Hypoglycemia hospitalizations increased from 1998 to 2013 in England

This is a very important and well-designed study that comprehensively examines the incidence rates of hospitalizations for severe hypoglycemia among adults with both type 1 and type 2 diabetes. Hypoglycemia is the most common serious adverse event in diabetes management. Over the past few decades, as we have made substantial strides in treating diabetes and reducing hyperglycemia, we have learned that hypoglycemia, too, can be very harmful. It is associated with increased risks for other diabetes complications, cardiovascular events (such as arrhythmias), decreased quality of life, cognitive impairment, functional decline, falls, and even increased risk for death. As a result, all clinical practice guidelines now urge patients and their health care providers to engage in shared decision-making and to individualize treatment goals and regimens to optimally balance the risks and benefits of treatment for each patient.

Importantly, while hypoglycemia had been, and often continues to be, considered a fact of life by many patients with diabetes and their health care providers — especially in type 1 diabetes — in many situations it may be prevented or minimized, particularly as multiple studies have demonstrated that there is no clear benefit to intensive glucose-lowering treatment targets (eg, lowering HbA1c below 6.5%-7%) and as new classes of type 2 diabetes medications have become available that are not associated with the same risk for hypoglycemia as insulin and sulfonylureas. Even in the management of type 1 diabetes, increasing availability and use of insulin pumps and continuous glucose monitors, and more recently very long-acting basal insulins, have allowed for individualization of diabetes management to reduce the risk of hypoglycemia.

The study by Zhong and colleagues found that the rates of severe hypoglycemia requiring hospitalization have increased consistently between 1998 and 2013 for all patient groups examined with the exception of elderly patients with type 2 diabetes, whose hypoglycemia rates have finally and slowly begun to decrease after 2009 following a nearly decade-long rise. Not unexpectedly, the increase in hypoglycemia hospitalizations was most apparent for patients with type 2 diabetes treated with insulin, and for patients with long duration of diabetes. Consistent with prior studies, there was no clear association between glycemic control and hypoglycemia hospitalization rates, although on the population level, the proportion of patients with type 2 diabetes whose HbA1c was less than 7.5% has increased consistently throughout the study period.

This study tells us that despite the increasing attention paid to hypoglycemia, a lot more needs to be done to stop these events. Hypoglycemia rates have not gone down despite guidelines that promote individualized treatment regimens and targets, nor have they been touched by greater availability and use of “safer” diabetes medications. This is particularly important for older patients and for patients with multiple comorbidities, who not only are at highest risk of hypoglycemia, but also stand to gain the least from intensive glycemic control. Health care providers should ask all patients about hypoglycemia at least annually, and high-risk patients (eg, those with type 1 diabetes, the elderly, those treated with insulin, and those with prior history of severe hypoglycemia) at each clinical encounter, in part because nonsevere hypoglycemia is a strong predictor of future severe hypoglycemia. We should individualize treatment regimens by selecting medications optimally suited for our patients, which includes their risk of hypoglycemia. We need to engage in shared decision-making with our patients, clearly explaining the risks and benefits of different treatment targets and regimens, such that neither we nor our patients overestimate the benefits of glycemic control while underestimating its potential harms.