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ADA: Vascular Status Predicts Hypoglycemia

Jul 1, 2011

Type 2 diabetes patients with microvascular or macrovascular complications, or those taking certain monotherapies, are more likely to experience hypoglycemia and require outpatient hospital visits….

Jason C. Simeone, PhD, from the University of Rhode Island College of Pharmacy in Kingston, stated that, “The risk of experiencing a hypoglycemic episode was notably higher among patients on insulin monotherapy when compared with patients not taking any anti-diabetes medicine.” 

“Medications should be carefully chosen for patients at high risk of hypoglycemia, particularly those with microvascular or macrovascular complication, or those taking insulin, meglitinides, or sulfonylureas.”  

Simeone and his co-researcher, Brian J. Quilliam, PhD, also from the University of Rhode Island College of Pharmacy, scrutinized pharmacy and medical claims from the 2004-2008 MarketScan database, eventually identifying 11,375 cases of type 2 diabetes patients who experienced hypoglycemic events that involved a hospital visit. They compared outcomes in those patients with 68,247 controls. 

All patients were over 18-years-old, had type 2 diabetes, were taking an oral antidiabetic drug at entry, and had at least 12 months enrollment in a non-capitated health plan. 

After adjusting for clinical factors, the researchers found the following predictors of an outpatient visit for a hypoglycemic event:

  • A microvascular diabetic complication, AOR 1.78 (CI 1.68-1.89)
  • A macrovascular diabetic event, AOR 2.80 (CI 2.64-2.97)
  • Liver disease, AOR 1.54 (CI 1.29-1.82)
  • Insulin plus any oral anti-diabetic agent, AOR 1.91 (CI 1.75-2.09)
  • Meglitinide monotherapy, AOR 1.40 (CI 1.02-1.93)
  • Metformin plus sulfonylurea plus thiazolidinedione, AOR 1.37 (CI 1.24-1.50)
  • Sulfonylurea monotherapy, AOR 1.16 (CI 1.06-1.26)
  • Metformin plus sulfonylurea, AOR 1.13 (CI 1.05-1.22) 

In addition, Simeone pointed out that women appeared at greater risk for hypoglycemia compared with men. Older patients (age 50-59) had the lowest odds of hypoglycemia compared with younger patients. 

“We found that thiazolidinedione monotherapy, metformin monotherapy, and metformin plus thiazolidinedione combination therapy were protective against having hypoglycemic episodes,” Simeone said.  

The researchers also determined that patients who were taking medications for other comorbidities were also at increased risk of hypoglycemia. They found significant relationships between the episodes and patients taking trimethoprim, fluoroquinolones, benzodiazepines, warfarin, non-steroidal anti-inflammatory drugs, and fibrates. 

Simeone suggested, “Physicians should monitor hypoglycemic events and educate patients with these risk factors.” “Alternative medications should be chosen if available for high-risk patients.” 

Robert Henry, MD, president of medicine and science for the ADA, agreed with Simeone, explaining that, “We try to avoid use of sulfonylureas and secretagogues among patients at risk of hypoglycemia.” 

The researchers noted that there appeared to be different risks of hypoglycemic events by region, with the highest risks in the southern U.S. and west U.S., and the lowest risks in the Midwest. However, the adjusted analysis did not find that any of those differences reached statistical significance. 

Simeone said he undertook the project because data on the risk of hypoglycemia among type 2 diabetes patients on oral medications is lacking even though hypoglycemia is a well-recognized problem in patients with type 1 diabetes, and insulin-treated patients with type 2 diabetes, he said.

Practice Pearls 
  • Explain that type 2 diabetes patients had higher odds of needing outpatient care for hypoglycemia if they had micro- or macrovascular complications or were taking insulin. 
  • Point out that the study used the 2004-2008 MarketScan database of pharmacy and medical claims.

Simeone J, et al “Predictors of outpatient visits for hypoglycemia in type 2 diabetes patients on oral antidiabetic agents” Diabetes 2011; 60 Supplement (1) A137.