High rates of severe hypoglycemia among African American patients with diabetes: the surveillance, prevention, and Management of Diabetes Mellitus (SUPREME-DM) network

Follow up care for adults with diabetes treated for severe hypoglycemia by emergency medical Services, 2013-2019

AIMS

To capture the types and content of healthcare encounters following severe hypoglycemia requiring emergency medical services (EMS) and to correlate their features with subsequent risk of severe hypoglycemia.

METHODS

A retrospective cohort was obtained by linking data from a multi-state health system and an advanced life support ambulance service. This identified 1977 EMS calls by 1028 adults with diabetes experiencing hypoglycemia between 1/1/2013-12/31/2019. We evaluated the healthcare engagement over the following 7 days to identify rates of discussion of hypoglycemia, change of diabetes medications, glucagon prescribing, and referral for diabetes.

RESULTS

Rates of hypoglycemia discussion increased with escalating levels of care, from 11.5 % after EMS calls without emergency department (ED) transport or outpatient clinical encounters to 98 % among hospitalized patients with outpatient follow-up. EMS transport and outpatient follow-up were associated with significantly higher odds of discussion of hypoglycemia (OR 60 and OR 22.1, respectively). Interventions were not impacted by previous severe hypoglycemia within 30 days. Prescription of glucagon was rare among all patients.

CONCLUSIONS

Interventions to prevent recurrent hypoglycemia increase with escalating levels of care but remain inadequate and inconsistent with clinical guidelines. Greater attention is needed to ensure timely diabetes-related follow-up and treatment modification for patients experiencing severe hypoglycemia.

Second-Line Pharmaceutical Treatments for Patients with Type 2 Diabetes

Importance

Assessing the relative effectiveness and safety of additional treatments when metformin monotherapy is insufficient remains a limiting factor in improving treatment choices in type 2 diabetes.

Objective

To determine whether data from electronic health records across the University of California Health system could be used to assess the comparative effectiveness and safety associated with 4 treatments in diabetes when added to metformin monotherapy.

Design, Setting, and Participants

This multicenter, new user, multidimensional propensity score-matched retrospective cohort study with leave-one-medical-center-out (LOMCO) sensitivity analysis used principles of emulating target trial. Participants included patients with diabetes receiving metformin who were then additionally prescribed either a sulfonylurea, dipeptidyl peptidase-4 inhibitor (DPP4I), sodium-glucose cotransporter-2 inhibitor (SGLT2I), or glucagon-like peptide-1 receptor agonist (GLP1RA) for the first time and followed-up over a 5-year monitoring period. Data were analyzed between January 2022 and April 2023.

Exposure

Treatment with sulfonylurea, DPP4I, SGLT2I, or GLP1RA added to metformin monotherapy.

Main Outcomes and Measures

The main effectiveness outcome was the ability of patients to maintain glycemic control, represented as time to metabolic failure (hemoglobin A1c [HbA1c] ≥7.0%). A secondary effectiveness outcome was assessed by monitoring time to new incidence of any of 28 adverse outcomes, including diabetes-related complications while treated with the assigned drug. Sensitivity analysis included LOMCO.

Results

This cohort study included 31 852 patients (16 635 [52.2%] male; mean [SD] age, 61.4 [12.6] years) who were new users of diabetes treatments added on to metformin monotherapy. Compared with sulfonylurea in random-effect meta-analysis, treatment with SGLT2I (summary hazard ratio [sHR], 0.75 [95% CI, 0.69-0.83]; I2 = 37.5%), DPP4I (sHR, 0.79 [95% CI, 0.75-0.84]; I2 = 0%), GLP1RA (sHR, 0.62 [95% CI, 0.57-0.68]; I2 = 23.6%) were effective in glycemic control; findings from LOMCO sensitivity analysis were similar. Treatment with SGLT2I showed no significant difference in effectiveness compared with GLP1RA (sHR, 1.26 [95% CI, 1.12-1.42]; I2 = 47.3%; no LOMCO) or DPP4I (sHR, 0.97 [95% CI, 0.90-1.04]; I2 = 0%). Patients treated with DPP4I and SGLT2I had fewer cardiovascular events compared with those treated with sulfonylurea (DPP4I: sHR, 0.84 [95% CI, 0.74-0.96]; I2 = 0%; SGLT2I: sHR, 0.78 [95% CI, 0.62-0.98]; I2 = 0%). Patients treated with a GLP1RA or SGLT2I were less likely to develop chronic kidney disease (GLP1RA: sHR, 0.75 [95% CI 0.6-0.94]; I2 = 0%; SGLT2I: sHR, 0.77 [95% CI, 0.61-0.97]; I2 = 0%), kidney failure (GLP1RA: sHR, 0.69 [95% CI, 0.56-0.86]; I2 = 9.1%; SGLT2I: sHR, 0.72 [95% CI, 0.59-0.88]; I2 = 0%), or hypertension (GLP1RA: sHR, 0.82 [95% CI, 0.68-0.97]; I2 = 0%; SGLT2I: sHR, 0.73 [95% CI, 0.58-0.92]; I2 = 38.5%) compared with those treated with a sulfonylurea. Patients treated with an SGLT2I, vs a DPP4I, GLP1RA, or sulfonylurea, were less likely to develop indicators of chronic hepatic dysfunction (sHR vs DPP4I, 0.68 [95% CI, 0.49-0.95]; I2 = 0%; sHR vs GLP1RA, 0.66 [95% CI, 0.48-0.91]; I2 = 0%; sHR vs sulfonylurea, 0.60 [95% CI, 0.44-0.81]; I2 = 0%), and those treated with a DPP4I were less likely to develop new incidence of hypoglycemia (sHR, 0.48 [95% CI, 0.36-0.65]; I2 = 22.7%) compared with those treated with a sulfonylurea.

Conclusions and Relevance

These findings highlight familiar medication patterns, including those mirroring randomized clinical trials, as well as providing new insights underscoring the value of robust clinical data analytics in swiftly generating evidence to help guide treatment choices in diabetes.

Racial and Ethnic Differences in the Association Between Mean Glucose and Hemoglobin A1c

Background: Studies have reported significantly higher hemoglobin A1c (A1C) in African American patients than in White patients with the same mean glucose, but less is known about other racial/ethnic groups. We evaluated racial/ethnic differences in the association between mean glucose, based on continuous glucose monitor (CGM) data, and A1C. Methods: Retrospective study among 1788 patients with diabetes from Kaiser Permanente Northern California (KPNC) who used CGM devices during 2016 to 2021. In this study population, there were 5264 A1C results; mean glucose was calculated from 124,388,901 CGM readings captured during the 90 days before each A1C result. Hierarchical mixed models were specified to estimate racial/ethnic differences in the association between mean glucose and A1C. Results: Mean A1C was 0.33 (95% confidence interval: 0.23-0.44; P < 0.0001) percentage points higher among African American patients relative to White patients for a given mean glucose. A1C results for Asians, Latinos, and multiethnic patients were not significantly different from those of White patients. The slope of the association between mean glucose and A1C did not differ significantly across racial/ethnic groups. Variance for the association between mean glucose and A1C was substantially greater within groups than between racial/ethnic groups (65% vs. 9%, respectively). Conclusions: For African American patients, A1C results may overestimate glycemia and could lead to premature diabetes diagnoses, overtreatment, or invalid assessments of health disparities. However, most of the variability in the mean glucose-A1C association was within racial/ethnic groups. Treatment decisions driven by guideline-based A1C targets should be individualized and supported by direct measurement of glycemia.

Advances in the management of type 2 diabetes in adults

Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A1c (HbA1c), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes.

Use of Real-World Data in Population Science to Improve the Prevention and Care of Diabetes-Related Outcomes

The past decade of population research for diabetes has seen a dramatic proliferation of the use of real-world data (RWD) and real-world evidence (RWE) generation from non-research settings, including both health and non-health sources, to influence decisions related to optimal diabetes care. A common attribute of these new data is that they were not collected for research purposes yet have the potential to enrich the information around the characteristics of individuals, risk factors, interventions, and health effects. This has expanded the role of subdisciplines like comparative effectiveness research and precision medicine, new quasi-experimental study designs, new research platforms like distributed data networks, and new analytic approaches for clinical prediction of prognosis or treatment response. The result of these developments is a greater potential to progress diabetes treatment and prevention through the increasing range of populations, interventions, outcomes, and settings that can be efficiently examined. However, this proliferation also carries an increased threat of bias and misleading findings. The level of evidence that may be derived from RWD is ultimately a function of the data quality and the rigorous application of study design and analysis. This report reviews the current landscape and applications of RWD in clinical effectiveness and population health research for diabetes and summarizes opportunities and best practices in the conduct, reporting, and dissemination of RWD to optimize its value and limit its drawbacks.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

6. Glycemic Targets: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Pathophysiology and management of hypoglycemia in diabetes

In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.

Evaluation of the Efficacy of a Hypoglycemia Protocol to Treat Severe Hypoglycemia

PURPOSE

The purpose of this quality improvement project was to evaluate the efficacy of the facility's Hypoglycemia Protocol when treating severe hypoglycemia (defined as blood glucose < 50 mg/dL).

DESCRIPTION

The diabetes clinical nurse specialists conducted a retrospective chart review of diabetic inpatients with severe hypoglycemia who were treated per the Hypoglycemia Protocol from October 1, 2017, through April 30, 2019. The primary outcome was achievement of euglycemia (defined as blood glucose ≥ 80 mg/dL) 15 to 30 minutes post treatment with either oral carbohydrates or intravenous dextrose.

OUTCOME

Two hundred twenty-two patients received treatment with oral carbohydrates versus 120 patients who received intravenous dextrose. Fifty patients receiving oral carbohydrates versus 106 patients receiving intravenous dextrose achieved euglycemia after 1 treatment. Compared with treatment with intravenous dextrose, the odds ratio of the rise in blood glucose to 80 mg/dL or greater within 15 to 30 minutes post treatment for a patient given oral carbohydrate was decreased by 97.2%.

CONCLUSION

Intravenous dextrose was more efficacious than oral carbohydrate treatment in patients with diabetes experiencing severe hypoglycemia. In response, the Hypoglycemia Protocol was revised to increase oral carbohydrate treatment for severe hypoglycemia and to expedite escalation from oral to intravenous treatment.

Severe Hypoglycemia and Incident Heart Failure Among Adults With Type 2 Diabetes

CONTEXT

The association of severe hypoglycemia on the incidence of heart failure (HF) is unclear.

OBJECTIVE

We evaluated the association of severe hypoglycemia with incident HF among individuals with type 2 diabetes.

METHODS

We included participants with type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. Severe hypoglycemia episodes were assessed during the initial 24 months following randomization and defined using 2 methods: (1) symptomatic, severe hypoglycemic event requiring medical assistance (first definition); or (2) requiring any assistance (second definition). Participants without HF at baseline and during the first 24 months of the study were prospectively followed for incident HF hospitalization. Multivariable Cox regression was used to generate adjusted hazard ratios (HR) for the association of severe hypoglycemia and incident HF.

RESULTS

Among 9208 participants (mean age 63 years, 38% female, 62% White), 365 had ≥ 1 episode of severe hypoglycemic. Over a median follow-up duration of 3 years, there were 249 incident HF events. After multivariable adjustment for relevant confounders, participants with severe hypoglycemia requiring medical assistance had a 68% higher relative risk of incident HF (HR 1.68; 95% CI, 1.06-2.66), as compared with individuals who never experienced any episode of hypoglycemia. Severe hypoglycemia requiring any assistance was also associated with a 49% higher relative risk of HF (HR 1.49; 95% CI, 1.01-2.21).

CONCLUSION

In a large cohort of adults with type 2 diabetes, severe hypoglycemia was independently associated with greater risk of incident HF.

Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes

IMPORTANCE

Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown.

OBJECTIVE

To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021.

EXPOSURES

Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation).

MAIN OUTCOMES AND MEASURES

The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county.

RESULTS

The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049).

CONCLUSIONS AND RELEVANCE

This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Hypoglycemic and Hyperglycemic Crises Among U.S. Adults With Diabetes and End-stage Kidney Disease: Population-Based Study, 2013-2017

OBJECTIVE

We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD).

RESEARCH DESIGN AND METHODS

This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United States Renal Data System registry, between 2013 and 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 person-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen, and U.S. region.

RESULTS

Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 57-73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (≥75 vs. 18-44 years old: incidence rate ratio 0.35, 95% CI 0.33-0.37, and 0.03, 0.02-0.03), women (1.09, 1.06-1.12, and 1.44, 1.35-1.54), and those with smoking (1.36, 1.28-1.43, and 1.71, 1.53-1.91), substance abuse (1.27, 1.15-1.42, and 1.53, 1.23-1.9), retinopathy (1.10, 1.06-1.15, and 1.36, 1.26-1.47), and insulin therapy (vs. no therapy; 0.60, 0.59-0.63, and 0.44, 0.39-0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08-1.15) and amputation history (1.20, 1.13-1.27).

CONCLUSIONS

In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected.

Hospital utilization for hypoglycemia among patients with type 2 diabetes using pooled data from six health systems

INTRODUCTION

Hypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among patients with type 2 diabetes using electronic health record data pooled from six academic health systems.

RESEARCH DESIGN AND METHODS

This retrospective open cohort study included 549 041 adults with type 2 diabetes receiving regular care from the included health systems between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated International Classification of Diseases Ninth Revision (ICD-9) algorithm from 2009 to 2014. After the transition to ICD-10 in 2015, we used two ICD-10 code sets (limited and expanded) for hypoglycemia hospital utilization from prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014.

RESULTS

Yearly rates of hypoglycemia hospital utilization decreased from 2.7 to 1.6 events per 1000 patients from 2009 to 2014 (p-trend=0.023). From 2016 to 2019, yearly event rates were stable ranging from 5.6 to 6.6, or 6.3 to 7.3, using the limited and expanded ICD-10 code sets, respectively. In 2014, the strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 2.86, 95% CI 2.33 to 3.57), ages 18-39 years (OR 2.43 vs age 40-64 years, 95% CI 1.78 to 3.31), and insulin use (OR 2.13 vs no diabetes medications, 95% CI 1.67 to 2.73).

CONCLUSIONS

Rates of hypoglycemia hospital utilization decreased from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared with ICD-9.

Second-Line Therapy for Type 2 Diabetes Management: The Treatment/Benefit Paradox of Cardiovascular and Kidney Comorbidities

OBJECTIVE

To examine whether glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are preferentially initiated among patients with cardiovascular disease, heart failure (HF), or nephropathy, where these drug classes have established benefit, compared with dipeptidyl peptidase 4 inhibitors (DPP-4i), for which corresponding benefits have not been demonstrated.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed claims of adults with type 2 diabetes included in OptumLabs Data Warehouse, a deidentified database of commercially insured and Medicare Advantage beneficiaries, who first started GLP-1RA, SGLT2i, or DPP-4i therapy between 2016 and 2019. Using multinomial logistic regression, we examined the relative risk ratios (RRR) of starting GLP-1RA and SGLT2i compared with DPP-4i for those with a history of myocardial infarction (MI), cerebrovascular disease, HF, and nephropathy after adjusting for demographic and other clinical factors.

RESULTS

We identified 75,395 patients who started GLP-1RA, 58,234 who started SGLT2i, and 91,884 who started DPP-4i. Patients with prior MI, cerebrovascular disease, or nephropathy were less likely to start GLP-1RA rather than DPP-4i compared with patients without these conditions (RRR 0.83 [95% CI 0.78-0.88] for MI, RRR 0.77 [0.74-0.81] for cerebrovascular disease, and RRR 0.87 [0.84-0.91] for nephropathy). Patients with HF or nephropathy were less likely to start SGLT2i (RRR 0.83 [0.80-0.87] for HF and RRR 0.57 [0.55-0.60] for nephropathy). Both medication classes were less likely to be started by non-White and older patients.

CONCLUSIONS

Patients with cardiovascular disease, HF, and nephropathy, for whom evidence suggests a greater likelihood of benefiting from GLP-1RA and/or SGLT2i therapy, were less likely to start these drugs. Addressing this treatment/benefit paradox, which was most pronounced in non-White and older patients, may help reduce the morbidity associated with these conditions.

Association of Serious Hypoglycemic Events in Older Adults With Changes in Glycemic Performance Measures

BACKGROUND

Reducing serious hypoglycemic events is a Federal-wide objective. Despite studies of trends for rates of serious hypoglycemia in existing literature, rigorous evaluation of links between the observed trends and changes in professional guidelines or performance measures for glycemic control is lacking.

OBJECTIVE

To evaluate whether changes in professional society guidelines and performance measures for glycemic control correspond to changes in rates of serous hypoglycemia.

RESEARCH DESIGN

This was a retrospective observational study. We merged Veterans Health Administration (VHA) and Medicare patient-level databases of VHA patients and identified those aged 65 years and above and receiving hypoglycemic agents. We derived age-adjusted and sex-adjusted annual rates and constructed piecewise Poisson regression models adjusting for age and sex to assess time trends of the rates.

SUBJECTS

VHA patients, 2002-2015.

MEASURES

The main outcome was the annual rates (2004-2015) of serious hypoglycemia, defined as hypoglycemia-related emergency department visits or hospitalizations. Secondary outcomes were annual rates of hemoglobin (Hb) A1c level <7% and >9%. Age and sex were additional variables.

RESULTS

The annual rate for hypoglycemia decreased by 4.8% (rate ratio: 0.952; 95% confidence interval, 0.949-0.956) for 2008-2015 but did not change (1.001; 0.994-1.001) in 2004-2008. In 2008-2015, the annual rate for HbA1c <7% decreased by 5.0% (0.950; 0.949-0.951) but for HbA1c >9%, increased by 7.9% (1.079; 1.076-1.082).

CONCLUSION

The cooccurrence of decreasing rates for HbA1c<7% and serious hypoglycemia since 2008 supports the possibility that withdrawal of a <7% HbA1c measure in 2008 impacted clinical practice and patient outcomes.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Retinopathy develops at similar glucose levels but higher HbA1c levels in people with black African ancestry compared to white European ancestry: evidence for the need to individualize HbA1c interpretation

AIMS

To examine the association of HbA_1c and glucose levels with incident diabetic retinopathy according to black African or white European ancestry.

METHODS

In this retrospective cohort study of 202 500 US Veterans with diabetes (2000-2014), measures included HbA_1c , outpatient random serum/plasma glucose, and incident retinopathy [conversion from negative to ≥2 positive evaluations (ICD-9 codes), without a subsequent negative].

RESULTS

At baseline, the study population had a mean age of 59.3 years, their mean BMI was 31.9 kg/m² , HbA_1c level was 57 mmol/mol (7.4%) and glucose level was 8.8 mmol/l, and 77% were of white European ancestry (white individuals) and 21% of black African ancestry (black individuals). HbA_1c was 0.3% higher in black vs white individuals (P < 0.001), adjusting for baseline age, sex, BMI, estimated glomerular filtration rate (eGFR), haemoglobin, and average systolic blood pressure and glucose. Over 11 years, incident retinopathy occurred in 9% of black and 7% of white individuals, but black individuals had higher HbA_1c , glucose, and systolic blood pressure (all P < 0.001); adjusted for these factors, incident retinopathy was reduced in black vs white individuals (P < 0.001). The population incidence of retinopathy (7%) was associated with higher mean baseline HbA_1c in individuals with black vs white ancestry [63 mmol/mol (7.9%) vs 58 mmol/mol (7.5%); P < 0.001)], but with similar baseline glucose levels (9.0 vs 9.0 mmol/l; P = 0.660, all adjusted for baseline age, sex and BMI).

CONCLUSIONS

Since retinopathy occurs at higher HbA_1c levels in black people for a given level of average plasma glucose, strategies may be needed to individualize the interpretation of HbA_1c measurements.

Impact of mismatches in HbA1c vs glucose values on the diagnostic classification of diabetes and prediabetes

AIMS

To determine whether HbA_1c mismatches (HbA_1c levels that are higher or lower than expected for the average glucose levels in different individuals) could lead to errors if diagnostic classification is based only on HbA_1c levels.

METHODS

In a cross-sectional study, 3106 participants without known diabetes underwent a 75-g oral glucose tolerance test (fasting glucose and 2-h glucose) and a 50-g glucose challenge test (1-h glucose) on separate days. They were classified by oral glucose tolerance test results as having: normal glucose metabolism; prediabetes; or diabetes. Predicted HbA_1c was determined from the linear regression modelling the relationship between observed HbA_1c and average glucose (mean of fasting glucose and 2-h glucose from the oral glucose tolerance test, and 1-h glucose from the glucose challenge test) within oral glucose tolerance test groups. The haemoglobin glycation index was calculated as [observed - predicted HbA_1c ], and divided into low, intermediate and high haemoglobin glycation index mismatch tertiles.

RESULTS

Those participants with higher mismatches were more likely to be black, to be men, to be older, and to have higher BMI (all P<0.001). Using oral glucose tolerance test criteria, the distribution of normal glucose metabolism, prediabetes and diabetes was similar across mismatch tertiles; however, using HbA_1c criteria, the participants with low mismatches were classified as 97% normal glucose metabolism, 3% prediabetes and 0% diabetes, i.e. mostly normal, while those with high mismatches were classified as 13% normal glucose metabolism, 77% prediabetes and 10% diabetes, i.e. mostly abnormal (P<0.001).

CONCLUSIONS

Measuring only HbA_1c could lead to under-diagnosis in people with low mismatches and over-diagnosis in those with high mismatches. Additional oral glucose tolerance tests and/or fasting glucose testing to complement HbA_1c in diagnostic classification should be performed in most individuals.

Racial differences in trends of serious hypoglycemia among higher risk older adults in US Veterans Health Administration, 2004-2015: Relationship to comorbid conditions, insulin use, and hemoglobin A1c level

AIMS

To evaluate temporal trends in racial/ethnic groups in rates of serious hypoglycemia among higher risk patients dually enrolled in Veterans Health Administration and Medicare fee-for-service and assess the relationship(s) between hypoglycemia rates, insulin/secretagogues and comorbid conditions.

METHODS

Retrospective observational serial cross-sectional design. Patients were ≥65 years receiving insulin and/or secretagogues. The primary outcome was the annual (period prevalence) rates (2004-2015), per 1000 patient years, of serious hypoglycemic events, defined as hypoglycemic-related emergency department visits or hospitalizations.

RESULTS

Subjects were 77-83% White, 7-10% Black, 4-5% Hispanic, <2% women; 38-58% were ≥75 years old; 72-75% had ≥1 comorbidity. In 2004-2015, rates declined from 63.2 to 33.6(-46.9%) in Blacks; 29.7 to 20.3 (-31.6%) in Whites; and 41.8 to 29.6 (-29.3%) in Hispanics. The Black-White rate differences narrowed regardless of insulin use, hemoglobin A1c level, and frequency and various combinations of comorbid conditions. Among insulin users, the Black-White contrast decreased from 34.7 (98.5 vs. 63.8) in 2004 to 13.2 (43.6 vs. 30.4) in 2015; in non-insulin users, the contrast was 25.7 (44.1 vs. 18.4) in 2004 and 10.1 (18.9 vs. 8.8) in 2015.

CONCLUSION

Marked declines in serious hypoglycemia events occurred across race, medications, and comorbidities, suggesting significant changes in clinical practice.

Hypoglycemic episodes are associated with an increased risk of incident frailty among new onset diabetic patients

AIMS

Patients with diabetes mellitus (DM) are at risk for developing frailty due to the complex interplay between different cardiometabolic factors. We examined whether hypoglycemia could independently increase frailty risk besides these factors.

METHODS

From the Longitudinal Cohort of Diabetic Patients, 210,254 patients with new onset DM between 2004 and 2011 were identified, among whom 2119 non-frail patients had at least 1 hypoglycemic episode within 3 years of DM diagnosis. They were propensity score-matched to 8432 non-frail ones without hypoglycemia throughout the study period. Both groups were followed up longitudinally for incident physical frailty according to a modified FRAIL scale (Fatigue, Resistance, Ambulation, Illness, and Loss of weight). We analyzed the risk of frailty (primary) and mortality (secondary outcome) introduced by hypoglycemia, adjusted for known risk factors of frailty.

RESULTS

The mean age of patients (46.2% male) was 65.9 ± 14 years; diabetic patients with hypoglycemia had significantly higher comorbidity burden than those without. After 2.68 years, 172 (1.6%) patients with hypoglycemia developed incident frailty, representing a 60% higher risk (hazard ratio [HR] 1.599, 95% confidence interval [CI] 1.14-2.42). After adjusting for other risk factors, those with hypoglycemia had a significantly higher risk of frailty than those without (HR 1.443, 95% CI 1.01-2.05). Additionally, the mortality of those with hypoglycemia was 2-fold higher than those without, and the risk persisted despite confounder adjustment (HR 1.462, 95% CI 1.3-1.65).

CONCLUSION

In this population-based cohort, hypoglycemic episodes among diabetic patients increased the risk of incident frailty and mortality.

Identifying Common Predictors of Multiple Adverse Outcomes Among Elderly Adults With Type-2 Diabetes

OBJECTIVE

As part of a multidisciplinary team managing patients with type-2 diabetes, pharmacists need a consistent approach of identifying and prioritizing patients at highest risk of adverse outcomes. Our objective was to identify which predictors of adverse outcomes among type-2 diabetes patients were significant and common across 7 outcomes and whether these predictors improved the performance of risk prediction models. Identifying such predictors would allow pharmacists and other health care providers to prioritize their patient panels.

RESEARCH DESIGN AND METHODS

Our study population included 120,256 adults aged 65 years or older with type-2 diabetes from a large integrated health system. Through an observational retrospective cohort study design, we assessed which risk factors were associated with 7 adverse outcomes (hypoglycemia, hip fractures, syncope, emergency department visit or hospital admission, death, and 2 combined outcomes). We split (50:50) our study cohort into a test and training set. We used logistic regression to model outcomes in the test set and performed k-fold validation (k=5) of the combined outcome (without death) within the validation set.

RESULTS

The most significant predictors across the 7 outcomes were: age, number of medicines, prior history of outcome within the past 2 years, chronic kidney disease, depression, and retinopathy. Experiencing an adverse outcome within the prior 2 years was the strongest predictor of future adverse outcomes (odds ratio range: 4.15-7.42). The best performing models across all outcomes included: prior history of outcome, physiological characteristics, comorbidities and pharmacy-specific factors (c-statistic range: 0.71-0.80).

CONCLUSIONS

Pharmacists and other health care providers can use models with prior history of adverse event, number of medicines, chronic kidney disease, depression and retinopathy to prioritize interventions for elderly patients with type-2 diabetes.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of Cumulative Multimorbidity, Glycemic Control, and Medication Use With Hypoglycemia-Related Emergency Department Visits and Hospitalizations Among Adults With Diabetes

IMPORTANCE

Severe hypoglycemia is a serious and potentially preventable complication of diabetes, with some of the most severe episodes requiring emergency department (ED) care or hospitalization. A variety of health conditions increase the risk of hypoglycemia. People with diabetes often have multiple comorbidities, and the association of such multimorbidity with hypoglycemia risk in the context of other risk factors is uncertain.

OBJECTIVE

To examine the associations of age, cumulative multimorbidity, glycated hemoglobin (HbA1c) level, and use of glucose level-lowering medication with hypoglycemia-related ED visits and hospitalizations.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study of claims and laboratory data from OptumLabs Data Warehouse, an administrative claims database of commercially insured and Medicare Advantage beneficiaries in the United States. Participants were adults (aged ≥18 years) with diabetes who had an available HbA1c level result in 2015. Data from January 1, 2014, to December 31, 2016, were analyzed. Final analyses were conducted from December 2017 to September 2018.

MAIN OUTCOMES AND MEASURES

This study calculated rates of hypoglycemia-related ED visits and hospitalizations during the year after the index HbA1c level was obtained, stratified by patient demographic characteristics, diabetes type, comorbidities (from 16 guideline-specified high-risk conditions), index HbA1c level, and glucose level-lowering medication use. The association of each variable with hypoglycemia-related ED and hospital care was examined using multivariable Poisson regression analysis overall and by diabetes type.

RESULTS

The study cohort was composed of 201 705 adults with diabetes (mean [SD] age, 65.8 [12.1] years; 102 668 [50.9%] women; 118 804 [58.9%] white; mean [SD] index HbA1c level, 7.2% [1.5%]). Overall, there were 9.06 (95% CI, 8.64-9.47) hypoglycemia-related ED visits and hospitalizations per 1000 persons per year. The risk of hypoglycemia-related ED visits and hospitalizations was increased by age 75 years or older (incidence rate ratio [IRR], 1.56 [95% CI, 1.23-2.02] vs 18-44 years), black race/ethnicity (IRR, 1.30 [95% CI, 1.16-1.46] vs white race/ethnicity), lower annual household income (IRR, 0.63 [95% CI, 0.53-0.74] for ≥$100 000 vs <$40 000), number of comorbidities (increasing from IRR of 1.66 [95% CI, 1.42-1.95] in the presence of 2 comorbidities to IRR of 4.12 [95% CI, 3.07-5.51] with ≥8 comorbidities compared with ≤1), prior hypoglycemia-related ED visit or hospitalization (IRR, 6.60 [95% CI, 5.77-7.56]), and glucose level-lowering treatment regimen (IRR, 6.73 [95% CI, 4.93-9.22] for sulfonylurea; 12.53 [95% CI, 8.90-17.64] for basal insulin; and 27.65 [95% CI, 20.32-37.63] for basal plus bolus insulin compared with other medications). Independent of these factors, having type 1 diabetes was associated with a 34% increase in the risk of hypoglycemia-related ED visits or hospitalizations (IRR, 1.34 [95% CI, 1.15-1.55]). The index HbA1c level was associated with hypoglycemia-related ED visits and hospitalizations when both low (IRR, 1.45 [95% CI, 1.12-1.87] for HbA1c level ≤5.6% vs 6.5%-6.9%) and high (IRR, 1.24 [95% CI, 1.02-1.50] for HbA1c level ≥10%).

CONCLUSIONS AND RELEVANCE

In this cohort study of adults with diabetes, the risk of an ED visit or hospitalization for hypoglycemia appeared to be highest among patients with type 1 diabetes, multiple comorbidities, prior severe hypoglycemia, and sulfonylurea and/or insulin use. At-risk patients may benefit from individualized treatment regimens to decrease their risk of hypoglycemia.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Racial differences in performance of HbA1c for the classification of diabetes and prediabetes among US adults of non-Hispanic black and white race

AIM

To characterize differences between black and white people in optimal HbA_1c thresholds for diagnoses of diabetes and prediabetes.

METHODS

Data were included from the National Health and Nutrition Examination Survey, 2005-2014. Black and white adults (age 18-70 years) who underwent an oral glucose tolerance test and had available fasting plasma glucose, 2-h plasma glucose and HbA_1c measurements were eligible for inclusion. Diabetes or prediabetes status was defined by fasting plasma glucose and 2-h plasma glucose using American Diabetes Association criteria. Classification of diabetes, prediabetes and dysglycaemia by HbA_1c was evaluated for a range of HbA_1c thresholds, with optimal thresholds defined as those values that maximized the sum of sensitivity and specificity (Youden's index).

RESULTS

In 5324 black (32.3%) and white (67.7%) individuals, Youden's index (optimal) thresholds for HbA_1c were ≥42 mmol/mol (6.0%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs non-diabetes, ≥ 44 mmol/mol (6.2%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs prediabetes (excluding normoglycaemia), ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating dysglycaemia vs normoglycaemia, and ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating prediabetes vs normoglycaemia (excluding diabetes), in black and white people, respectively.

CONCLUSIONS

Consistently higher optimal HbA_1c thresholds in black people than in white people suggest a need to individualize HbA_1c relative to glucose levels if HbA_1c is used to diagnose diabetes and prediabetes.

Incidence and severity of hypoglycaemia in type 2 diabetes by treatment regimen: A UK multisite 12-month prospective observational study

AIMS

To determine the incidence and severity of self-reported hypoglycaemia in a primary care population with type 2 diabetes. The study also aimed to compare incidence by treatment regimen.

MATERIALS AND METHODS

A prospective observational study in 17 centres throughout the UK was conducted. Recruitment was based on treatment regimen (metformin alone, sulphonylurea-, insulin- or incretin-based therapy). Participants were asked to keep a blood glucose diary and self-report hypoglycaemia episodes [non-severe (self-treated) and severe (requiring external help)] over a 12-month period.

RESULTS

Three hundred and twenty-five participants were enrolled, of whom 274 (84%) returned ≥1 monthly diaries. Overall, 39% reported experiencing hypoglycaemia; 32% recorded ≥1 symptomatic, 36% ≥1 non-severe, and 7% ≥1 severe episodes. By treatment, incidence (events per person/year) for any hypoglycaemia type was 4.39 for insulin, 2.34 for sulphonylurea, 0.76 for metformin, and 0.56 for incretin-based therapy. Compared with metformin, risk of non-severe hypoglycaemia was ~3 times higher for participants on sulphonylureas and > 5 times higher for those on insulin [incidence rate ratio (IRR) 3.02 (1.76-5.18), P < 0.001, and IRR 5.96 (3.48-10.2), P < 0.001, respectively]. For severe episodes, the incidence for sulphonylurea (0.09) was similar to metformin (0.07) and incretin-based therapy (0.07); for insulin the risk remained almost 5 times higher than metformin [incidence 0.32; IRR 4.55 (1.28-16.20), P = 0.019].

CONCLUSIONS

Hypoglycaemia represents a substantial burden for people with type 2 diabetes. Sulphonylureas and insulin are both associated with a risk of reported non-severe hypoglycaemia, but only insulin with severe episodes. This suggests the importance of the continued use of sulphonylureas in appropriate patients with type 2 diabetes.

Occurrence of severe hypoglycaemic events among US youth and young adults with type 1 or type 2 diabetes

OBJECTIVE

Although severe hypoglycaemia (SH) can lead to adverse health outcomes, little is known about its occurrence and re-occurrence among youth with type 1 or type 2 diabetes.

METHODS

This study included 2740 participants aged <20 years at diabetes diagnosis and 5-14 years diabetes duration from the SEARCH for Diabetes in Youth Cohort Study. Participants reported SH events in the past 6 months. Differences in SH events by demographic and clinical factors were tested using logistic regression models.

RESULTS

Severe hypoglycaemia in the past 6 months was more common among youth with type 1 (7.0%, 168 of 2399) than with type 2 diabetes (2.6%, nine of 341) (P < 0.002). The median number of SH events per youth who had at least one SH event in the past 6 months was 1 for both type 1 type 2 diabetes. For youth with type 1 diabetes, those who reported SH events were older, were more likely to have obesity or to be physically active, and had lower HbA1c. After adjustments, one unit increase in HbA1c was associated with 16% lower likelihood (OR 0.84, 95% CI 0.75, 0.94) and being physically active was associated with an 87% higher likelihood (OR 1.87, 95% CI 1.23, 2.86) of reporting a SH event. There were too few SH events among youth with type 2 diabetes to analyse further.

CONCLUSIONS

In youth with diabetes, SH was common even within a short 6-month window. Better understanding the causes of SH may help prevent them from occurring.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Ethnic variations in the risk of hypoglycaemia among people with Type 2 diabetes prescribed insulins and/or sulfonylureas: a historical cohort study using general practice-recorded data

AIM

To identify ethnic differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulins and/or sulfonylureas in community settings.

METHODS

Using routine general practice-recorded data, two cohorts of adults with Type 2 diabetes from east London were studied between January 2013 and December 2015: (1) adults prescribed insulins ± other antidiabetes medications (n=7269) and (2) adults prescribed sulfonylureas ± other antidiabetes medications excluding insulins (n=12 502). Incidence rate ratios of hypoglycaemia by ethnicity, adjusting for age, sex, socio-economic status and clustering within Clinical Commissioning Groups, were estimated using random effects Poisson regression.

RESULTS

Compared with white British people prescribed insulins, those of black Caribbean ethnicity were at increased hypoglycaemic risk [adjusted incidence rate ratio 1.56 (95% CI 1.21,2.01)], while Bangladeshi people had a lower risk [adjusted incidence rate ratio 0.49 (95% CI, 0.38,0.64)]. In the sulfonylurea cohort, black Caribbean, black African and Indian people all had increased risks of hypoglycaemia compared with white British people [adjusted incidence rate ratios 1.63 (95% CI 1.15,2.29), 1.90 (95% CI 1.32,2.75) and 1.93 (95% CI 1.39,2.69), respectively].

CONCLUSION

The differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulin and/or sulfonylureas warrant further investigation of any differing biological responses and/or cultural attitudes to antidiabetes therapy among ethnic groups, and should be considered by clinicians evaluating the treatment goals of people with Type 2 diabetes using insulins or sulfonylureas.

Development and validation of a risk prediction model for severe hypoglycemia in adult patients with type 2 diabetes: a nationwide population-based cohort study

Purpose

There is a scarcity of long-term prediction models for severe hypoglycemia (SH) in subjects with type 2 diabetes mellitus (T2DM). In this study, a model was developed and validated to predict the risk of SH in adult patients with T2DM.

Patients and methods

Baseline and follow-up data from patients with T2DM who received health evaluations from January 1, 2009, to December 31, 2010 (n=1,676,885) were analyzed as development (n=1,173,820) and validation (n=503,065) cohorts using the National Health Insurance Database (DB) in Korea. New SH episodes were identified using ICD-10 codes. A Cox proportional hazards regression model and Cox model coefficients were used to derive a risk scoring system, and 14 predictive variables were selected. A risk score nomogram based on the risk prediction model was created to estimate the 1-year risk of SH.

Results

In the development cohort, a total of 5,325 (0.45%) patients experienced SH episodes during the follow-up period. After multivariable adjustment, older age, female sex, current smoker, drinking, low body mass index, lack of exercise, previous SH events, insulin or multiple oral hypoglycemic agent use, presence of hypertension or chronic kidney disease, longer duration of diabetes, low or high glucose level, and high Charlson Comorbidity Index score were found to be significant risk factors for the development of SH and were incorporated into the risk model. The concordance indices were 0.871 (95% confidence interval, 0.863-0.881) in development cohort and 0.866 (95% CI, 0.856-0.879) in the validation cohort. The calibration plot showed a nearly 45° line, which indicates that this model predicts well an absolute SH event.

Conclusion

This 14-variable prediction model for SH events may be a useful tool to identify high-risk patients and guide prevention of SH in adult patients with T2DM.

Association of Initiation of Basal Insulin Analogs vs Neutral Protamine Hagedorn Insulin With Hypoglycemia-Related Emergency Department Visits or Hospital Admissions and With Glycemic Control in Patients With Type 2 Diabetes

IMPORTANCE

In clinical trials of patients with type 2 diabetes, long-acting insulin analogs modestly reduced the risk of nocturnal hypoglycemia compared with human neutral protamine Hagedorn (NPH) insulin, but cost 2 to 10 times more. Outcomes in clinical practice may differ from trial results.

OBJECTIVE

To compare the rates of hypoglycemia-related emergency department (ED) visits or hospital admissions associated with initiation of long-acting insulin analogs vs human NPH insulin in patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective observational study using data from Kaiser Permanente of Northern California from January 1, 2006, through September 30, 2015. Patients with type 2 diabetes who initiated a long-acting insulin analog or NPH insulin were included and censored at death, loss of health plan coverage, change in insulin treatment, or study end on September 30, 2015.

EXPOSURE

Initiation of basal insulin analogs (glargine or detemir) vs NPH insulin.

MAIN OUTCOMES AND MEASURES

The primary outcome was the time to a hypoglycemia-related ED visit or hospital admission and the secondary outcome was the change in hemoglobin A1c level within 1 year of insulin initiation.

RESULTS

There were 25 489 patients with type 2 diabetes who initiated basal insulin therapy (mean age, 60.2 [SD, 11.8] years; 51.9% white; 46.8% female). During a mean follow-up of 1.7 years, there were 39 hypoglycemia-related ED visits or hospital admissions among 1928 patients who initiated insulin analogs (11.9 events [95% CI, 8.1 to 15.6] per 1000 person-years) compared with 354 hypoglycemia-related ED visits or hospital admissions among 23 561 patients who initiated NPH insulin (8.8 events [95% CI, 7.9 to 9.8] per 1000 person-years) (between-group difference, 3.1 events [95% CI, -1.5 to 7.7] per 1000 person-years; P = .07). Among 4428 patients matched by propensity score, the adjusted hazard ratio was 1.16 (95% CI, 0.71 to 1.78) for hypoglycemia-related ED visits or hospital admissions associated with insulin analog use. Within 1 year of insulin initiation, hemoglobin A1c level decreased from 9.4% (95% CI, 9.3% to 9.5%) to 8.2% (95% CI, 8.1% to 8.2%) after initiation of insulin analogs and from 9.4% (95% CI, 9.3% to 9.5%) to 7.9% (95% CI, 7.9% to 8.0%) after initiation of NPH insulin (adjusted difference-in-differences for glycemic control, -0.22% [95% CI, -0.09% to -0.37%]).

CONCLUSIONS AND RELEVANCE

Among patients with type 2 diabetes, initiation of a basal insulin analog compared with NPH insulin was not associated with a reduced risk of hypoglycemia-related ED visits or hospital admissions or with improved glycemic control. These findings suggest that the use of basal insulin analogs in usual practice settings may not be associated with clinical advantages for these outcomes.

Global burden of hypoglycaemia-related mortality in 109 countries, from 2000 to 2014: an analysis of death certificates

AIMS/HYPOTHESIS

In the context of increasing prevalence of diabetes in elderly people with multimorbidity, intensive glucose control may increase the risk of severe hypoglycaemia, potentially leading to death. While rising trends of severe hypoglycaemia rates have been reported in some European, North American and Asian countries, the global burden of hypoglycaemia-related mortality is unknown. We aimed to investigate global differences and trends of hypoglycaemia-related mortality.

METHODS

We used the WHO mortality database to extract information on death certificates reporting hypoglycaemia or diabetes as the underlying cause of death, and the United Nations demographic database to obtain data on mid-year population estimates from 2000 to 2014. We calculated crude and age-standardised proportions (defined as number of hypoglycaemia-related deaths divided by total number of deaths from diabetes [i.e. the sum of hypoglycaemia- and diabetes-related deaths]) and rates (hypoglycaemia-related deaths divided by mid-year population) of hypoglycaemia-related mortality and compared estimates across countries and over time.

RESULTS

Data for proportions were extracted from 109 countries (31 had data from all years analysed [2000-2014] available). Combining all countries, the age-standardised proportion of hypoglycaemia-related deaths was 4.49 (95% CI 4.44, 4.55) per 1000 total diabetes deaths. Compared with the overall mean, most Central American, South American and (mainly) Caribbean countries reported higher proportions (five more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths in Chile, six in Uruguay, 11 in Belize and 22 in Aruba), as well as Japan (11 more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths). In comparison, lower proportions were noted in most European countries, the USA, Canada, New Zealand and Australia. For countries with data available for all years analysed, trend analysis showed a 60% increase in hypoglycaemia-related deaths until 2010 and stable trends onwards. Rising trends were most evident for Argentina, Brazil, Chile, the USA and Japan. Data for rates were available for 105 countries (30 had data for all years analysed [2000-2014] available). Combining all countries, the age-standardised hypoglycaemia-related death rate was 0.79 (95% CI 0.77, 0.80) per 1 million person-years. Most Central American, South American and Caribbean countries similarly reported higher rates of hypoglycaemia-related death, whilst virtually all European countries, the USA, Canada, Japan, New Zealand and Australia reported lower rates compared with the overall mean. Age-standardised rates were very low for most countries (lower than five per 1 million person-years in 89.5% of countries), resulting in small absolute differences among countries. As noted with the proportions analysis, trend analysis showed an overall 60% increase in hypoglycaemia-related deaths until 2010 and stable rate trends onwards; rising rates were particularly evident for Brazil, Chile and the USA.

CONCLUSIONS/INTERPRETATION

Most countries in South America, Central America and the Caribbean showed the highest proportions of diabetes-related deaths attributable to hypoglycaemia and the highest rates of hypoglycaemia-related deaths. Between 2000 and 2014, rising trends were observed in Brazil, Chile and the USA for both rates and proportions of hypoglycaemia-related death, and in Argentina and Japan for proportions only. Further studies are required to unravel the contribution of clinical and socioeconomic factors, difference in diabetes prevalence and heterogeneity of death certification in determining lower rates and proportions of hypoglycaemia-related deaths in high-income countries in Europe, North America and Asia.

DATA AVAILABILITY

Data used for these analyses are available at https://doi.org/10.17632/ndp52fbz8r.1.

Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies

PURPOSE OF REVIEW

Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies.

RECENT FINDINGS

Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.

Devoting attention to glucose variability and hypoglycaemia in type 2 diabetes

In the Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE), insulin degludec was non-inferior to insulin glargine in terms of cardiovascular events and mortality. However, there were lower rates of severe hypoglycaemia with insulin degludec. DEVOTE investigators now extend these findings by presenting the results of two observational epidemiological analyses based on trial data. In the first of these analyses (DEVOTE 2), Zinman et al (Diabetologia DOI: 10.1007/s00125-017-4423-z ) demonstrate that, compared with individuals with lower day-to-day fasting glycaemic variability, those with higher day-to-day fasting glycaemic variability had a similar risk of major adverse cardiovascular events (MACE) but a higher risk of severe hypoglycaemia and all-cause mortality. In the second analysis (DEVOTE 3), Pieber et al (Diabetologia DOI: 10.1007/s00125-017-4422-0 ) found that individuals who experienced severe hypoglycaemia had a similar risk of MACE compared with those who never experienced severe hypoglycaemia, but had a more than twofold higher risk of subsequent total mortality and cardiovascular disease (CVD) mortality. The strengths of these studies relate to the availability of high-quality prospective data on adjudicated severe hypoglycaemia, MACE and mortality events in a large number of high-risk insulin-treated individuals with type 2 diabetes. Limitations include the observational nature of the data and thus residual confounding remains possible. Furthermore, the short duration of the trial resulted in limited statistical power for some analyses. Therefore, whilst DEVOTE 2 and DEVOTE 3 raise awareness of the mortality risks associated with glucose variability and severe hypoglycaemia in high-risk, insulin-treated patients with type 2 diabetes, they cannot clarify causal relationships. Preventing severe hypoglycaemia in those with type 2 diabetes should already be a priority in clinical practice. However, findings from future clinical trials are needed to guide physicians on whether it is beneficial to target glucose variability, and risk for severe hypoglycaemia, to reduce the risks for CVD events and mortality in these individuals.

Risk Factors for Severe Hypoglycemia in Black and White Adults With Diabetes: The Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

Severe hypoglycemia is a rare but important complication of type 2 diabetes. Few studies have examined the epidemiology of hypoglycemia in a community-based population.

RESEARCH DESIGN AND METHODS

We included 1,206 Atherosclerosis Risk in Communities (ARIC) Study participants with diagnosed diabetes (baseline: 1996-1998). Severe hypoglycemic events were identified through 2013 by ICD-9 codes from claims for hospitalizations, emergency department visits, and ambulance use. We used Cox regression to evaluate risk factors for severe hypoglycemia.

RESULTS

The mean age of participants was 64 years, 32% were black, and 54% were female. During a median follow-up period of 15.2 years, there were 185 severe hypoglycemic events. Important risk factors after multivariable adjustment were as follows: age (per 5 years: hazard ratio [HR] 1.24; 95% CI 1.07-1.43), black race (HR 1.39; 95% CI 1.02-1.88), diabetes medications (any insulin use vs. no medications: HR 3.00; 95% CI 1.71-5.28; oral medications only vs. no medications: HR 2.20; 95% CI 1.28-3.76), glycemic control (moderate vs. good: HR 1.78; 95% CI 1.11-2.83; poor vs. good: HR 2.62; 95% CI 1.67-4.10), macroalbuminuria (HR 1.95; 95% CI 1.23-3.07), and poor cognitive function (Digit Symbol Substitution Test z score: HR 1.57; 95% CI 1.33-1.84). In an analysis of nontraditional risk factors, low 1,5-anhydroglucitol, difficulty with activities of daily living, Medicaid insurance, and antidepressant use were positively associated with severe hypoglycemia after multivariate adjustment.

CONCLUSIONS

Poor glycemic control, glycemic variability as captured by 1,5-anhydroglucitol, kidney damage, and measures of cognitive and functional impairments were strongly associated with increased risk of severe hypoglycemia. These factors should be considered in hypoglycemia risk assessments when individualizing diabetes care for older adults.