Response to Comment on: Cryer. Severe Hypoglycemia Predicts Mortality in Diabetes. Diabetes Care 2012;35:1814–1816

I am pleased that Kerner and Völzke (1) believe, based on their experience and assumptions, that the death rate from hypoglycemia in their patients with type 1 diabetes is lower than in the published literature. In my commentary (2) on the report of McCoy et al. (3) of a 3.4-fold higher mortality in patients with diabetes who self-reported severe hypoglycemia 5 years earlier, I cited four relatively recent series (all cited specifically in ref. 4) reporting that 4, 6, 7, and 10% of deaths of people with type 1 diabetes were attributed to hypoglycemia. Those proportions do not require any assumptions aside from the accuracy of the attributions. They are generally higher than the proportions of 2–4% of deaths reported in three earlier series (all also cited specifically in ref. 4), and are of even greater concern in view of the increasing life expectancy of individuals with type 1 diabetes (5). Given those published data—4% = 1 in 25 and 10% = 1 in 10—I concluded (2) that “it is sobering to think that as many as 1 in 25—or even 1 in 10—patients with type 1 diabetes will die of iatrogenic hypoglycemia. Obviously, life-threatening episodes of hypoglycemia need not be frequent to be devastating.” Whatever the precise hypoglycemic mortality rate, I think all who care for people with diabetes should consider these data (4).