LAUSR

T o Drs. Brož and Brožová: Thank you for the interest in our study, and your suggestion that future studies should examine communication around nocturnal hypoglycemia. We agree and thank you for pointing out this important research gap. In our study, the coding framework for hypoglycemia assessment was based on recommendations in major diabetes guidelines from the American Diabetes Association, the Endocrine Society, and the U.S. Department of Veterans Affairs. Nocturnal hypoglycemia was not a focus in any of these guidelines, so this was not a part of our coding framework a priori. During coding, we noted aspects of hypoglycemia communication that emerged from the visit dialogue such as patients expressing fear of hypoglycemia; we did not note any examples of clinicians assessing for nocturnal hypoglycemia. It is possible that clinicians felt that asking patients about hypoglycemic events in general would be sufficient to prompt patients to report nocturnal events, although as you mentioned nocturnal hypoglycemia may present with symptoms that may not be recognize as hypoglycemia such as vivid dreams or morning headaches. Future studies with larger samples would help determine the frequency by which assessment for nocturnal hypoglycemia occurs in clinical practice, and how this assessment might be optimized. We agree that important context is evidence from studies using continuous glucose monitoring that there is a high prevalence of nocturnal hypoglycemia in patients with type 2 diabetes. This is especially true among older adults who, as you mentioned, often have hypoglycemia unawareness or experience only the neuroglycopenic symptoms of hypoglycemia. Your letter suggests that a careful clinical assessment of overnight symptoms may reveal nocturnal hypoglycemic episodes in these patients. We feel that this is reasonable, but to our knowledge the effectiveness of this strategy for detecting nocturnal hypoglycemia has not been established. This would be another important area for future research. Thank you again for your interest in our paper and highlighting these important aspects of hypoglycemia prevention.