result of this statute, doctors treating this condition are unable to assist with improving the well-being and safety of their Medicare patients experiencing hypoglycemia outside of diabetes. It is currently impossible to request coverage via an appeal process for individual patients.  I have spoken with Medicare DME Medical Directors from around the country about this issue; while they agree a change in coverage is important from a medical perspective, they suggested pursuing a change in the relevant Medicare statute on behalf of patients with severe hypoglycemia.

HSF: Thank you Dr. Patti, we are committed to supporting this advocacy effort and have initiated a petition for the public to sign here: (click on banner below).