Of more than 10.7 million U.S. adults with diabetes who had HbA1c levels less than 7.0%, 2.3 million were treated much more intensively than recommended by current evidence-based guidelines, a study found.
To analyze the rate of intensive glucose-lowering therapy among adults with diabetes and model the number of hypoglycemia-related ED visits and hospitalizations attributable to it, researchers reviewed data from the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2014. Participants were defined as clinically complex if they were age 75 years or older or if they had two limitations in activities of daily living, end-stage renal disease, or three or more chronic conditions. Intensive treatment was defined as any glucose-lowering medications prescribed to patients with an HbA1c level of 5.6% or less or two or more medications prescribed to those with HbA1c levels of 5.7% to 6.4%. Results were published by Mayo Clinic Proceedings on Aug. 15.
About half (48%) of the studied patients had HbA1c levels less than 7.0%. Of these, 32.3% met the study's definition of clinically complex and 21.6% were intensively treated, with no difference by clinical complexity. Over a two-year period, there were an estimated 31,511 hospitalizations and 30,954 ED visits for hypoglycemia, with 4,774 (95% CI, 954 to 9,714) of those hospitalizations and 4,804 (95% CI, 862 to 9,851) ED visits attributable to intensive treatment, primarily among clinically complex patients.
“These findings are consistent with historical data demonstrating a high prevalence of potential overtreatment in a variety of settings in the United States, and lack of improvement in recent years despite growing recognition of the harms of overtreatment is concerning,” the study authors said. They noted that the study's results likely underestimate the true scope of hypoglycemia in the United States, because the rates of hypoglycemia were extrapolated from lower-risk patients (that is, a population without insulin use or prior hypoglycemia who were commercially insured). The estimates also only reflect the most severe hypoglycemic episodes that required ED care or hospitalization.
“Such intensive treatment is not harmless,” the authors wrote. “It promotes polypharmacy, with 13.9% (320,194 of 2,309,556) of intensively treated patients taking 3 or more noninsulin medications, sometimes in addition to insulin, thereby increasing treatment burden, risk for adverse drug reactions, and costs of diabetes care.”