Preventing hypoglycaemia: an elusive quest

Abstract

Although our understanding of the causes and consequences of hypoglycaemia has improved greatly, prevention of hypoglycaemia in patients with diabetes remains a major challenge. 1 Symptomatic mild and severe hypoglycaemia is not only associated with increased risk of cardiovascular events, all-cause hospitalisation, and all-cause mortality 2 it is also linked to concerns about driving competence, socialisation issues, self -care capacity, serious falls, physical and cognitive status, and impairments in emotional wellbeing and quality of life. 3 Hypoglycaemia in any adult with diabetes must not only be viewed as a serious adverse drug event, but also as a failure of system process and clinical review by health-care organisations. Over the past decade, recognition of this problem has led to important changes in diabetes management including an increased awareness of hypoglycaemia among health professionals and more focused education for patients. However, based on data presented by Francesco Zacchardi and colleagues 4 in The Lancet Diabetes & Endocrinology, the impact of these changes has been limited. The authors report on the trends in admissions with hypoglycaemia in England over a10yearperiod and its impact on length of stay and mortality. There was an initial increase in admissions for hypoglycaemia between 2005 and 2010 (from 7868 in 2005, to 11756 in 2010; 49% increase), followed by a modest decline in subsequent years (to 10 977 in 2014; 39% increase from baseline); similar trends have been reported in the USA. 5 Despite varying regional rates of admission, little preadmission review by general practitioners (which might preclude the need for hospital admission in many cases), and the presence of a moderate degree of comorbidity, patients admitted with hypoglycaemia in 2014 were often discharged within 24 h, experienced less in-hospital mortality and fewer were readmitted in the month after discharge when compared with those admitted in 2005. Thus, our admission policies might now be working well but the flood of admissions into hospital for hypoglycaemia continues.Although this is promising news for the UK National Health Service, the observed figures are likely to be an underestimate of the true extent of the problem.Severity of hypoglycaemia varies considerably and not all people experiencing a hypoglycaemic episode present to emergency departments. The occurrence of hypoglycaemia is also often documented by patient report, which, in the case of mild to moderate episodes, remains highly unreliable.Another important and worrying observation from the data by Zaccardi and colleagues is the high prevalence of hypoglycaemia in adults aged 60 years or older (72% of all admissions throughout the study period). In one European study 6 nearly one in five of all emergency admissions to hospital in patients with type 2 diabetes aged 80 years or older was due to hypoglycaemia. A review of the clinical characteristics of those admitted revealed that half were demented, half were in renal failure, and their average ...

Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes

“…In addition to being at increased risk of hypoglycaemia, frail older adults are more vulnerable to its consequences. Hypoglycaemia in older people increases the risk of serious outcomes, such as falls, fractures, cognitive decline, hospitalisation, CV events (thought to involve cardiac conduction disturbances) and all-cause mortality [40]. In the landmark ACCORD trial, the risk of severe hypoglycaemia increased with age and, for participants reporting severe hypoglycaemia, mortality was increased threefold [41].…”

“…Additionally, the presence of comorbidities such as osteoporosis or of conditions requiring anticoagulation may further compound the effects of a fall resulting from a hypoglycaemic episode. Even mild hypoglycaemic events can be consequential for older people, since they can raise concerns about an individual's driving competence, social isolation issues, self-care capacity, confidence and cognitive status, as well as impacting upon emotional wellbeing [21] [40].…”

Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

“…More recently, the need for a comprehensive geriatric assessment has been highlighted by an understanding of the role of frailty in diabetes and individualization of targets and strategies [ 16 , 17 ]. Hypoglycemia risk is high, even in those with poor glycemic control [ 18 ], and it must be viewed as a serious adverse event [ 19 ]. Advancing age is the most common risk factor for hypoglycemia-related hospitalizations [ 20 ].…”

Challenges and Strategies for Diabetes Management in Community-Living Older Adults

“…Symptomatic mild and severe hypoglycemia are not only associated with increased risk of cardiovascular events, allcause hospitalization, and all-cause mortality ( 71), but are also linked to concerns about driving competence, socialization issues, self-care capacity, serious falls, physical and cognitive status, and impairments in emotional well-being and quality of life (72).…”