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Intensive diabetes therapy increases hypoglycemia hospitalization rates
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Use of intensive glucose-lowering agents to treat patients with diabetes and lower HbA1c may be leading to more instances of hypoglycemia that require hospital and emergency department visits, according to findings published in Mayo Clinic Proceedings.
“It is important to call attention to the persistent problem of intensive treatment, and potential overtreatment, of clinically complex patients with diabetes,” Rozalina G. McCoy, MD, MS, an associate professor of medicine in the division of community internal medicine of the department of medicine at Mayo Clinic in Rochester, Minnesota, told Endocrine Today. “While it is very important to ensure that our patients with diabetes receive the care that they need and do not develop short-term and long-term complications of diabetes, we also do not want to overtreat and cause health problems stemming from hypoglycemia.”
McCoy and colleagues examined data from 662 adults with diabetes and HbA1c less than 7% from the 2011-2012 and 2013-2014 National Health and Nutrition Examination Survey cohorts. The presence of comorbidities, such as congestive heart failure, lung disease and kidney disease, as well as medication use and difficulty with performing basic daily functions were self-reported by the participants, whose results could be projected for roughly 10.7 million people, according to the researchers.
Participants were also evaluated for how complex their health was. Those who were aged at least 75 years, had end-stage renal disease, reported an inability to perform at least two daily functions, such as dressing or eating, or were diagnosed with at least three additional health complications were defined as “clinically complex.” This status was met by 32.3% of the cohort, according to the researchers.
In addition, participants with HbA1c of no more than 5.6% who underwent glucose-lowering therapy and those with HbA1c between 5.7% and 6.4% who received at least two glucose-reducing drugs were defined as intensively treated by the researchers, who noted that such treatment occurred in 21.6% of those with a complex form of diabetes and 21.5% of those without the complex classification.
“I was disappointed, but unfortunately not very surprised, to see how often clinically complex patients — people 75 years of age and older, those with end-stage kidney disease, with substantial debility, or with three or more serious comorbid health conditions — were treated intensively,” McCoy said. “Older, more frail patients should not be treated the same as those who are younger and healthier.”
The researchers then used previously reported data on hypoglycemia hospitalizations and ED visits in similar populations to project how often these events would occur across 2 years in the NHANES cohort. A total of 31,511 hospitalizations were expected. Intensive therapy would be responsible for 15.2%, or 4,774, of those visits, the researchers wrote.
In addition, 30,954 ED visits were projected. The researchers stated that intensive therapy would account for 15.5%, or 4,804, of them. It was furthered projected that there would be 25,712 hospitalizations and 24,625 ED visits for hypoglycemia in participants who did not take insulin, and intensive therapy would be the cause of 13.3% and 13.8% of those events, respectively.
“Most population health efforts to improve diabetes management are focused on lowering hemoglobin HbA1c and blood sugar, not on preventing overtreatment and hypoglycemia. High-risk patients would benefit from proactive efforts to identify them, engage them in shared decision-making with the goal of de-intensifying therapy and de-prescribing glucose-lowering drugs,” McCoy said. “Such patients would also benefit from diabetes self-management education, though unfortunately reimbursement for these services and their availability nationwide remain inadequate.”– by Phil Neuffer
For more information:
Rozalina G. McCoy, MD, MS, can be reached at Mayo Clinic, 200 First St. SW, Rochester, MN 55905; email: mccoy.rozalina@mayo.edu.
Disclosures: The authors report no relevant financial disclosures.
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Mahoney GK, et al. Mayo Clin Proc. 2019;doi:10.1016/j.mayocp.2019.02.028.
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