ADA: Hypoglycemia Poorly Controlled

Kasia Lipska, MD, MHS, of Yale, and colleagues reported that, hyperglycemia-related hospitalizations fell 39% overall in the Medicare population from 1999 to 2011. During the same period hospitalizations for hypoglycemia rose from 94 per 100,000 patient-years to a peak of 130 per 100,000 patient-years in 2007 before declining slightly to 105 per 100,000 patient-years in the wake of the ACCORD trial data showing higher mortality with intensive therapy targeting 6.5% hemoglobin A1c.

Lt. Commander Andrew Geller, MD, of the CDC in Atlanta, and colleagues reported at the same session that insulin-related events accounted for 6.5% of all emergency department visits for adverse drug effects with a rate of 14 to 35 per 1,000 patients on the drug.

These numbers include only the most severe events and vastly underestimate the day-to-day hypoglycemia and insulin events sustained in the community, commented Bessie Young, MD, a nephrologist and epidemiologist at the University of Washington in Seattle who served as session co-chair.

Dr. Young added that, "People may be seen by paramedics and receive glucose and they’re fine and then never make it to the hospital. So it’s really the tip of the iceberg because so many more patients have hypoglycemic episodes that we don’t even have a clue as to the numbers." The numbers were particularly dramatic at older ages in both studies.

In Lipska’s analysis of nearly 34 million Medicare Fee-For-Service beneficiaries, hyperglycemia hospitalizations came down the most in the older age groups from the highest at baseline in 1999:

• In those 85 and older, a reduction from 136 to 68 per 100,000 patient-years
• In those age 75 to 84, a drop from 132 to 75 per 100,000 patient-years
• In those 65 to 74, a decline from 97 to 67 per 100,000 patient-years

Hypoglycemia admissions were two times more common for the older group among seniors and remained that way over time with relatively little change, ending up at 152, 141, and 72 per 100,000 patient-years across those age groups from 85 and older to 65-74.

In Geller’s analysis of the nationally-representative active surveillance for adverse drug events in U.S. emergency departments in 2007 through 2011, insulin-taking patients ages 80 and older had 2.5-times more emergency visits for insulin adverse events than those ages 45 to 64 (35 versus 14 per 1,000 persons).

Hospitalizations for such events were five-fold more common at age 80 and older (16 versus 3 per 1,000 persons ages 45 to 64).

The hyperglycemia rate among black adults was 335 per 100,000 versus 92 per 100,000 among whites in 1999 and 217 versus 55 in 2011. Hypoglycemia rates were also almost four-fold higher, rising from 294 to 315 per 100,000 patient-years versus from 74 to 82 per 100,000 patient-years among whites.

After adjustment for the rise in diabetes prevalence, the decrease in hospitalizations in the overall cohort was an even more dramatic 55% over the study period, while the hypoglycemia admissions rate held steady.

Young suggested education for both patients and their families to boost awareness, reinforcing the need to eat after insulin injections.

In Geller’s study, an estimated 46% of the related emergency visits were due to failure to eat after insulin injection, while 22% could be linked to taking the wrong drug (half mix-ups with rapid-acting insulin instead of long-acting insulin) and 12% were associated with a wrong dose or confused units.

Lipska KJ, et al "National trends in hospital admissions for hyperglycemia and hypoglycemia among medicare beneficiaries, 1999-2010" ADA 2013; Abstract 274-OR.