The prevalence of diabetes is increasing world-wide. Tight glycaemic control has been shown to reduce diabetes
complications in a number of landmark trials. Apart from increasing the risk of microvascular and macrovascular disease,
poor glycaemic control is also associated with cognitive and memory impairment as well as with mood disturbance.
However, tighter glycaemic control with conventional anti-hyperglycaemic medication is also associated with increased
risk of hypoglycaemia. There is increasing evidence that hypoglycaemia is much more than a troublesome inconvenience.
Indeed it is associated with acute cognitive impairment, dementia, increased risk of falls, rebound hyperglycaemia with
consequent loss of glycaemic control, acute coronary syndrome and increased mortality. Hence, a very difficult balance
needs to be achieved so as to achieve the best glycaemic control possible, whilst avoiding hypoglycaemia. This paper will
briefly discuss the potential benefits of tight glycemic control and reviews the risks associated with hypoglycaemia. A
paradigm shift in diabetes care may be needed; use of newer anti-hyperglycemic agents with low hypoglycaemia risk may
allow us to achieve good control in most patients whilst avoiding the serious consequences of hypoglycaemia. This may
be especially important in those at significant risk of hypoglycaemia (e.g. those with brittle diabetes) or of its consequences
such as elderly patients, those in certain occupations or those with cardiovascular disease or epilepsy.