Incidence and prognostic significance of hypoglycemia in hospitalized non-diabetic elderly patients

Hypoglycemia in non-diabetic in-patients at a teaching referral hospital in Iran

Purpose

This study aims to investigate comorbidities, clinical features, laboratory values, and diagnoses in non-diabetic patients experiencing hypoglycemic episodes.

Methods

A retrospective observational study was conducted at Shariati Hospital in Iran from 2016 to 2023. Seventy-four non-diabetic patients admitted with a diagnosis of hypoglycemia were included, while patients with diabetes were excluded. Demographic data, symptoms, and biochemical assessments were obtained from the hospital information system. Hypoglycemic episodes were identified based on low measured blood glucose, recorded medications for hypoglycemia treatment, or recorded codes indicating hypoglycemia. Hypoglycemia was defined as blood glucose below 70 mg/dL (3.9 mmol/L) along with two other criteria of the Whipple triad. Statistical analysis was performed using SPSS software (version 26).

Results

Among the enrolled patients, 63.5% were female, and 13.5% were elderly (≥ 65 years). The most common comorbidities observed were cardiovascular disease (20.3%), psychological disorders (20.3%), hypothyroidism (14.9%), and hypertension (8.1%). The prevalent symptoms included weakness, loss of consciousness, sweating, palpitations, dizziness, and tremors. Non-diabetic hypoglycemia was caused by factitious disorders, insulinoma, organ failure, and infection, respectively.

Conclusion

Due to the diverse range of clinical symptoms, hypoglycemia in non-diabetic patients may be diagnosed late, leading to misdiagnoses such as psychological disorders or seizures. It is crucial to consider the possibility of hypoglycemia in non-diabetic patients and determine its underlying cause. Given the poor prognosis associated with hypoglycemia, timely interventions are essential.

Severe hypoglycaemia in adults presenting to a hospital emergency department: Clinical characteristics, comorbidities, and mortality outcomes

AIMS

To determine the clinical characteristics, risk factors and mortality outcomes associated with severe hypoglycaemia (SH) treated at a hospital emergency department.

MATERIALS AND METHODS

Adult patients presenting with SH to the Northern General Hospital, Sheffield, UK over a 44-month period were assessed for clinical characteristics, coexisting comorbidities and mortality outcomes, including cause of death, and analysed by age of diabetes onset, below and above age 40 years. Factors that predicted mortality were determined.

RESULTS

A total of 619 episodes of SH occurred in 506 individuals. Most had type 1 (T1D; n = 172 [34.0%]) or type 2 diabetes (T2D; n = 216 [42.7%]), but several attendees did not have diabetes (non-DM; n = 110 [21.7%]). Irrespective of age of diabetes onset, patients with T2D had more socioeconomic deprivation and comorbidities (P < 0.005). SH was uncommon in those with young-onset T2D, who constituted 7.2% of all episodes in diabetes. Hospital admission was high (60%-75%). The T2D cohort had the longest inpatient stay (median 5 days, vs. 2 and 3 days for the T1D and non-DM cohorts, respectively). Survival after the index SH episode was lower and mortality was higher in the non-DM (39.1%) and T2D (38.0%) cohorts than the T1D cohort (13.3%; all P < 0.05), with a median time to death of 13, 113 and 465 days, respectively. Most deaths (78%-86%) were from non-cardiovascular causes. Charlson index predicted mortality and poor survival in T1D and T2D (both P < 0.05).

CONCLUSIONS

Severe hypoglycaemia requiring emergency hospital treatment is associated with non-cardiovascular deaths and exerts a disproportionately greater impact on mortality in people with T2D and those without diabetes. Multimorbidity is an important risk factor for SH and increases mortality risk.

Cefcapene pivoxil-induced hypocarnitinemic hypoglycemia in elderly man with subclinical ACTH deficiency: a case report

BACKGROUND

Drug-induced hypocarnitinemia has been noted as a cause of hypoglycemia in children. However, adult cases are extremely rare and pre-existing conditions (including endocrine disorders and frailty) have been suggested to be involved. Hypoglycemia due to drug-induced hypocarnitinemia is quite rare, and there were few reports of pivoxil-containing cephalosporin (PCC)-induced hypocarnitinemia in adults.

CASE PRESENTATION

We present a case of an 87-year-old man with malnutrition, and frailty. He developed severe hypoglycemia with unconsciousness after taking cefcapene pivoxil hydrochloride, one of PCC, and hypocarnitinemia was diagnosed. Despite levocarnitine administration, asymptomatic mild hypoglycemia had persisted. Subsequent investigation revealed subclinical ACTH deficiency due to empty sella, which played a key role to maintain mild hypoglycemia as underlying disorder, and PCC-induced hypocarnitinemia triggered severe hypoglycemia. The patient responded to hydrocortisone therapy.

CONCLUSIONS

We need to be aware of the facts that PCC can induce severe hypocarnitinemic hypoglycemia in elderly adults associated with frailty, malnutrition, and subclinical ACTH syndrome.

Insulin murder and the case of Colin Norris

Although insulin is an essential medicine and a life-saving drug, it has also been incriminated in many poisoning deaths; accidental, suicidal and some with malicious intent. Overdosing with insulin precipitates a life-threatening state of hypoglycemia and if untreated leads to coma, irreversible brain damage and death. Normally, the pancreatic β-cells secrete equimolar amounts of insulin and C-peptide into the portal venous blood, although under physiological conditions the plasma concentration ratio (insulin/C-peptide) is less than unity, because insulin is more susceptible to hepatic first-pass metabolism. A high ratio of insulin/C-peptide in plasma from a poisoned patient is compelling evidence that pharmaceutical insulin was administered, which does not contain C-peptide. The analysis of insulin and C-peptide was traditionally done by immunoassay methods (RIA and/or ELISA), although high resolution LC-MS/MS is more suitable for forensic purposes and permits the identification of insulin analogues. Use of insulin as a murder weapon is exemplified by the case of Colin Norris, a male nurse found guilty of murdering four elderly patients and the attempted murder of a fifth by injecting them with insulin. However, the prosecution evidence against Norris was mainly circumstantial and hearsay. Toxicological evidence against Norris consisted of a high insulin/C-peptide concentration ratio in plasma from one of the victims. This analysis was done by an immunoassay method at a clinical laboratory and not a forensic laboratory. Analytical procedures, including chain-of-custody routines, are more stringent at forensic laboratories. Since his conviction, some of the medical evidence against Norris has been called into question, especially the prevalence of spontaneous attacks of hypoglycemia in elderly and frail patients with co-morbidities.

Fasting biochemical hypoglycemia and related-factors in non-diabetic population: Kanagawa Investigation of Total Check-up Data from National Database-8

BACKGROUND

In healthy people, the lowest daily blood glucose concentration is usually observed in the early morning, after overnight fasting. However, the clinical relevance and the prevalence of fasting biochemical hypoglycemia (FBH) are poorly understood in people who do not have diabetes, although the clinical implications of such hypoglycemia have been extensively studied in patients with diabetes. FBH can be influenced by many factors, including age, sex, body mass, smoking, alcohol drinking, exercise levels, medications, and eating behaviors, such as breakfast skipping and late-night eating.

AIM

To determine the prevalence of FBH and investigated its association with potential risk factors in a population without diabetes.

METHODS

Clinical parameters and lifestyle-related factors were assessed in a cross-sectional study of 695613 people aged 40-74 years who had undergone a health check-up (390282 men and 305331 women). FBH was defined as fasting plasma glucose < 70 mg/dL (3.9 mmol/L) after overnight fasting, regardless of any symptoms. The absence of diabetes was defined as HbA1c < 6.5%, fasting plasma glucose < 126 mg/dL (7.0 mmol/L), and no pharmacotherapy for diabetes. Multivariate logistic regression analysis, with adjustment for confounding factors, was used to identify associations.

RESULTS

FBH was present in 1842 participants (0.26%). There were significantly more women in the FBH group (59.1%) than in the non-FBH group (43.9%). Values of most of the clinical parameters, but not age, were significantly lower in the FBH group than in the non-FBH group. Logistic regression analysis showed that a body mass index of ≤ 20.9 kg/m² (reference: 21-22.9 kg/m²) and current smoking were significantly associated with FBH, and this was not altered by adjustment for age, sex, and pharmacotherapy for hypertension or dyslipidemia. Female sex was associated with FBH. When the data were analyzed according to sex, men in their 60s or 70s appeared more likely to experience FBH compared with their 40s, whereas men in their 50s and women aged ≥ 50 years appeared less likely to experience FBH. The relationships of FBH with other factors including alcohol drinking and pharmacotherapies for hypertension and dyslipidemia also differed between men and women.

CONCLUSION

FBH occurs even in non-diabetic people, albeit at a very low frequency. FBH is robustly associated with low body mass and smoking, and its relationship with lifestyle factors varies according to sex.

Hypoglycemia, Malnutrition and Body Composition

Hypoglycemia is one of the most significant factors to affect prognosis, and is detrimental to patients regardless of diabetes mellitus (DM) status. The classical paradigms dictate that hypoglycemia is a result of overtreatment with glucose lowering agents (iatrogenic hypoglycemia), or, as among patients without DM, this condition is attributed to disease severity. New information shows that hypoglycemia occurs among patients that have a tendency for it. Incident hypoglycemia is very prevalent in the hospital setting, occurring in 1:6 patients with DM and in 1:17 patients without DM (Leibovitz E, Khanimov I, Wainstein J, Boaz M; Diabetes Metab Syndr Clin Res Rev. 13:222-226, 2019).One of the major factors associated with incidence of hypoglycemia is the nutritional status on hospital admission and during the hospitalization. Assessment of nutritional status using questionnaires and biomarkers might be helpful in determining risk of hypoglycemia. Moreover, administration of oral nutritional supplements was shown to decrease this risk.It is also well known that a high burden of comorbidities is associated with an increased risk of hypoglycemia. For example, kidney disease, whether acute or chronic, was shown to increase the risk for hypoglycemia, as well as some endocrine disorders.In this review we elaborate on specific findings that are characteristic of patients at risk for developing hypoglycemia, as well as treatment aimed at preventing its occurrence.

Association of silent hypoglycemia with cardiac events in non-diabetic subjects with acute myocardial infarction undergoing primary percutaneous coronary interventions

Background

Some studies have shown that hypoglycemic episodes in diabetic patients might be associated with increased cardiovascular events. It is not clear whether episodes of silent hypoglycemia had greater prognostic value on cardiac events compared with normoglycemia or hyperglycemia in non-diabetic patients, so the aim of this study was to investigate the association of silent hypoglycemia and cardiac events in non-diabetic patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (p-PCI).

Methods

We enrolled non-diabetic patients with STEMI who underwent p-PCI and whose clinical and laboratory data were collected. Interstitial glucose values were recorded using a continuous glucose monitoring system (CGMS), and Holter monitoring was recorded for 3 days in parallel. Cardiac ischemia and ventricular arrhythmia was evaluated.

Results

Based on the inclusion and exclusion criteria, we enrolled 164 STEMI patients undergoing p-PCI for final analysis. A total of 280 episodes of silent hypoglycemia (CGMS glucose <70 mg/dl) were recorded. Episodes of silent cardiac ischemia were recorded in 50 of 280 hypoglycemic episodes. The incidence of silent cardiac ischemia during hypoglycemia was significantly higher than the incidence during both hyperglycemia and normoglycemia(P < 0.01). Moreover, we found a significantly higher frequency of ventricular extrasystoles (VESs) or nonsustained ventricular tachycardias (NSVTs) in patients with silent hypoglycemia. The average number of events of silent cardiac ischemia was also significantly increased in the silent hypoglycemia group (0.91 ± 0.82 vs. 0.35 ± 0.54, P < 0.01) compared with either hyperglycemia or normoglycemia group.

Conclusions

Hypoglycemia was frequent and most of the time asymptomatic in non-diabetic patients with STEMI undergoing p-PCI. Silent hypoglycemia was associated with silent cardiac ischemia. STEMI patients with silent hypoglycemia had a significantly higher frequency of VESs or NSVTs.

Management of Hypoglycemia in Nondiabetic Palliative Care Patients: A Prognosis-Based Approach

Hypoglycemia due to underlying terminal illness in nondiabetic end-of-life patients receiving palliative care has not been fully studied. For example, we do not have adequate information on the frequency of spontaneous hypoglycemia in patients as occurs during the different stages of palliative care. Depending on the case-mix nature of the palliative care ward, at least 2% of palliative care patients may develop hypoglycemia near the end of life when the remaining life expectancy counts down in days. As many as 25%-60% of these patients will neither have autonomic response nor have neuroglycopenic symptoms during a hypoglycemic episode. Although it is not difficult to diagnose and confirm a true hypoglycemia when it is suspected clinically, an episode of hypoglycemic attack may go unnoticed in some patients in a hospice setting. Current trends in palliative care focus on providing treatments based on a prognosis-based framework, involving shared decision-making between the patient and caregivers, after considering the prognosis, professional recommendations, patient's autonomy, family expectations, and the current methods for treating the patient's physical symptoms and existential suffering. This paper provides professional care teams with both moral and literature support for providing care to nondiabetic patients presenting with hypoglycemia.

The impact of hypoglycaemia on patients admitted to hospital with medical emergencies

AIMS

To quantify the frequency of biochemical hypoglycaemia in acutely unwell patients in the medical assessment unit and relate this to their subsequent outcomes.

METHODS

A retrospective audit was conducted on all emergency medical patients attending the medical assessment unit between November 2010 and April 2011. Capillary blood glucose measurements were obtained and electronically stored for all patients. Admission details, presence of diabetes, type of diabetes and treatment, length of stay in hospital and death in hospital were obtained from the hospital clinical coding data and electronic discharge summary. The incidence of hypoglycaemia in patients with and without diabetes was quantified. The mean age, length of stay and percentage of death in hospital were compared between groups with and without hypoglycaemia.

RESULTS

One hundred and thirty-eight (9.5%) patients with diabetes and 70 (2.7%) patients without diabetes had an episode of hypoglycaemia in the medical assessment unit. Patients with diabetes and hypoglycaemia on admission had a significantly longer length of stay (mean ± sd) (10.3 ± 11.2 vs. 7.3 ± 9.5 days, P = 0.001) and higher rate of hospital mortality (14.5 vs. 5.2%, P < 0.001) compared with those without hypoglycaemia. Patients without diabetes with hypoglycaemia had a longer length of stay (mean ± sd) (9.1 ± 10.5 vs. 6.7 ± 9.9 days, P = 0.05) and a higher rate of hospital mortality (24.3 vs. 5.4%, P < 0.001) compared with those without hypoglycaemia.

CONCLUSION

Hypoglycaemia is associated with an increased length of stay in hospital and an increased in-hospital mortality rate. Hypoglycaemia may have contributed to the poorer outcome, but would also appear to be a marker of disease severity in unwell patients, especially patients with sepsis.

Hypoglycemia in non-diabetic in-patients: clinical or criminal?

BACKGROUND AND AIM

We wished to establish the frequency of unexpected hypoglycemia observed in non diabetic patients outside the intensive care unit and to determine if they have a plausible clinical explanation.

METHODS

We analysed data for 2010 from three distinct sources to identify non diabetic hypoglycaemic patients: bedside and laboratory blood glucose measurements; medication records for those treatments (high-strength glucose solution and glucagon) commonly given to reverse hypoglycemia; and diagnostic codes for hypoglycemia. We excluded from the denominator admissions of patients with a diagnosis of diabetes or prescribed diabetic medication. Case notes of patients identified were reviewed. We used capture-recapture methods to establish the likely frequency of hypoglycemia in non-diabetic in-patients outside intensive care unit at different cut-off points for hypoglycemia. We also recorded co-morbidities that might have given rise to hypoglycemia.

RESULTS

Among the 37,898 admissions, the triggers identified 71 hypoglycaemic episodes at a cut-off of 3.3 mmol/l. Estimated frequency at 3.3 mmol/l was 50(CI 33-93), at 3.0 mmol/l, 36(CI 24-64), at 2.7 mmol/l, 13(CI 11-19), at 2.5 mmol/l, 11(CI 9-15) and at 2.2 mmol/l, 8(CI 7-11) per 10,000 admissions. Admissions of patients aged above 65 years were approximately 50% more likely to have an episode of hypoglycemia. Most were associated with important co-morbidities.

CONCLUSION

Significant non-diabetic hypoglycemia in hospital in-patients (at or below 2.7 mmol/l) outside critical care is rare. It is sufficiently rare for occurrences to merit case-note review and diagnostic blood tests, unless an obvious explanation is found.

Hypoglycemia revisited in the acute care setting

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

[Influence of pre-operative fasting time on blood glucose in older patients]

PURPOSE

This study was performed to identify changes in blood glucose at preoperative fasting time in surgical patients over 60 yr.

METHODS

Data collection was performed from July, 2008 through July, 2009. Participants consisted of 80 nondiabetic surgical patients. Blood glucose was checked from 3 to 5 times. The 5 times were 2-hr fasting on the pre-operative day (T1, n=80), 8 hr (T2, n=80), 10 hr (T3, n=17), 12 hr (T4, n=34) and 14 hr fasting on the day of the operation (T5, n=29).

RESULTS

Of the patients, 27.5% had a blood glucose level of less than 79 mg/dL at T2; 17.6% at T3; 32.4% at T4; and 17.2% at T5. Mean blood glucose levels were 93.8 mg/dL at T1; 88.4 mg/dL at T2; 91.7 mg/dL at T3; 87.4 mg/dL at T4: and 94.1 mg/dL at T5. Blood glucose was the lowest at T2 (p<.001).

CONCLUSION

As 17.6-32.4% of the patients showed the blood glucose level of less than 79 mg/dL at 8-14 hr pre-operative fasting, the authors recommend that surgical patients >60 yr-of-age be observed for hypoglycemia during pre-operative fasting of more than 10 hr and that surgical patients >60 yr-of-age with risks for hypoglycemia be scheduled for operation within 10 hr preoperative fasting.

Admission hypoglycemia and increased mortality in patients hospitalized with pneumonia

BACKGROUND

The relationship between spontaneous admission hypoglycemia and mortality in patients hospitalized with community-acquired pneumonia is unclear.

METHODS

From 2000 to 2002, clinical data were prospectively collected on all patients with community-acquired pneumonia who were admitted to all 6 hospitals in Edmonton, Alberta, Canada. Patients with admission glucose greater than 6.1 mmol/L (n=1996) were excluded; the remaining patients were categorized as having admission hypoglycemia (<4.0 mmol/L [n=54]) or normoglycemia (4.0 to< or =6.1 mmol/L [n=902]). Multivariable Cox proportional hazards models were used to examine the relationship between hypoglycemia and all-cause mortality in-hospital, at 30 days, and at 1 year.

RESULTS

The mean age was 65 (standard deviation=20) years, 48% were female, 8% had diabetes, and 56% had severe pneumonia. Overall, admission hypoglycemia was present in 2% (54/2990) of the entire cohort and 6% of those with glucose of 6.1 mmol/L or less. Total deaths were 89 (9%) in-hospital, 96 (10%) at 30 days, and 247 (26%) at 1 year. In-hospital mortality was higher among patients with admission hypoglycemia (11 [20%] deaths) compared with those with normoglycemia (78 [9%]; adjusted hazards ratio [aHR] 2.96; 95% confidence interval [CI], 1.39-6.31; P=.005). An increased risk of mortality was observed at 30 days (11 [20%] vs 85 [10%]; aHR 2.89; 95% CI, 1.32-6.29) and remained elevated at 1 year (19 [35%] vs 228 [25%]; aHR1.80; 95% CI, 1.02-3.17). These results were not influenced by treatment for diabetes (P>.4 for interaction).

CONCLUSION

In a population-based sample of patients with community-acquired pneumonia, spontaneous admission hypoglycemia was independently associated with increased mortality during hospitalization that persisted to 1 year. Patients with hypoglycemia are an easily identified group that may warrant more intensive inpatient and postdischarge follow-up.

Hyperglycemia in critical illness: a review

Hyperglycemia is commonplace in the critically ill patient and is associated with worse outcomes. It occurs after severe stress (e.g., infection or injury) and results from a combination of increased secretion of catabolic hormones, increased hepatic gluconeogenesis, and resistance to the peripheral and hepatic actions of insulin. The use of carbohydrate-based feeds, glucose containing solutions, and drugs such as epinephrine may exacerbate the hyperglycemia. Mechanisms by which hyperglycemia cause harm are uncertain. Deranged osmolality and blood flow, intracellular acidosis, and enhanced superoxide production have all been implicated. The net result is derangement of endothelial, immune and coagulation function and an association with neuropathy and myopathy. These changes can be prevented, at least in part, by the use of insulin to maintain normoglycemia.

Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) Study

AIMS

This study was undertaken to evaluate (i) factors associated with patient-reported hypoglycaemia; (ii) association of patient-reported hypoglycaemic symptoms with treatment satisfaction and barriers to adherence and (iii) association between treatment satisfaction, adherence and glycaemic control among patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin.

METHODS

This observational, cross-sectional, multicentre study was conducted in seven countries (Finland, France, Germany, Norway, Poland, Spain and UK) from June 2006 to February 2007. Patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin therapy on a date (index date) from January 2001 through January 2006 and who had at least one haemoglobin A1C (HbA1C) measurement in the 12-month period before the visit date were eligible. Questionnaires were used to ascertain patients' reports of hypoglycaemic symptoms, treatment satisfaction, and treatment adherence. The Treatment Satisfaction Questionnaire for Medication was used to measure patients' treatment satisfaction. An adherence and barriers questionnaire was used to measure patients' adherence to treatment. Glycaemic control was based on documented HbA1C measurements within the prior 12 months.

RESULTS

The mean +/- s.d. age was 62.9 +/- 10.6 years, and the mean +/- s.d. duration of diabetes was 7.8 +/- 5.1 years. HbA1C in this population of patients who had failed metformin monotherapy and were treated with oral antihyperglycaemic agents was below the International Diabetes Federation goal of 6.5% in only 477 (27.9%) patients. Approximately 38% of patients reported hypoglycaemic symptoms during the past year. Hypoglycaemia was significantly more likely in patients with a history of macrovascular complications of diabetes (OR = 1.346; 95% CI = 1.050-1.725) and with no regular physical activity (OR = 1.295; 95% CI = 1.037-1.618). Patients reporting hypoglycaemia had significantly lower treatment satisfaction scores (71.6 +/- 17.6 vs. 76.3 +/- 16.8; p < 0.0001 for global satisfaction). Compared with their counterparts reporting no hypoglycaemic symptoms, patients with such symptoms were also significantly more likely to report barriers to adherence, including being unsure about instructions (37.0 vs. 30.5%; p = 0.0057). Patients at HbA1C goal had significantly higher treatment satisfaction and adherence compared with those who were not.

CONCLUSIONS

Patients' reports of hypoglycaemic symptoms are common in European outpatients with type 2 diabetes and are associated with significantly lower treatment satisfaction and with barriers to adherence. In addition, being at HbA1C goal is associated with treatment satisfaction and adherence.