Do Clinical Standards for Diabetes Care Address Excess Risk for Hypoglycemia in Vulnerable Patients? A Systematic Review

Abstract

Objective To determine if diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients. Data Sources MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources. Study Design Systematic review of clinical standards (guidelines, quality metrics, or pay-for-performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations. Data Collection/Extraction Methods Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form. Principal Findings We screened 1166 titles, and reviewed 220 manuscripts in full text. 44 guidelines, 17 quality metrics, and 8 pay-for-performance programs were included. 5 (11%) guidelines, and no quality metrics or pay-for-performance programs met the primary outcome. Conclusions Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.

National Estimates of Insulin-Related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations

“…34 The higher rates of ED visits and hospitalizations for IHEs among older insulin-treated patients with diabetes suggest that individualizing glycemic targets by balancing hypoglycemia risks with long-term benefits of glycemic control is appropriate. 22, 35–37 Updated guidelines and treatment recommendations are now advising glycemic targets be relaxed for patients with advanced age, high risk of hypoglycemia or shorter life expectancy.…”

Incidence and Trends in Hypoglycemia Hospitalization in Adults With Type 1 and Type 2 Diabetes in England, 1998–2013: A Retrospective Cohort Study

“…Further, wellpublicized results in 2008-2009 from three trials (ACCORD [19], ADVANCE [20], and VADT [21]) suggested that elderly adults may not gain macrovascular benefits from aggressive glycemic control; rather, intensive therapy was associated with increased risk of severe hypoglycemia and may increase mortality. With a few exceptions (42,43), most diabetes guidelines did not emphasize, until very recently, adjustment of glycemic targets through evaluating an individual's hypoglycemia risk factors (2,3,44).…”

Physician perspectives on de-intensifying diabetes medications

“…Few guidelines provide recommendations on how to de-intensify or address hypoglycemia risk. [22] The most relevant recommendations are from the AGS, which cautions against polypharmacy, [12] and Choosing Wisely/AGS, which recommends against using medications other than metformin to achieve HbA 1C  < 7.5% in most older patients. [23] …”