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Makam AN, Nguyen OK. An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment. Circulation 2017; 135:180-195. [PMID: 28069712 DOI: 10.1161/circulationaha.116.022622] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Overtreatment is pervasive in medicine and leads to potential patient harms and excessive costs in health care. Although evidence-based medicine is often derided as practice by rote algorithmic medicine, the appropriate application of key evidence-based medicine principles in clinical decision making is fundamental to preventing overtreatment and promoting high-value, individualized patient-centered care. Specifically, this article discusses the importance of (1) using absolute rather than relative estimates of benefits to inform treatment decisions; (2) considering the time horizon to benefit of treatments; (3) balancing potential harms and benefits; and (4) using shared decision making by physicians to incorporate the patient's values and preferences into treatment decisions. Here, we illustrate the application of these principles to considering the decision of whether or not to recommend intensive glycemic control to patients to minimize microvascular and cardiovascular complications in type 2 diabetes mellitus. Through this lens, this example will illustrate how an evidence-based medicine approach can be used to individualize glycemic goals and prevent overtreatment, and can serve as a template for applying evidence-based medicine to inform treatment decisions for other conditions to optimize health and individualize patient care.
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Affiliation(s)
- Anil N Makam
- From Division of General Internal Medicine, UT Southwestern Medical Center, Dallas (A.N.M., O.K.N.); and Division of Outcomes & Health Services Research, UT Southwestern Medical Center, Dallas (A.N.M., O.K.N.).
| | - Oanh K Nguyen
- From Division of General Internal Medicine, UT Southwestern Medical Center, Dallas (A.N.M., O.K.N.); and Division of Outcomes & Health Services Research, UT Southwestern Medical Center, Dallas (A.N.M., O.K.N.)
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Meneilly GS. Glycemic targets in the elderly and the risks of hypoglycemia. J Diabetes Complications 2017; 31:783-784. [PMID: 28254447 DOI: 10.1016/j.jdiacomp.2017.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 01/29/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Graydon S Meneilly
- Division of Geriatric Medicine, Department of Medicine, Vancouver Hospital and the University of British Columbia, Vancouver, BC, Canada.
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Karter AJ, Lipska KJ, O'Connor PJ, Liu JY, Moffet HH, Schroeder EB, Lawrence JM, Nichols GA, Newton KM, Pathak RD, Desai J, Waitzfelder B, Butler MG, Thomas A, Steiner JF. High rates of severe hypoglycemia among African American patients with diabetes: the surveillance, prevention, and Management of Diabetes Mellitus (SUPREME-DM) network. J Diabetes Complications 2017; 31:869-873. [PMID: 28319006 PMCID: PMC5491095 DOI: 10.1016/j.jdiacomp.2017.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/02/2017] [Accepted: 02/14/2017] [Indexed: 02/03/2023]
Abstract
AIMS Seven-year surveillance study (2005-2011) to evaluate race/ethnic differences in the trends in rates of severe hypoglycemia (SH) in a population of insured, at-risk adults with diabetes. METHODS SH events were identified via any primary or principal diagnosis from emergency department or inpatient encounters among African American, Asian, Latino and White adult diabetes patients treated with insulin or secretagogues (Sulfonylureas or Meglitinides), receiving care from integrated healthcare delivery systems across the United States. We calculated age- and sex-standardized annual SH rates and average annual percent change (AAPC) in SH rates. RESULTS Annual SH rates ranged from 1.8% to 2.1% during this 7-year observation period (2,200,471 person-years). African Americans had consistently higher SH rates compared with Whites, while Latinos and Asians had consistently lower rates compared with Whites in each of the 7 years (all p < 0.01). The trend increased significantly only among African Americans (AAPC = +4.3%; 95% CI: +2.1, +6.5%); in the other groups, the AAPC was not significantly different from zero. CONCLUSIONS Surveillance efforts should monitor the racial/ethnic-specific rates. The factors underlying substantially higher rates of hypoglycemia in African Americans should be evaluated. Clinically and culturally-appropriate strategies to reduce the risk of SH need to be developed and tested.
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Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612.
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, PO Box 208020, New Haven, CT 06520
| | | | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612
| | - Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237
| | - Jean M Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 2nd Floor, Pasadena, CA 91101
| | - Gregory A Nichols
- Kaiser Permanente Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR 97227
| | - Katherine M Newton
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101
| | - Ram D Pathak
- Department of Endocrinology, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449
| | - Jay Desai
- HealthPartners Institute, P.O. Box 1524, Minneapolis, MN 55440
| | - Beth Waitzfelder
- Center for Health Research, Kaiser Permanente Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI 96817
| | - Melissa G Butler
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, 3495 Piedmont Road NE, Building 11, Suite 110, Atlanta, GA 30305
| | - Abraham Thomas
- Department of Medicine, New York University (NYU) Lutheran, 150 55th St, Brooklyn, NY 11220
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237
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Lipska KJ, Yao X, Herrin J, McCoy RG, Ross JS, Steinman MA, Inzucchi SE, Gill TM, Krumholz HM, Shah ND. Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013. Diabetes Care 2017; 40:468-475. [PMID: 27659408 PMCID: PMC5360291 DOI: 10.2337/dc16-0985] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/31/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine temporal trends in utilization of glucose-lowering medications, glycemic control, and rate of severe hypoglycemia among patients with type 2 diabetes (T2DM). RESEARCH DESIGN AND METHODS Using claims data from 1.66 million privately insured and Medicare Advantage patients with T2DM from 2006 to 2013, we estimated the annual 1) age- and sex-standardized proportion of patients who filled each class of agents; 2) age-, sex-, race-, and region-standardized proportion with hemoglobin A1c (HbA1c) <6%, 6 to <7%, 7 to <8%, 8 to <9%, ≥9%; and 3) age- and sex-standardized rate of severe hypoglycemia among those using medications. Proportions were calculated overall and stratified by age-group (18-44, 45-64, 65-74, and ≥75 years) and number of chronic comorbidities (zero, one, and two or more). RESULTS From 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P < 0.001). The proportion of patients with HbA1c <7% declined (from 56.4 to 54.2%; P < 0.001) and with HbA1c ≥9% increased (9.9 to 12.2%; P < 0.001). Glycemic control varied by age and was poor among 23.3% of the youngest and 6.3% of the oldest patients in 2013. The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P < 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36). CONCLUSIONS During the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. Overall glycemic control has not improved and remains poor among nearly a quarter of the youngest patients. The overall rate of severe hypoglycemia remains largely unchanged.
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Affiliation(s)
- Kasia J Lipska
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Xiaoxi Yao
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Rozalina G McCoy
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health and Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco VA Health Care System, San Francisco, CA
| | - Silvio E Inzucchi
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health and Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- OptumLabs, Cambridge, MA
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Haak T, Hanaire H, Ajjan R, Hermanns N, Riveline JP, Rayman G. Flash Glucose-Sensing Technology as a Replacement for Blood Glucose Monitoring for the Management of Insulin-Treated Type 2 Diabetes: a Multicenter, Open-Label Randomized Controlled Trial. Diabetes Ther 2017; 8:55-73. [PMID: 28000140 PMCID: PMC5306122 DOI: 10.1007/s13300-016-0223-6] [Citation(s) in RCA: 383] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Glycemic control in participants with insulin-treated diabetes remains challenging. We assessed safety and efficacy of new flash glucose-sensing technology to replace self-monitoring of blood glucose (SMBG). METHODS This open-label randomized controlled study (ClinicalTrials.gov, NCT02082184) enrolled adults with type 2 diabetes on intensive insulin therapy from 26 European diabetes centers. Following 2 weeks of blinded sensor wear, 2:1 (intervention/control) randomization (centrally, using biased-coin minimization dependant on study center and insulin administration) was to control (SMBG) or intervention (glucose-sensing technology). Participants and investigators were not masked to group allocation. Primary outcome was difference in HbA1c at 6 months in the full analysis set. Prespecified secondary outcomes included time in hypoglycemia, effect of age, and patient satisfaction. RESULTS Participants (n = 224) were randomized (149 intervention, 75 controls). At 6 months, there was no difference in the change in HbA1c between intervention and controls: -3.1 ± 0.75 mmol/mol, [-0.29 ± 0.07% (mean ± SE)] and -3.4 ± 1.04 mmol/mol (-0.31 ± 0.09%) respectively; p = 0.8222. A difference was detected in participants aged <65 years [-5.7 ± 0.96 mmol/mol (-0.53 ± 0.09%) and -2.2 ± 1.31 mmol/mol (-0.20 ± 0.12%), respectively; p = 0.0301]. Time in hypoglycemia <3.9 mmol/L (70 mg/dL) reduced by 0.47 ± 0.13 h/day [mean ± SE (p = 0.0006)], and <3.1 mmol/L (55 mg/dL) reduced by 0.22 ± 0.07 h/day (p = 0.0014) for intervention participants compared with controls; reductions of 43% and 53%, respectively. SMBG frequency, similar at baseline, decreased in intervention participants from 3.8 ± 1.4 tests/day (mean ± SD) to 0.3 ± 0.7, remaining unchanged in controls. Treatment satisfaction was higher in intervention compared with controls (DTSQ 13.1 ± 0.50 (mean ± SE) and 9.0 ± 0.72, respectively; p < 0.0001). No serious adverse events or severe hypoglycemic events were reported related to sensor data use. Forty-two serious events [16 (10.7%) intervention participants, 12 (16.0%) controls] were not device-related. Six intervention participants reported nine adverse events for sensor-wear reactions (two severe, six moderate, one mild). CONCLUSION Flash glucose-sensing technology use in type 2 diabetes with intensive insulin therapy results in no difference in HbA1c change and reduced hypoglycemia, thus offering a safe, effective replacement for SMBG. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02082184. FUNDING Abbott Diabetes Care.
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Affiliation(s)
- Thomas Haak
- Diabetes Zentrum Mergentheim, Bad Mergentheim, Germany.
| | - Hélène Hanaire
- Department of Diabetology, Metabolic Diseases, and Nutrition, CHU Toulouse, University of Toulouse, Toulouse, France
| | - Ramzi Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, The LIGHT Laboratories, University of Leeds, Leeds, West Yorkshire, UK
| | | | - Jean-Pierre Riveline
- Department of Diabetes and Endocrinology, Assistance Publique-Hôpitaux de Paris, DHU FIRE, Lariboisière Hospital, University Paris-Diderot Paris-7, Paris, France
| | - Gerry Rayman
- The Diabetes Centre, Ipswich Hospital NHS Trust, Ipswich, Suffolk, UK
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106
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Kho AR, Choi BY, Kim JH, Lee SH, Hong DK, Lee SH, Jeong JH, Sohn M, Suh SW. Prevention of hypoglycemia-induced hippocampal neuronal death by N-acetyl-L-cysteine (NAC). Amino Acids 2016; 49:367-378. [PMID: 27990559 DOI: 10.1007/s00726-016-2370-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/22/2016] [Indexed: 12/25/2022]
Abstract
Type 1 and type 2 diabetic patients who are treated with insulin or other blood glucose reducing agents for tight control of blood glucose levels are frequently at risk of experiencing severe hypoglycemia which can lead to seizures, loss of consciousness and death. Hypoglycemic neuronal cell death is not a simple result of low glucose supply to the brain, but, instead, results from a cell death signaling pathway that is started by the re-administration of glucose after glucose deprivation. Zinc is a biologically important element for physiological function of central nervous system. However, excessive zinc release from the presynaptic terminals and subsequent translocation into the postsynaptic neurons may contribute to neuronal death following hypoglycemia. N-acetyl-L-cysteine (NAC) acts as a zinc chelator that alleviates zinc-induced neuronal death processes. In addition, NAC restores levels of neuronal glutathione (GSH), a potent antioxidant, by providing a cell-permeable source of cysteine. Thus, we hypothesized that NAC treatment can reduce neuronal cell death, not only by increasing GSH concentration but also by zinc chelation. As a result, we found that NAC decreased the oxidative stress, zinc release and translocation, and improved the level of glutathione. Therefore, NAC administration alleviated hippocampal neuron death in hypoglycemia-induced rats.
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Affiliation(s)
- A Ra Kho
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Bo Young Choi
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Jin Hee Kim
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Song Hee Lee
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Dae Ki Hong
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Sang Hwon Lee
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea
| | - Jeong Hyun Jeong
- Department of Neurology, College of Medicine, Hallym University, Chuncheon, Korea
| | - Min Sohn
- Department of Nursing, Inha University, Incheon, Korea
| | - Sang Won Suh
- Department of Physiology, Hallym University, College of Medicine, Chuncheon, Korea.
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Yun JS, Ko SH. Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus. Diabetes Metab J 2016; 40:423-432. [PMID: 27766794 PMCID: PMC5167706 DOI: 10.4093/dmj.2016.40.6.423] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/15/2022] Open
Abstract
Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.
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Affiliation(s)
- Jae Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea.
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108
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Joy NG, Perkins JM, Mikeladze M, Younk L, Tate DB, Davis SN. Comparative effects of acute hypoglycemia and hyperglycemia on pro-atherothrombotic biomarkers and endothelial function in non-diabetic humans. J Diabetes Complications 2016; 30:1275-81. [PMID: 27445005 PMCID: PMC4987190 DOI: 10.1016/j.jdiacomp.2016.06.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND The comparative effects of acute moderate hyperglycemia and hypoglycemia on in vivo endothelial function together with pro-inflammatory and pro-atherothrombotic responses in healthy individuals have not been determined. METHODS To investigate this question, 45 healthy subjects were compared during glucose clamp studies consisting of euinsulinemic hyperglycemia and hyperinsulinemic hyperglycemia (plasma glucose 11.1mmol/L, both with pancreatic clamps) and hyperinsulinemic euglycemia and hyperinsulinemic hypoglycemia (plasma glucose 5.1 and 2.9mmol/L, respectively). Two-dimensional Doppler ultrasound was used to determine brachial artery endothelial function. RESULTS Insulin levels during euinsulinemia hyperglycemia were 194±23 and (850±49-988±114) pmol/L during all hyperinsulinemic protocols. Responses of VCAM-1, ICAM-1, E-selectin, P-selectin, PAI-1, and IL-6 were increased (p<0.05-0.0001) during euinsulinemic hyperglycemia or hypoglycemia as compared to hyperinsulinemic euglycemia or hyperinsulinemic hyperglycemia. PAI-1 was increased (p<0.04) during hypoglycemia as compared to euinsulinemic hyperglycemia, and TNF-α responses were also increased during hypoglycemia as compared to hyperinsulinemic euglycemia or hyperinsulinemic hyperglycemia (p<0.05). In vivo endothelial function was similarly blunted by acute moderate hyperglycemia or hypoglycemia. CONCLUSION In summary, acute moderate hypoglycemia and euinsulinemic hyperglycemia can result in similar endothelial dysfunction and pro-atherothrombotic responses. Fibrinolytic balance was reduced by a greater extent by hypoglycemia as compared to moderate hyperglycemia. Acutely, hyperinsulinemia can prevent the acute pro-atherothrombotic and pro-inflammatory effects of moderate hyperglycemia but not hypoglycemia.
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Affiliation(s)
- Nino G Joy
- University of Maryland, Baltimore, Baltimore, MD
| | | | | | - Lisa Younk
- University of Maryland, Baltimore, Baltimore, MD
| | - Donna B Tate
- University of Maryland, Baltimore, Baltimore, MD
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Mantovani A, Grani G, Chioma L, Vancieri G, Giordani I, Rendina R, Rinaldi ME, Andreadi A, Coccaro C, Boccardo C, Fraenza C, Bertazzoni G, Bellia A, Zoppini G, Targher G, Baroni MG, Lauro D, D'Armiento M, Bonora E. Severe hypoglycemia in patients with known diabetes requiring emergency department care: A report from an Italian multicenter study. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2016; 5:46-52. [PMID: 29067235 PMCID: PMC5644438 DOI: 10.1016/j.jcte.2016.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/05/2016] [Accepted: 08/17/2016] [Indexed: 02/08/2023]
Abstract
Patients were frail and had a high prevalence of serious comorbidities. Insulin treatment was the most important cause of severe hypoglycemia. Among oral drugs, glibenclamide and repaglinide were the main used. The rate of all-cause mortality was similar with that reported in other studies. Liver and kidney diseases were the main predictors of hospitalization.
Aims To describe the characteristics and associated risk factors of patients with established diabetes who required Emergency Department (ED) care for severe hypoglycemia. Methods We performed an observational retrospective study to identify all cases of severe hypoglycemia among attendees at the EDs of three Italian University hospitals from January 2010 to December 2014. Results Overall, 520 patients with established diabetes were identified. Mean out-of-hospital blood glucose concentrations at the time of the hypoglycemic event were 2.2 ± 1.3 mmol/L. Most of these patients were frail and had multiple comorbidities. They were treated with oral hypoglycemic drugs (43.6%), insulin (42.8%), or both (13.6%). Among the oral hypoglycemic drugs, glibenclamide (54.5%) and repaglinide (25.7%) were the two most frequently used drugs, followed by glimepiride (11.3%) and gliclazide (7.5%). Hospitalization rates and in-hospital deaths occurred in 35.4% and in 2.3% of patients, respectively. Cirrhosis (odds ratio [OR] 6.76, 95% confidence interval [CI] 1.24–36.8, p < 0.05), chronic kidney disease (OR 2.42, 95% CI 1.11–8.69, p < 0.05) and center (Sapienza University OR 3.70, 95% CI 1.57–8.69, p < 0.05) were the strongest predictors of increased rates of hospital admission. Conclusions Severe hypoglycemia is a remarkable burden for patients with established diabetes and increases the risk of adverse clinical outcomes (in-hospital death and hospitalization), mainly in elderly and frail patients. This study further reinforces the notion that careful attention should be taken by health care providers when they prescribe drug therapy in elderly patients with serious comorbidities.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giorgio Grani
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Chioma
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Vancieri
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Ilaria Giordani
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Roberta Rendina
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Elena Rinaldi
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Aikaterini Andreadi
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carmela Coccaro
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Boccardo
- Emergency Medicine Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Costanza Fraenza
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giuliano Bertazzoni
- Emergency Medicine Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Alfonso Bellia
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giacomo Zoppini
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Marco Giorgio Baroni
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Davide Lauro
- Endocrinology and Diabetology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimino D'Armiento
- Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Enzo Bonora
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
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