Spotlight on response to hypoglycemia

The response to hypoglycemic episodes was the focus of several recent studies.

A retrospective cohort study, published by the Journal of General Internal Medicine on Sept. 15, used electronic medical records from two hospitals over four years to identify episodes in which a patient had an ambulatory serum glucose level below 50 mg/dL (2.8 mmol/L). It found 209 such episodes, 61.2% of which led to contact between a patient and clinician. No etiology was documented in 63.3%, and no recommendations were provided in 25.0%. No patient-reported hypoglycemic symptoms were documented in 80.5%, and only 3.1% of episodes were associated with a serious adverse event. Clinician-patient contact was more common in patients with a malignant neoplasm or a hypoglycemic disorder and was inversely associated with a longer time from specimen collection to test result availability, which the study authors suggested might be due to clinicians assuming that patients would have treated themselves already if they were symptomatic. The study showed that blood glucose levels that qualify as critical action values (CAVs) were relatively rare, but “exposed deficiencies in the current process of responding to CAV for hypoglycemia, which if designed to protect patients from harm, would need to be re-examined to ensure that there is a more consistent and prompt response,” the authors said.

Another study, published as an e-letter by Diabetes Care on Sept. 17, looked at patients with type 2 diabetes who had an ED visit, observation stay, or hospital admission with a primary code of hypoglycemia. Among the 5,721 studied patients, 68% used insulin and 37% used sulfonylureas. HbA1c values were available for 1,305 patients, and the average at baseline was 7.5% (range, 4.3% to 17.6%). Compared to before the hypoglycemic episode, the proportion of the patients seeing an endocrinologist went up slightly in the six months afterward (16.7% to 18.2%). Among the patients with a baseline HbA1c level less than 6%, HbA1c level increased by at least 0.5% in only 30.5%. Of the 905 patients filling prescriptions for both insulin and a sulfonylurea at baseline, 70.5% did so again afterward, and fewer than 5% of patients filled a prescription for glucagon. The use of sulfonylureas declined from 37.0% to 30.7%, “but few other changes in diabetes management were evident following the event,” the authors said. They noted that the study could not capture dose reductions in insulin and couldn't assess the appropriateness of the individual clinical decisions reflected in the data but noted that there are many barriers to timely treatment deintensification, including performance metrics, inadequate integration of care, and insufficient guidance.

Finally, a scoping review published by Diabetic Medicine on Sept. 23 assessed overall deprescribing of glucose-, blood pressure-, or lipid-lowering medications in people with diabetes. Deprescribing rates ranged from 14% to 27% in older patients (ages ≥65 years) with HbA1c levels less than 6.5%. (Deprescribing for older patients with low systolic blood pressure ranged from 16% to 19% and the review found no articles reporting deprescribing of lipid-lowering medications.) The review included two studies of reminder systems that identified patients with hypoglycemia documented in the electronic health record, which resulted in deprescribing rates of 26% in one study and 37% in another that combined the intervention with shared decision making. Such programs appear to reduce overtreatment and hypoglycemic events, the study authors noted in their conclusion, which called generally for support systems and research to be focused on deprescribing for older patients with diabetes.