Prior research indicates that hypoglycemia is a frequently occurring byproduct of intensive diabetes treatment, correlated with increased risk of death, cardiovascular disease, cognitive impairment, and poor quality of life. Many diabetes patients are older, have multiple comorbidities, and may have limited life expectancy. Such patients are at high risk for hypoglycemia after intensive diabetes treatment, sometimes severe enough to require an emergency department (ED) visit or hospitalization. “We know that the benefits of intensive glycemic control may take decades to realize, and may not be apparent for some patients who already have established or advanced comorbidities” says Dr. Rozalina G. McCoy, MD, MS. “People with a limited life expectancy or poor health may not derive this benefit, yet they are likely to be harmed by intensive control in real-time.”
Clinicians need to find balance between undertreating and overtreating, focusing on each individual patient’s needs, according to Dr. McCoy. “We should personalize diabetes management to ensure that the care we provide is safe, effective, evidence-based, equitable, and timely,” she says. “Clinical guidelines strongly encourage individualizing glucose-lowering therapy for people with diabetes in order to yield the most benefit with the least harm.”
Taking a Deeper Look
For a study published in Mayo Clinic Proceedings, Dr. McCoy and colleagues estimated the number of ED visits and hospitalizations specifically due to intensive glucose–lowering therapy and identified the frequency with which adults were treated “very intensively”—possibly over-treated—between 2011 and 2014. The researchers defined “intensive treatment” as any glucose-lowering medications leading to A1C levels of 5.6% or lower or as two or more glucose-lowering medications leading to A1C levels of 5.7% to 6.4%.
Dr. McCoy and colleagues used population-level data from the National Health and Nutrition Examination Survey (NHANES) to determine the quantity of diabetics receiving intensive treatment. Participants had A1C levels less than 7.0% and were assessed to determine how many were treated very intensively.
“We used data from a previous study in which we quantified rates of ED visits and hospitalizations experienced by intensively treated and normally treated clinically complex and non-clinically complex adults and applied those rates to the population estimates from NHANES to model the number of events attributable to intensive treatment,” adds Dr. McCoy.
Examining Key Findings
Nearly half (48.8%) of US adults with diabetes had A1C levels less than 7.0%. Nearly 22% of these patients received intensive treatment, and 32.3% of patients were clinically complex. Hypoglycemia accounted for an estimated 31,511 hospitalizations and 30,954 ED visits in the whole population.
“There were more than 9,500 ED visits and hospitalizations for hypoglycemia that were due to intensive treatment and may have been prevented if patients were treated less intensively,” says Dr. McCoy. “Most of these occurred among older and clinically complex patients, despite guidelines clearly recommending that such patients not be treated intensively.”
The Table shows the estimate of at least 9,578 hospitalizations and ED visits for hypoglycemia that could be due to intensive diabetes treatment, particularly among clinically complex patients.
While the study produces significant evidence that intensive glucose–lowering therapy, especially as it pertains to clinically complex adults, may induce hypoglycemia, clinical complexity did not appear to be a factor in determining which patients were subject to intensive treatment despite clinical guidelines and evidence recommending otherwise.
In providing appropriate care for patients with diabetes, clinicians should take precautions not to cause any additional health complications, says Dr. McCoy. “We need to promote balanced diabetes care,” she says, to ensure that patients “do not experience preventable complications of uncontrolled hyperglycemia or hypoglycemia. We need to prevent overtreatment, particularly of vulnerable, clinically complex patients.” Personalizing diabetes management with methods like hypoglycemia risk prediction and frameworks for identifying overtreated patients can help clinicians pinpoint at-risk patients and ideally avert hypoglycemia.
Severe Hypoglycemia Attributable to Intensive Glucose-Lowering Therapy Among US Adults With Diabetes