March 10, 2014
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Insulin-induced hypoglycemia significant cause of emergency visits

In a recent study, researchers report a significant number of visits to the ED for insulin-related hypoglycemia, and demonstrate that elderly adults are at higher risk for hypoglycemia and are twice as likely to be hospitalized for the condition.

The data showed confusion over dose and insulin type were behind many of the incidents.

“Rates of ED visits and subsequent hospitalizations for [insulin-related hypoglycemia and errors] were highest in patients 80 years or older; the risks of hypoglycemic sequelae in this age group should be considered in decisions to prescribe and intensify insulin. Meal-planning misadventures and insulin product mix-ups are important targets for hypoglycemia prevention efforts,” researchers wrote.

Investigators based their findings on 8,100 cases from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project. Data showed an estimated 97,648 IHEs occurred annually over the period studied, from 2007 through 2011. Almost one-third (29.3%; 95% CI, 21.8-36.8) resulted in hospitalization and in an estimated 60.6% (95% CI, 51.3-69.9) of ED visits for IHE, severe neurologic sequelae were documented. Blood glucose levels of 50 mg/dL or less were recorded in a total of 53.4% of visits. Patients aged 80 years or older were more than twice as likely to present to the ED for insulin-related hypoglycemia  events (rate ratio: 2.5; 95% CI, 1.5-4.3), and were nearly five times as likely to be hospitalized following their ED visits (rate ratio: 4.9; 95% CI, 2.6-9.1) than insulin-treated patients aged 45 to 64 years. Reduced food intake and administration of the wrong insulin product were identified as the most common causes of hypoglycemia and errors.

In an accompanying editorial, Sei J. Lee, MD, MAS, suggested three clinical practice and guideline changes to stop the “hypoglycemia epidemic.” First, Lee proposes using a target range for HbA1c opposed to “less than 7%.”

“By recommending a target of less than 7%, proponents are sending a subtle but powerful message that lower is better,” he wrote. “Recommending a target range (e.g. 6.5%-7.0%) rather than a ‘less than’ target (e.g. 7%) would immediately send the message that too low can be dangerous and a happy medium is best.”

Second, Lee emphasized the need for the development of quality indicators to avoid glycemic overtreatment.

“Potential measures for glycemic overtreatment include reporting episodes of hypoglycemia or HbA1c levels less than 7% for adults older than 65 years at high risk for hypoglycemia,” he wrote.

Last, due to comorbid conditions, functional limitations and shorter life expectancy, treatment with insulin should be avoided in most nonhospitalized adults older than the age of 80 years.

“Occasional episodes of hypoglycemia have long been accepted as the price of good glycemic control,” Lee wrote. “However, the findings reported by Geller et al show that insulin-related hypoglycemia is far too common to be an acceptable price for treatment.”

For more information:

Geller AI. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014-136.

Lee SJ. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2013.13307.

Disclosure: The researchers report no relevant financial disclosures.