Predictors of severe hypoglycemia in type 2 diabetes identified
medwireNews: The incidence of severe hypoglycemia in patients with type 2 diabetes has increased over time and may be predicted by previous nonsevere hypoglycemic episodes, data from a large integrated healthcare system in the USA show.
Black race, increased diabetes medication use, comorbidity, and having a glycated hemoglobin (HbA1c) level below 6% were also associated with an increased likelihood for severe hypoglycemia in the study of 50,439 patients (median age 61 years, 52% men) with type 2 diabetes receiving care in the Cleveland Clinic Health System between 2006 and 2010.
Anita Misra-Hebert (Cleveland Clinic, Ohio) and colleagues report that the cumulative incidence of severe hypoglycemia requiring an emergency department visit or hospitalization increased significantly from 0.12% in 2006 to 0.31% in 2015, with the majority of these events (63% in 2006 and 88% in 2015) resulting in hospitalization.
The researchers note that most of the severe hypoglycemia events were the first such event for patients, and those who experienced severe hypoglycemia had similar median HbA1c levels to those who did not (6.8 vs 6.7%).
On multivariable analysis, adjusted for age, sex, and income, several variables significantly predicted an increased risk for severe hypoglycemia, including a prior diagnosis of nonsevere hypoglycemia, at an odds ratio (OR) of 3.01.
Indeed, 9% of patients with severe hypoglycemia had a prior diagnosis of nonsevere hypoglycemia compared with 2% of those with no severe hypoglycemia.
“The ability to capture documented nonsevere hypoglycemia in the EMR [electronic medical record] presents an additional opportunity to use our EMR systems to identify patients who may be at increased risk for severe hypoglycemia,” Misra-Hebert and co-authors remark.
Other factors significantly associated with an increased likelihood for a severe hypoglycemia event included an HbA1c level below 6% (OR=1.95), insulin use (OR=2.77), sulfonylurea use (OR=2.49), increasing number of diabetes medications (OR=1.56 per medication), Black race (OR=2.55), cardiovascular disease (OR=1.68), congestive heart failure (OR=1.33), and increased Charlson comorbidity index (OR=1.15).
By contrast, male gender (OR=0.67), higher BMI (HR=0.96) and the use of metformin, dipeptidyl peptidase-4 inhibitors (OR=0.51) and glucagon-like peptide 1 agonists (OR=0.23) were associated with a decreased likelihood for severe hypoglycemia.
The investigators also found that, at the time of the severe hypoglycemic event, a greater proportion of patients were taking insulin or three or more diabetes medications and had more comorbidities compared with the time of their last outpatient primary care or endocrinology visit.
“[This] leads us to question whether treatment may have actually been inappropriately intensified at that last visit, especially in patients at risk for comorbidities,” Misra-Hebert et al write in Diabetes Care.
The team concludes: “Future work should focus on identification of patients at high risk at the point of care to allow for change in modifiable risk factors and prevention of severe hypoglycemic events.”
By Laura Cowen
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